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Setting the stage for pain relief: how treatment setting impacts interdisciplinary multimodal pain treatment for patients with chronic back pain

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While interdisciplinary multimodal pain treatment (IMPT) is an effective treatment option for chronic low back pain, it is usually accomplished as an inpatient treatment incurring substantial healthcare costs. Day hospital IMPT could be a resource-saving alternative approach, but whether treatment setting is associated with differences in treatment outcomes has not yet been studied. In a retrospective matched cohort study including data from N = 595 patients diagnosed with chronic back pain and undergoing IMPT at the back pain center in Essen, Germany, we investigated the association between treatment setting (ie, inpatient or day patient of an otherwise identical IMPT) and pain intensity, disability, and self-efficacy after treatment. Outcomes were assessed by questionnaires used in clinical routine, collected at pre-IMPT, post-IMPT, and at 3-, 6-, and 12-month follow-up. The results indicate that day patients showed greater improvements in pain-related disability at 3-month post-IMPT (d = 0.74) and in pain intensity at 6-month post-IMPT (d = 0.79), compared to a matched sample of inpatients. Moreover, day patients achieved higher scores in pain-related self-efficacy at discharge, 3- and 6-month post-IMPT (d = 0.62, 0.99, and 1.21, respectively) and reported fewer incapacity-for-work days than inpatients at 6-month post-IMPT (d = 0.45). These data suggest that day hospital IMPT can be as effective as inpatient treatment and might even be more effective for the less afflicted patients. Further research regarding treatment setting and indication could guide optimized and cost-efficient treatments that are more closely tailored to the individual patient's needs.
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Research Paper PAIN 165 (2024) 2909–2919
Setting the stage for pain relief: how treatment
setting impacts interdisciplinary multimodal pain
treatment for patients with chronic back pain
Dustin Maser
a,
*, Diana M ¨ußgens
a
, Julian Kleine-Borgmann
a
, Balint Kincses
a
, Katharina Schmidt
a
,
Sigrid Elsenbruch
a,b
, Daniel M ¨uller
a
, Ulrike Bingel
a
Abstract
While interdisciplinary multimodal pain treatment (IMPT) is an effective treatment option for chronic low back pain, it is usually
accomplished as an inpatient treatment incurring substantial healthcare costs. Day hospital IMPT could be a resource-saving
alternative approach, but whether treatment setting is associated with differences in treatment outcomes has not yet been
studied. In a retrospective matched cohort study including data from N 5595 patients diagnosed with chronic back pain and
undergoing IMPT at the back pain center in Essen, Germany, we investigated the association between treatment setting (ie,
inpatient or day patient of an otherwise identical IMPT) and pain intensity, disability, and self-efficacy after treatment. Outcomes
were assessed by questionnaires used in clinical routine, collected at pre-IMPT, post-IMPT, and at 3-, 6-, and 12-month follow-
up. The results indicate that day patients showed greater improvements in pain-related disability at 3-month post-IMPT (d 50.74)
and in pain intensity at 6-month post-IMPT (d 50.79), compared to a matched sample of inpatients. Moreover, day patients
achieved higher scores in pain-related self-efficacy at discharge, 3- and 6-month post-IMPT (d 50.62, 0.99, and 1.21,
respectively) and reported fewer incapacity-for-work days than inpatients at 6-month post-IMPT (d 50.45). These data suggest
that day hospital IMPT can be as effective as inpatient treatment and might even be more effective for the less afflicted patients.
Further research regarding treatment setting and indication could guide optimized and cost-efficient treatments that are more
closely tailored to the individual patient’s needs.
Keywords: Interdisciplinary multimodal pain treatment, Inpatient treatment, Day patient treatment, Day hospital, Pain intensity,
Pain-related disability, Pain-related self-efficacy, Incapacity for work days, Biopsychosocial model of pain, Chronic back pain,
Treatment setting, Linear mixed model, Propensity score matching
1. Introduction
Back pain is the most frequent noncancer pain,
24,54,56
affecting
at least half of all patients with localized chronic pain.
24
The
psychosocial consequences of chronic back pain are often
severe. Among many detrimental sequelae, affected patients
frequently suffer from family strain and social withdrawal and are
at increased risk of unemployment.
39
Chronic back pain
produces high global healthcare costs, mainly due to indirect
costs.
40
It is 1 of the leading causes of activity limitation, work
absence,
63
and years lived with disability worldwide.
26
Up to 71% of patients with acute back pain show only
incomplete recuperation after 1 year,
27
and approximately 10%
to 15% of patients develop persistent chronic pain.
15,27,40
As
initial bio-anatomical causes play a subsidiary role,
58
interven-
tions for chronic pain are primarily aimed at ameliorating negative
long-term consequences and improving quality of life despite
some degree of pain.
40
Many treatment options for chronic pain have been deemed
ineffective.
29
However, several meta-analyses support interdis-
ciplinary multimodal pain treatment (IMPT) as an effective
treatment for different types of chronic pain,
29
including chronic
back pain.
22,31,48,61
Although IMPT can be delivered in different
treatment settings, eg, in inpatient or day hospital settings, the
impact of treatment setting on treatment outcomes and its
possible interaction with the patient and disease-specific
characteristics remains unclear.
29
Day hospital treatments, where patients receive specialized
treatments during the day but do not stay overnight, could
represent a cost-saving alternative to inpatient IMPT while
providing identical treatment content and duration. While day
hospital treatments have historically been developed for mental
disorders
9
and are still more common in psychiatry, day hospital
Sponsorships or competing interests that may be relevant to content are disclosed
at the end of this article.
a
Department of Neurology, Center for Translational Neuro- and Behavioral
Sciences, University Medicine Essen, Essen, Germany,
b
Department of Medical
Psychology and Medical Sociology, Faculty of Medicine, Ruhr University Bochum,
Bochum, Germany
*Corresponding author. Address: Department of Neurology, Cente r for Translational
Neuro- and Behavioral Sciences, University Medicine Essen, Essen 45147,
Germany. Tel.: 149 176/71201161; fax: 149 201/7237228. E-mail address:
dustin.maser@uk-essen.de (D. Maser).
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text and are provided in the HTML and PDF versions of this article on
the journal’s Web site (www.painjournalonline.com).
Copyright ©2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf
of the International Association for the Study of Pain. This is an open access article
distributed under the terms of the Creative Commons Attribution-Non Commercial-
No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and
share the work provided it is properly cited. The work cannot be changed in any way
or used commercially without permission from the journal.
http://dx.doi.org/10.1097/j.pain.0000000000003318
December 2024·Volume 165 ·Number 12 www.painjournalonline.com 2909
concepts also exist for somatic diseases and pain syn-
dromes.
6,34,62
Although day hospital IMPT has already been
shown to be effective across multiple patient popula-
tions,
23,49,50,55
the treatment setting has often been reported
incidentally. To our knowledge, there is no systematic research
about day hospital indications and benefits beyond general
clinical assumptions. This study is the first to directly compare
differences between inpatient and day hospital treatment for
chronic back pain.
At the University Medicine Essen back pain center, patients
receive the identical treatment program within the same
treatment context, regardless of whether they are admitted as
inpatients or day patients, which presents a unique opportunity to
elucidate the effects of the treatment setting.
The aim of this study was first to evaluate the effectiveness of
IMPT within our sample and second to compare the effect of
setting (inpatient vs day hospital) on treatment outcomes, ie, pain
and disability, in a large representative patient cohort with long-
term follow-up. As self-efficacy is known to be an important
protective factor and essential mediator in different chronic pain
diseases
13,28,30,44,57
and we hypothesized that partial hospital-
ization encourages more active coping and less passivity, we
chose self-efficacy as a secondary outcome. Because indirect
costs comprise the lion’s share of socioeconomic damage,
40
we
also explored the effects on incapacity-for-work days.
2. Methods
2.1. Study design
This retrospective matched cohort study included data from N 5
595 patients diagnosed with chronic back pain at the back pain
center in Essen, Germany, who followed an IMPT between
January 2015 and December 2021. We analyzed data collected
as part of standard treatment monitoring at 5 different time points
(ie, pre-IMPT, post-IMPT, 3-, 6-, and 12-month follow-up). This
study was registered at the German Clinical Trials Register
(DRKS00022951). This article follows the Strengthening the
Reporting of Observational Studies in Epidemiology guidelines,
including the REporting of studies Conducted using Observa-
tional Routinely collected Data statement (RECORD).
59
2.2. Setting (exposure)
Although IMPT protocols often share similar characteristics (eg,
acknowledging the biopsychosocial determinants of pain and an
interlocking of medicine, physical therapy, and psychotherapy),
there are still large international and regional disparities concern-
ing contents, dosage, and treatment modalities.
16,29
While
standardized procedures exist in Germany,
7
large global hetero-
geneity requires a precise treatment protocol description: At the
back pain center Essen, patients are admitted either with
inpatient or day hospital status, depending on their health
insurance’s coverage (in Germany, inpatient treatment is the
standard) and whether other medical conditions, eg, concomitant
somatic diagnoses, require inpatient admission. Patients could
follow the IMPT as day hospital patients, even if their insurance
covered only inpatient treatment, but they had to apply for that in
advance. Regardless of status, treatment duration is mostly
3 weeks and less commonly 2 weeks. In total, patients receive
approximately 30 or 20 hours of treatment, ie, $41 or 27
therapeutic units, with the duration of each unit ranging between
15 minutes and 45 minutes, depending on the type of
intervention. Interventions included pharmaceutical pain
management, health education (eg, biopsychosocial model of
chronic pain,
17
pharmaceutical targets, treatment expectations),
psychotherapeutic counseling, and physical therapy. If needed,
patients also undergo changes in medication, which could entail
withdrawal. Treatment groups normally consist of 8 patients, with
approximately 6 inpatients and 2 day patients per group. Most of
the therapy sessions are conducted with the whole group, while
each patient also receives at least 1 personalized one-on-one
session with a physical therapist, a pain psychologist, and
a medical doctor. Each day, guided relaxation therapy, including
some elements of mindfulness training is scheduled. For both
inpatients and day hospital patients, treatment takes place on
weekdays from 9:00 AM to 4:00 PM. On weekends, patients are
expected to complete psychological homework and integrate the
acquired skills into their daily routine (inpatients remain at the
hospital).
To enroll in an IMPT, all patients have to meet at least 3 of the
following criteria of the German adaptation of the International
Classification of Procedures in Medicine, as defined by the World
Health Organization
7
: (1) manifest or imminent impairment of
quality of life or capacity to work, (2) failure of unimodal, surgical,
or withdrawal treatment, (3) manifest medication dependency or
abuse, (4) pain maintaining psychological disturbance or severe
somatic comorbidity.
7
As recommended by the German national
treatment guidelines for back pain,
1
patients were selected for the
program following an interdisciplinary assessment by a team
consisting of physicians, psychotherapists, and physical thera-
pists. The selection was based on those criteria as well as on the
clinical impression of a patient’s suitability. Patients with severe
medication abuse (eg, mental and behavioral disorders due to
multiple drug use) are generally referred to a specialized
withdrawal treatment at the local department of psychiatry before
enrolling in our IMPT. Milder cases and medication overcon-
sumption are treated as part of the IMPT. Patients were mainly
referred regionally but, in some cases, also nationally.
2.3. Patient cohort
This matched cohort study analyzed data from patients who were
diagnosed with a chronic pain condition (International Statistical
Classification of Diseases and Related Health Problems-10
F45.41
8
) by a board-certified pain specialist and underwent IMPT
either as an inpatient or day patient between January 2015 and
December 2021 at the University Medicine Essen back pain
center, Germany. We included only patients who underwent the
whole treatment for the first time at our center. Cases with
individually tailored IMPT schedules and/or treatment sessions
due to special clinical or social needs were excluded from the
analysis. Other than that, we included all treated patients,
irrespective of specific pain phenotypes or other varying factors
as, eg, different comorbidities. The matching procedure (see
below) was performed to account for covariance that would be
controlled in randomized procedures (eg, patients are matched
on physical and mental health, which should reduce possible bias
introduced by variance in comorbidities). For a detailed flow chart
of inclusions and exclusions, see Figure 1.
All outcomes were collected using the encrypted online
platform PainPool (smart-Q Softwaresysteme GmbH, Bochum,
Germany) as part of routine clinical care at 5 specified time points:
at pre- and post-IMPT as well as at 3-, 6-, and 12-month follow-
up assessments (for details see Table S1 in the supplementary
material, http://links.lww.com/PAIN/C82). Responses outside
the allocated timeframe measurement windows were excluded
from further analysis. If patients could not use tablets, had no
2910 D. Maser et al.·165 (2024) 2909–2919 PAIN
®
e-mail address, or did not fill in the admission questionnaire on
time, they were given paper versions.
2.4. Matching
As patient allocation to either the inpatient or day hospital group
was neither randomized nor balanced, we used propensity score
matching (logistic greedy matching with a ratio of 1:2) to reduce
the risk of a priori group differences (for a detailed description of
the matching procedure see the supplementary material, http://
links.lww.com/PAIN/C82). We first performed a covariate bal-
ance analysis to test for differences between the 2 treatment
setting groups at admission with a cut-off of 0.1 in absolute
standardized mean difference to detect imbalance
65
(see
supplementary Fig. S1, http://links.lww.com/PAIN/C82). Ac-
cordingly, we matched the samples based on self-reported sex
or gender, age, scheduled treatment duration (2 vs 3 weeks), and
the pre-IMPT measurements of pain intensity, pain-related
disability, incapacity-for-work days measured by the Question-
naire for Grading the Severity of Chronic Pain by von Korff et al.,
60
the affective component of pain measured with the German Pain
Description List,
33
depression, anxiety, and stress assessed with
the Depression Anxiety Stress Scale,
38,46
physical and mental
health measured with the Veterans RAND 12-Item Health
Survey,
32
pain-related self-efficacy measured by the German
version of the Pain Self-Efficacy Questionnaire (PSEQ),
41
and
acceptance of pain (divided into activity endurance and pain
willingness), assessed with the Chronic Pain Acceptance
Questionnaire.
47
The matched sample consists of 176 inpatients
and all 88 day patients at baseline (see Fig. 1 and supplement for
details, http://links.lww.com/PAIN/C82).
2.5. Outcomes
As co-primary outcomes, the change in pain intensity and
pain-related disability were assessed at 3-, 6-, and 12-month
post-IMPT using the respective subscales (ie, pain and
disability) of the Questionnaire for Grading the Severity of
Chronic Pain by von Korff et al.
60
Pain was assessed by
calculating the means of current, mean, and maximal pain
intensity over the last 4 weeks. Disability was assessed by
calculating the mean of subjective impairment concerning
daily, leisure/social, and work-related activities in the previous
3 months. A secondary outcome was the change in pain-
related self-efficacy after IMPT, as measured by the German
version of the Pain Self-Efficacy Questionnaire.
41
Analogously
to pain and disability, we explored the course of pain-related
self-efficacy at 3-, 6-, and 12-months post-IMPT.
Figure 1. Flowchart of patient cohort and subgroup selection. IMPT, interdisciplinary multimodal pain treatment.
December 2024·Volume 165 ·Number 12 www.painjournalonline.com 2911
Moreover, we exploratorily assessed the association of
treatment setting and incapacity-for-work days, which were
operationlized by the disability days of the Questionnaire for
Grading the Severity of Chronic Pain by von Korff et al.
60
, ie, the
number of days during the past 3 months on which the patient
was unable to carry out their usual activities (eg. work, school,
housework), 3 and 6 months post-IMPT.
2.6. Statistics
First, to analyze the overall treatment effect, we used linear mixed
model regression to examine the development over time of our
predefined outcomes (ie, pain intensity, pain-related disability,
pain-related self-efficacy) in the full cohort. We used 3 separate
linear mixed model analyses for pain intensity, pain-related
disability, and pain-related self-efficacy, respectively. The design
included the following factors: treatment group (n 5114),
subjects (n 5595), and time point (n 55). For the multilevel
diagram, see Table S2 in the supplementary material (http://links.
lww.com/PAIN/C82). We compared different models and chose
the best-fitting error structures (for Akaike information criterions
and P-values, see Table S3 in the supplemental material, http://
links.lww.com/PAIN/C82). We discarded age and sex as
covariates of no interest because their inclusion did not improve
the model fit. We conducted all analyses with RStudio (Version
2023.06.11524)
52
using R (Version 4.3.1.).
51
For model fitting,
we used the lme4 package.
5
Degrees of freedom were estimated
using the Satterthwaite method. Post hoc tests and effect sizes
were calculated with the emmeans package.
36
Second, to analyze the association between treatment setting
and outcomes, we performed linear mixed model analyses in
a matched cohort for each outcome (see above and supplemen-
tary Tables S5 and S6, http://links.lww.com/PAIN/C82). Again,
age and sex did not improve model fit and could thus be
discarded. As the treatment setting groups seemed to diverge
mainly between time points T1 and T3 (see supplementary Figs.
S2–S4, http://links.lww.com/PAIN/C82) and propensity match-
ing produced a homogeneous baseline (see Fig. S1 in the
supplement, http://links.lww.com/PAIN/C82), we included only
the 3 divergent time points in these models. Thus, the design had
the following levels: treatment setting (n 52), treatment group
(n 598), subjects (n 5264), and time point (n 53; T1-T3).
Degrees of freedom were again estimated using the Satterthwaite
method.
A Mann–Whitney Utest was used for the exploratory analysis
of incapacity-for-work days due to the nonnormal distribution of
the outcome measure.
3. Results
3.1. Patient sample
Between January 2015 and December 2021, 595 patients were
admitted to the back pain center in Essen, completed the IMPT,
and filled in at least 1 questionnaire. Of these, 83 (14.0%), 209
(35.1%), 351 (59.0%), 479 (80.5%), and 116 (19.5%) filled in the
questionaries at 5, 4, 3, 2, and 1 time points, respectively. The
patients were distributed over 114 treatment cohorts, starting
successively in different calendar weeks over 6 years.
For the overall sample, patients’ age ranged between 19 and
84 years (mean: 53.64 614.32), with 56.8% being women. The
majority of patients (82.4%) were treated as inpatients. Treatment
duration was usually 3 weeks (72.8%), with 1 outlier treatment of
Table 1
Descriptive statistics of the sample at T0 as a function of group (inpatients vs matched inpatients vs day hospital patients).
Inpatients (n 5391) Matched inpatients (n 5176) Day hospital patients (n 588)
Sex female/male (n [%]) 242/149 (61.89/38.11) 62/114 (35.23/64.77) 27/61 (30.68/69.32)
Age (Median [IQR]) 55 (44.25-65) 52 (40-61) 50 (42.75-60)
Degree of chronification (von Korff)
1 (n [%]) 21 (5.37) 14 (7.95) 6 (6.82)
2 (n [%]) 50 (12.79) 27 (15.34) 14 (15.91)
3 (n [%]) 81 (20.72) 36 (20.45) 24 (27.27)
4 (n [%]) 239 (61.13) 99 (56.25) 44 (50.00)
Treatment duration
2-week (n [%]) 105 (26.85) 42 (23.86) 18 (20.45)
3-week (n [%]) 284 (72.63) 134 (76.14) 70 (79.55)
Other (n [%]) 2 (0.51) 0 (0.00) 0 (0.00)
Incapacity for work days* (Median [IQR]) 30 (6-85) 29 (5-90) 20 (1-90)
Pain intensity (von Korff) (M 6SD [min-max]) 68.84 615.74 (20-100) 65.27 615.53 (20-100) 63.79 616.13 (20-100)
Disability (von Korff) (M 6SD [min-max]) 67.49 621.99 (0-100) 62.08 622.19 (0-100) 61.82 620.03 (0-100)
Depression (M 6SD [min-max]) 8.19 65.56 (0-21) 7.57 65.04 (0-21) 7.19 65.23 (0-21)
Anxiety (M 6SD [min-max]) 5.17 64.64 (0-21) 4.53 64.05 (0-17) 4.35 64.11 (0-19)
Stress (M 6SD [min-max]) 9.1 64.98 (0-21) 9.14 65.13 (0-21) 8.81 64.66 (0-20)
Wellbeing (FW-7) (M 6SD [min-max]) 13.15 68.61 (0-35) 14.86 68.42 (0-35) 14.24 67.8 (0-30)
Quality of life (VR12)
Physical health (M 6SD [min-max]) 28.24 68.78 (6.78-53.03) 31.4 68.86 (13.84-53.03) 31.84 68.39 (14.71-63.92)
Mental health (M 6SD [min-max]) 38.38 613.17 (10.22-72.41) 39.22 612.59 (10.22-72.41) 39.47 613.15 (13.32-67.59)
Self-efficacy (FESS) (M 6SD [min-max]) 29.98 611.49 (10-59) 33.59 611.02 (11-58) 34.44 611.08 (12-58)
Activity endurance (CPAQ) (M 6SD [min-max]) 28.48 612.14 (0-66) 32.32 611.64 (0-66) 33.12 611.76 (7-62)
Pain willingness (CPAQ) (M 6SD [min-max]) 21.25 69.63 (0-51) 20.93 68.92 (0-45) 21.88 69.57 (3-44)
2912 D. Maser et al.·165 (2024) 2909–2919 PAIN
®
9 days (0.5%). The remaining treatments lasted for 2 weeks. For
a detailed overview of the patient sample divided by treatment
setting, see Table 1.
3.2. Effect of treatment on primary and secondary outcome
In the first step, before investigating the main research question
concerning the effect of the treatment setting, we tested whether
the treatment had an effect on the primary and secondary
outcomes (see Table 2 for details). There were significant main
effects of time point on pain, F(4, 1252.2) 589.80, P,0.001;
disability, F(4, 1245.7) 5130.1, P,0.001; and on the secondary
outcome pain-related self-efficacy, F(4, 1200.1) 552.34, P,
0.001. Post hoc contrasts indicated significant decreases in pain
between admission and all other time points (ΔM
T0-T1
512.42,
ΔM
T0-T2
516.89, ΔM
T0-T3
515.60, ΔM
T0-T4
515.49, see Table
S4 in the supplement for details, http://links.lww.com/PAIN/
C82). As measured by Cohen’s d,effect sizes indicate large
effects (mean d 51.07, see Table S4 in the supplement for
details, http://links.lww.com/PAIN/C82).
12
In addition, there was
a further decrease in pain between the end of IMPT and 3 months
later (ΔM
T1-T2
54.47), with a small effect size (d 50.26).
12
In
addition, disability decreased significantly between admission
and all other time points (ΔM
T0-T1
59.88, ΔM
T0-T2
524.07,
Table 2
Post hoc t-tests and Cohen’s d showing overall treatment effects.
Estimate SE df t-ratio P* Cohen’s d CI
Pain
T0
vs. T1 12.54 0.91 1217 13.83 ,0.001† 0.930.80 to 1.07
vs. T2 16.12 1.04 1245 15.44 ,0.001† 1.201.04 to 1.35
vs. T3 14.94 1.12 1255 13.30 ,0.001† 1.110.94 to 1.27
vs. T4 14.11 1.21 1253 11.64 ,0.001† 1.050.87 to 1.23
T1
vs. T2 3.58 1.06 1229 3.38 0.005* 0.26‡ 0.11 to 0.42
vs. T3 2.40 1.14 1239 2.11 0.18
vs. T4 1.57 1.23 1242 1.28 0.61
T2
vs. T3 21.19 1.22 1212 20.97 0.66
vs. T4 22.02 1.31 1224 21.54 0.49
T3
vs. T4 20.83 1.36 1210 20.61 0.66
Disability
T0
vs. T1 9.93 1.11 1222 8.93 ,0.001† 0.60§ 0.47 to 0.74
vs. T2 23.58 1.27 1244 18.51 ,0.001† 1.431.28 to 1.58
vs. T3 22.51 1.37 1250 16.47 ,0.001† 1.371.20 to 1.53
vs. T4 23.11 1.48 1248 15.61 ,0.001† 1.401.23 to 1.58
T1
vs. T2 13.65 1.29 1229 10.55 ,0.001† 0.830.67 to 0.98
vs. T3 12.57 1.38 1237 9.09 ,0.001† 0.76§ 0.60 to 0.93
vs. T4 13.18 1.50 1238 8.81 ,0.001† 0.800.62 to 0.98
T2
vs. T3 21.07 1.48 1213 20.72 1.00
vs. T4 20.47 1.60 1222 20.29 1.00
T3
vs. T4 0.60 1.65 1213 20.37 1.00
Pain-related self-efficacy
T0
vs. T1 6.01 0.52 1189 11.66 ,0.001† 0.79§ 0.66 to 0.93
vs. T2 7.32 0.60 1206 12.20 ,0.001† 0.970.81 to 1.12
vs. T3 5.02 0.63 1210 7.92 ,0.001† 0.66§ 0.49 to 0.83
vs. T4 5.58 0.69 1208 8.16 ,0.001† 0.74§ 0.56 to 0.92
T1
vs. T2 1.31 0.61 1198 2.15 0.13
vs. T3 20.99 0.64 1200 21.54 0.37
vs. T4 20.43 0.69 1200 20.61 0.91
T2
vs. T3 22.30 0.69 1174 22.33 0.005* 20.30‡ 20.12 to (20.48)
vs. T4 22.73 0.74 1183 21.34 0.10
T3
. T4 0.57 0.76 1174 0.74 0.91
P
-values were adjusted according to the Bonferroni–Holm correction for 10 comparisons for each outcome.
* Significant at
P
,0.01.
Significant at
P
,0.001.
Small effect size.
§ Moderate effect size.
Large effect size.
December 2024·Volume 165 ·Number 12 www.painjournalonline.com 2913
ΔM
T0-T3
523.78, ΔM
T0-T4
525.28), with moderate-to-large
effect sizes (mean d 51.20).
12
They decreased further between
the end of IMPT and all later time points (ΔM
T1-T2
515.41,
ΔM
T1-T3
514.12, ΔM
T1-T4
514.01), with moderate-to-large
effect sizes (mean d 50.80).
12
In addition, we found moderate-
to-large effect sizes for the change in pain-related self-efficacy
between admission and all other time points (ΔM
T1-T0
55.95,
ΔM
T2-T0
57.51, ΔM
T3-T0
56.23, ΔM
T4-T0
57.37, mean d 5
0.79
12
). There was a small decrease in self-efficacy between
3 and 6 months after treatment (ΔM
T2-T3
51.28). Changes in
outcome measures over time are shown in Figures 2–4.
3.3. Impact of treatment setting on treatment effects
For pain intensity, there was a significant interaction between time
point and treatment setting, F(2, 254.3) 54.50, P50.012, with
post hoc contrasts revealing significantly less pain for day patients
6 months after IMPT than for inpatients (ΔM513.20, P50.03,
d50.79; Fig. 5).
For disability, there was again an interaction between the time
point and treatment setting F(2, 263.6) 55.11, P50.007, with
post hoc contrasts showing significantly less disability for day
patients than for inpatients 3 months after IMPT (ΔM514.39, P5
0.022, d 50.74; Fig. 6).
For self-efficacy, there was a significant main effect of
treatment setting, F(1, 230.5) 513.77, P,0.001, with greater
self-efficacy among day hospital patients. Post hoc contrasts
revealed that day patients had significantly greater pain-related
self-efficacy directly after the IMPT (ΔM53.66, P50.03, d 5
0.62), which they retained at 3 (ΔM58.32, P50.003, d 50.99)
and 6 months after treatment (ΔM59.29, P,0.001, d 51.21;
Fig. 7).
The results of the post hoc contrasts are listed in Table 3. Since
the dropout rate was relatively large, we also calculated the
Figure 2. Overall treatment effect on pain intensity independent of treatment setting, showing mean, SDs, and raw data scatter of the total cohort per time point.
*Significant at P,0.05, **significant at P,0.001,
a
d50.26,
c
d$0.93.
Figure 3. Overall treatment effect on pain-related disability independent of treatment setting showing mean, SDs, and raw data scatter of the total cohort per time
point. *Significance at P,0.001,
b
d$0.6,
c
d$0.8.
2914 D. Maser et al.·165 (2024) 2909–2919 PAIN
®
effects using a CopyMean imputation method for missing
values.
18,19
However, this did not change the results substantially
(for details, see the supplement Table S9 and Figs. S5-S7, http://
links.lww.com/PAIN/C82).
3.4. Exploratory analysis—effects on incapacity for work
Mann–Whitney 2 sample-rank-sum tests revealed significantly
fewer incapacity-for-work days for day patients (Median 50,
range: 0-2.5) than for inpatients (Median 57, range: 0-49) at
6 months after treatment, U(N
1
577, N
2
531) 51615; z5
3.046; P50.002; r50.29, which corresponds to an effect size of
d50.45. This difference remained significant even when
excluding patients above working age (ie, .65 years) from the
analysis, U(N
1
563, N
2
526) 51106.5; z52.75; P50.006;
r50.29. For a detailed overview of the exploratory analysis, see
Tables S7 and S8 in the supplement (http://links.lww.com/
PAIN/C82).
4. Discussion
This study investigated the effect of treatment setting (inpatient vs
day hospital) on treatment outcomes in a cohort of patients with
chronic back pain undergoing an otherwise identical IMPT at
a specialized German pain clinic. Interdisciplinary multimodal pain
treatment constituted a successful treatment, as reflected by
improvements in pain and disability, which were sustained in the
retained sample for up to 12 months. These average decreases in
pain and disability are likely to be perceived as notable and
meaningful improvements by many patients.
53
These changes
Figure 4. Overall treatment effect on pain-related self-efficacy independent of treatment setting showing mean, SDs, and raw data scatter of the total cohort per
time point. *Significance at P,0.01, **significance at P,0.001,
a
d520.3,
b
d$0.66,
c
d50.97.
Figure 5. Differences in pain intensity between day patients (blue) and matched inpatients (red) showing mean, SDs, and raw data scatter. *Significance at P,
0.05,
b
d50.79.
December 2024·Volume 165 ·Number 12 www.painjournalonline.com 2915
were even more pronounced for day patients. This corroborates
the results of a Cochrane meta-analysis of 2014
31
regarding the
efficacy of IMPT for patients suffering from chronic low back pain.
Furthermore, the results of our direct comparison of treatment
settings support that day hospital treatment could be more
effective than inpatient treatment for some patients. Compared
with a group of inpatients that was effectively matched on
sociodemographic variables (eg, sex, age) and various clinical
baseline measures (eg, pain, disability, depression), day patients
showed greater treatment benefits 3 and 6 months after
treatment. This benefit could be partly driven by stronger
increases in pain-related self-efficacy among the day hospital
patients, which were already observable immediately after IMPT.
In both settings, the increase in self-efficacy also qualified as
a minimal important change (ie, a change score .5.5),
11
suggesting a clinically relevant impact. An exploratory analysis
revealed less incapacity-for-work days, which implies lower
socioeconomic costs produced later by day patients.
Concerning the ratio of cost and effect of IMPT, 2 critical
questions are currently debated: (1) What are the minimal content
and dosage that are necessary to obtain positive treatment
effects? and (2) How do content and dosage interact with
interpersonal differences of chronic back pain patients?,
29,40
or in
simpler terms: What works for whom? Our results suggest that
the less cost-intensive day hospital treatment may not only be
sufficient for some patients but may even be the better treatment
option. At our facility, inpatient IMPT with $14 treatment days
costs 6418.62 ($7044.84), while 2 weeks, ie, 10 treatment days,
of day hospital cost 3060 ($3322.52), reflecting a reduction of
52.33% for day hospital treatments.
Figure 6. Differences in pain-related disability between day patients (blue) and mat ched inpatients (red) showing mean, SDs, and raw data scatter. *Significance at
P,0.01,
b
d50.74.
Figure 7. Differences in pain-related self-efficacy between day patients (blue) and matched inpatients (red) showing mean, SDs, and raw data scatter.
*Significance at P,0.05, **significance at P,0.01, ***significance at P,0.001,
b
d50.62,
c
d$0.99.
2916 D. Maser et al.·165 (2024) 2909–2919 PAIN
®
Another advantage seems to be fewer incapacity-for-work
days 6 months after treatment, suggesting that day hospital
treatment may be protective against absenteeism from work.
Although we cannot fully rule out that inpatients exhibited a higher
risk profile, this is an important finding, since the large
socioeconomic burden of back pain is mainly caused by indirect
costs.
40
While day hospital treatments have traditionally been more
common for mental disorders,
10
they also exist for somatic
diseases and pain syndromes.
6,34,62
Although IMPTs in a day
hospital setting have also been shown to be effective,
49,55
the
treatment setting has often been reported incidentally, and its
effect has not been investigated systematically. To our knowl-
edge, this study is the first to directly compare differences
between inpatient and day hospital treatment for chronic
back pain.
We found that day hospital treatment was at least as effective
as inpatient treatment, albeit at a lower cost. This is in line with
studies comparing treatment settings for active rheumatic
arthritis
35
and medication withdrawal treatment for patients with
migraine.
21
A study with psychiatric patients reported similar
clinical and social outcomes 12 months after treatment,
14
but
inpatients improved significantly faster, and the burden on
relatives was lower.
Furthermore, our data suggest that day patients even
benefited more from treatment when compared with a matched
group of inpatients, with advantages emerging at the later follow-
up assessment points. While pain and disability as primary
outcome measures were comparable between groups directly
after the IMPT, their levels of self-efficacy already diverged at the
end of the IMPT. This could indicate that day hospital treatment
fostered greater self-efficacy, facilitating later treatment benefits
that surpassed the inpatients’ improvements in disability, pain,
and incapacity for work days. This is in line with the notion that
self-efficacy is a predictor for experiences of functional impair-
ment, distress, and pain among patients with chronic pain.
28
It is
also a protective resource and a resiliency factor for people with
chronic pain
57
and acts as an essential mediator in different
chronic pain diseases.
13,30,44
It thus seems to be a malleable
psychological factor that can be modulated and enhanced by
treatment interventions.
37
But why should day hospital treatment foster greater self-
efficacy? Bandura
3
defines self-efficacy as the belief in one’s
capacity to perform certain behaviors within a particular environ-
ment to reach specific goals. Thus, pain-related self-efficacy
relates to beliefs about one’s ability to control the pain and its
negative emotions and maintain everyday life despite the pain.
43
The most influential technique for enhancing self-efficacy is
enactive self-mastery,
2,20
which is achieved when patients
experience success by performing tasks autonomously. Al-
though self-mastery is fostered by positive achievements and
dampened by repeated disappointments, too-easy successes
may lead to the expectation of quick results and easy
discouragement by setbacks and failures. Therefore, it is crucial
to find the right balance between task difficulty and an individual’s
capabilities.
4
Interdisciplinary multimodal pain treatment in a day
hospital setting might provide a better balance between (a more
challenging) task difficulty and patients’ capabilities, while
characteristics of the domestic context, such as better sleep
quality or family contacts, might also be relevant.
The biopsychosocial model of pain
17
implicates that factors
within the psychosocial environment can interact with pain
processing and coping. This interaction can be proximal, eg,
the contribution of fear to hyperalgesia,
42
or distal, eg, the
contribution of dysfunctional pain-coping behavior to pain
chronification.
25
To implement behavioral change (eg, to continue
a training routine or implement relaxation and recovery intervals),
patients may need to restructure their psychosocial context and
address some of their illness determinants in their home
environment. Coping strategies learned during day hospital
treatment can be directly transferred and tried out at home, and
challenges encountered in this process can be addressed during
the IMPT treatment effort to help with adaptation. This would lead
to more self-mastery and, in turn, more self-efficacy. By contrast,
the relatively sheltered environment of the hospital may prevent
some inpatients from adapting to the same extent. They might
have fewer enactive self-mastery experiences or fewer chances
to learn how to handle setbacks during the transfer of skills into
their everyday lives after treatment. Furthermore, the inpatient
treatment setting may foster a passive patient role with the patient
receiving support rather than actively participating and in fact
working toward their personal treatment goals. This interpretation
Table 3
Post hoc contrasts between inpatients and day hospital patients.
Estimate SE df t-ratio PCohen’s dCI
After IMPT
Pain 0.17 3.10 335 0.05 0.96
Disability 1.11 3.86 340 0.29 0.77
Self-efficacy 4.11 1.83 304 2.25 0.03* 0.62§ 0.08-1.16
Three months after IMPT
Pain 7.75 3.62 404 2.14 0.06
Disability 12.16 4.51 410 2.70 0.022* 0.74§ 0.20-1.27
Self-efficacy 6.59 2.08 385 3.18 0.003† 0.990.38-1.60
Six months after IMPT
Pain 10.33 3.62 420 2.64 0.03* 0.79§ 0.20-1.38
Disability 9.72 4.82 424 2.02 0.089
Self-efficacy 8.03 2.18 406 3.68 ,.001‡ 1.210.56-1.85
P
-values were adjusted according to the Bonferroni–Holm correction for 3 comparisons.
* Significant at
P
,0.05.
†Significant at
P
,0.01.
Significant at
P
,0.001.
§Moderate effect size.
Large effect size.
IMPT, interdisciplinary multimodal pain treatment.
December 2024·Volume 165 ·Number 12 www.painjournalonline.com 2917
aligns with a study of psychosomatic patients,
64
which found that
if there are illness determinants in the home environment,
motivated patients benefit more from day hospital treatment.
64
Moreover, illness determinants at home and secondary disease
gains were identified as contraindications for inpatient treatment.
Therefore, training in the home environment, as well as daily
exposure to illness-sustaining determinants, might be helpful and
even necessary for achieving and maintaining treatment success
for some patients.
45,64
The large dropout rate might have introduced a bias to our
sample, eg, patients might have dropped out either because they
did not benefit from the treatment or because they saw no further
need to participate. This is a common limitation of observational/
longitudinal studies. Yet, replacing missing values using a cross-
sectional and longitudinal imputation method (CopyMean
18,19
)
yielded similar results (for details see supplementary material,
http://links.lww.com/PAIN/C82). Since patients were not ran-
domly assigned to the treatment settings, we cannot rule out that
there remained systematic pretreatment differences despite our
carefully executed matching procedure. Although we could
compare the effect of the treatment setting irrespective of any
noticeable baseline differences, the matching approach gener-
ated a particular subset of inpatients. The observed effects could
thus be a function of the unique characteristics of our matched
patient groups. Nevertheless, there will always be patients for
whom there is no viable alternative to inpatient treatment, eg,
because of comorbidities or simply because the hospital is too far
away from home. However, there is currently no systematic
research that could guide these clinical decisions in the context of
IMPT treatment setting indications. Further research is needed to
identify which patient characteristics should be considered when
determining the ideal treatment setting.
In conclusion, our data provide novel insights by suggesting at
least equal effectiveness of day hospitals compared with inpatient
treatment for patients with chronic back pain. Within the matched
sample, the day hospital treatment was even partly superior, with
greater improvements in pain, disability, and self-efficacy.
Moreover, it was associated with fewer incapacity-for-work days,
which implies lower indirect disease costs. These findings have
important implications for healthcare systems and clinical
decision-making and should seek further confirmation using
larger-scale randomized trials. Future studies should aim to
provide more insights into individual response trajectories and
their interaction with patient characteristics and potential
mediators such as self-efficacy. Eventually, these insights can
be therapeutically leveraged to tailor personalized clinical
decisions and balance them with economic considerations.
Conflict of interest statement
The authors have no conflicts of interest to declare.
Acknowledgments
The authors would like to thank all team members of the Bingel
Laboratory for the valuable discussion of their findings and Dirk
Neumann for his support with data collection. This study is part of
a larger retrospective and prospective study on the interindividual
differences and psychological predictors of the interdisciplinary
multimodal pain therapy at the University Hospital Essen (ethics
vote: 18-8251-BO), which was registered in the German Clinical
Trials Register (ID: DRKS00022951). Compared with the original
registration, the statistical analysis plan was improved before the
first data analysis, eg, by implementing matching.
The work is funded by the Deutsche Forschungsgemeinschaft
(DFG, German Research Foundation)—Project-ID
422744262—TRR 289 (Gef ¨ordert durch die Deutsche Forschungs-
gemeinschaft (DFG)—Projektnummer 422744262—TRR 289).
The anonymized data will be shared upon request.
Supplemental digital content
Supplemental digital content associated with this article can be
found online at http://links.lww.com/PAIN/C82.
Article history:
Received 15 February 2024
Received in revised form 20 May 2024
Accepted 21 May 2024
Available online 19 July 2024
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