Qualitative analysis of long-term chronic pain program management outcomes: Veterans and civilians
Publication: Journal of Military, Veteran and Family Health
Volume 8, Number 2
LAY SUMMARY
LAY SUMMARY
This study sought to determine how much patients with chronic pain could be helped to function better long after completing a four-week interdisciplinary pain management program. Comments from 16 Veterans and 23 civilians four months to four years after the end of the program showed 10 common themes: 1) gratefulness for their treatment in the program, 2) improved ability to function, 3) better coping strategies and confidence, 4) empowered to overcome daily challenges, 5) on a path to rehabilitation and recovery, 6) the need for support groups, 7) still had struggles, 8) the need for additional follow-up to maintain gains, 9) wishing they had attended the program sooner, and 10) would recommend the program to others. Veterans’ comments were no different from those of civilians. Results emphasize that Veterans and civilians share a common experience and maintain their benefits from interdisciplinary care in managing chronic pain. On the basis of these findings, clinicians have opportunities to improve quality and apply new services to the program.
Abstract
Introduction : This study evaluated the long-term (four months to four years) effectiveness of a four-week interdisciplinary chronic pain management program through qualitative analysis while also identifying differences between Veterans and civilians. Methods : This study used a mixed-methods approach. The quantitative data for this study are descriptive statistics for patient demographics and satisfaction measures. Qualitative data were collected through participants’ comments on two satisfaction measures, the Pain Program Satisfaction Questionnaire and the Self-Evaluation Scale. Of the 197 participants who completed the program, 67 returned follow-up measures, 39 of whom provided written comments. The 39 commenters consisted of 16 Veterans and 23 civilians. Comments were independently organized into themes by four researchers using an inductive approach. Results : Ten main themes emerged: 1) gratefulness for treatment and program, 2) improvement in ability, 3) new sense of resiliency, ability to cope, and new confidence, 4) empowered over recovery, 5) on the path to rehabilitation and recovery — a process and journey, 6) need for support groups, 7) some patients are doing well, but some still struggle, 8) patients need continued follow-up to ensure they are on track and do not regress, 9) timeliness of program — needed earlier in course of chronic pain, 10) program merits recommendation. Veterans and civilians had all themes in common. Discussion : Results emphasize the commonality of experience and sustained benefits of interdisciplinary care for managing chronic pain among both Veterans and civilians and provide opportunities for clinicians to improve quality and apply new services to the program.
Résumé
Introduction : La présente étude évalue l’efficacité à long terme (de quatre mois à quatre ans) d’un programme de gestion interdisciplinaire de la douleur chronique de quatre semaines en utilisant une analyse qualitative, tout en cernant les différences entre les vétérans et les civils. Méthodologie : L’étude utilise une approche par méthodes mixtes. Les données quantitatives utilisées pour la présente étude sont des statistiques descriptives de données démographiques des patients et de mesures de satisfaction. Les données qualitatives ont été recueillies en obtenant les commentaires de participants dans deux cadres de mesures de la satisfaction, le Pain Program Satisfaction Questionnaire (questionnaire sur la satisfaction à l’égard du programme de gestion de la douleur) et la Self-Evaluation Scale (échelle d’autoévaluation). Parmi les 197 participants qui ont terminé le programme, 67 nous ont fait parvenir un suivi, dont 39 ont donné des commentaires écrits. Des 39 commentateurs, 16 étaient des vétérans et 23 des civils. Les commentaires ont été ventilés de façon indépendante par thème par quatre chercheurs, à l’aide d’une approche inductive. Résultats : On a noté dix principaux thèmes : 1) gratitude à l’égard du traitement et du programme, 2) amélioration des capacités, 3) nouveau sens de la résilience, capacité à composé avec les problèmes de la vie quotidienne et une confiance en soi améliorée, 4) responsabilisation quant au rétablissement, 5) cheminements vers la réadaptation et le rétablissement – un processus et un parcours, 6) besoin de groupes d’appui, 7) certains patients vont bien, mais d’autres ont encore des difficultés, 8) les patients ont besoin de suivis continus pour faire en sorte qu’ils continuent à progresser sans régresser, 9) le moment du programme – requis plus tôt pour la douleur chronique, 10) programme mérite d’être recommandé. Tous les thèmes étaient communs aux vétérans et aux civils. Discussion : Les résultats mettent l’accent sur la similitude de l’expérience et les avantages soutenus de soins interdisciplinaires pour la gestion de la douleur chronique chez les vétérans et les civils et donnent l’occasion aux cliniciens d’améliorer le programme et d’y ajouter de nouveaux services.
INTRODUCTION
Patient experience, “the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care,”1(p.8) is asso ciated with clinical effectiveness when evaluating health care quality.2 Qualitative analysis answers the what, why, or how versus the how many or how much of quantitative methods.3 A major method of qualitative analysis — thematic analysis — involves coding and extracting themes from comments.4 Approaches to thematic analysis are deductive and inductive. The former involves identifying whether comments fit in predefined domains, whereas the latter involves identifying patterns within the comments.4
Studies identified the benefit of interdisciplinary programs through qualitative analysis methods for patients with chronic pain in general and Veterans in particular.5–9 Hapidou and Horst conducted an inductive thematic analysis of 50 patient comments collected from two measures at discharge from a four-week interdisciplinary program:5 Self-Evaluation Scale (SES) and Pain Program Satisfaction Questionnaire (PPSQ).10,11 Six themes emerged: impact of a strong interdisciplinary team, learning to adapt to manage pain, the program as a stepping stone, positive effects of a group effort, improved mental health, and benefits of the program.5
Themes showed the overall success of the program in helping patients manage chronic pain, changing their perception of pain, and allowing them to apply tools learned in the program to everyday life.5 Egan and colleagues also identified six themes several years after participation in a cognitive-behavioural program: universal long-term positive feedback on the usefulness of the program, the program facilitated long-term changes in daily life, participants emerged as new persons after completing the program, requests for more updated information on emerging treatments or pain knowledge, learning the importance of listening and accepting new information, and the importance of sharing their pain experiences.6
Holmner and colleagues interviewed participants in a multimodal pain program and identified four themes: patients’ perceptions of the program influenced their benefits, the group setting created a sense of togetherness, the program provided more knowledge about pain, and accepting pain is an ongoing process.7
A qualitative analysis study examined Veterans’ experiences with an integrated pain care model in a primary care centre.8 Patients found the model efficient and beneficial and liked seeing all clinicians in a single appointment, addressing their concerns cohesively as a team.8 Some Veterans felt goals were reflected in care planning, noting that the team listened, addressed concerns, and made them feel like human beings.8 Changes in treatment plans were clear and had a positive impact on pain and quality of life. Adding non-pharmacological treatments, such as stress reduction, mindfulness, and activity pacing was helpful.8 Finally, a qualitative analysis of Veterans’ experiences in the Empower Veterans Program of the VA Atlanta Healthcare System further demonstrated the effectiveness of interdisciplinary programs.9 Divided into focus groups, patients answered open-ended questions evaluating their experiences.9 Themes identified were new or adjusted daily practices, coping skills, accepting, adjusting, and setting boundaries, feeling empowered, participating in life, adjusted medication use, and being stuck.9
This study was part of a larger project investigating maintenance of outcomes after discharge from the four-week interdisciplinary chronic pain management program at the Michael G. DeGroote Pain Clinic in Hamilton, Ontario, Canada. The cognitive-behaviourally based group program is conducted from 9:30 a.m. to 3:30 p.m., Monday to Friday. The interdisciplinary team consists of a physician, pharmacist, dietician, social worker, occupational therapists, physiotherapist, psychologists, psychometrist-psychotherapist, and Tai Chi and yoga instructors. Patients may also attend a wood workshop once a week outside of the hospital as part of functional activity.
The focus of this study was qualitative analysis of comments provided by participants clarifying evaluations of goal accomplishment via the SES and program satisfaction via the PPSQ. Mixed methods were used, with minor emphasis on quantitative analysis to describe participant demographics, the SES, and the PPSQ and greater emphasis on qualitative analysis of participant comments about the program. Qualitative analysis was conducted by four different assessors to provide a broad approach to extracting themes from comments.
METHODS
Eligible participants completed the interdisciplinary program Jul. 1, 2015, to Aug. 31, 2019, were aged 18 years or older, completed outcome measures at admission and discharge, and had a telephone or email address on file. Follow-up points varied from four months to four years.
Potential participants were emailed a letter introducing the study. If they agreed to participate, they used a unique link provided in the email that took them to the survey on REDCap (Vanderbilt University, Nashville, TN). Participants reviewed an information sheet, provided consent, and completed the survey, which took about 30 minutes. Those who did not respond, or who did not have email, were mailed the study information along with a consent form, survey, and stamped return envelope. Participants were also given the option to contact the research team to complete the survey by telephone. A CAD$10 gift card was offered to survey completers. The study received ethical approval from the Hamilton Integrated Research Ethics Board on Nov. 26, 2019 (clearance no. 7845).
Quantitative data included demographics such as age, gender, marital and employment status, and SES and PPSQ scores. Descriptive statistics, t-tests and chi-squares were obtained with IBM SPSS Statistics version 27 (IBM Corporation, Armonk, NY). Further analysis of outcome measures is reported in detail elsewhere.12 Qualitative data were collected through patient comments on the SES and PPSQ as described next.
Self-evaluation scale
On the SES, patients rated goal accomplishment in the four-week program on a 5-point Likert scale ranging from 1 (poorly) to 5 (excellent).10–11,13 The SES also contains an open-ended section for comments to allow patients to illustrate ratings. Modified SES wording reflected the nature of the follow-up study in that participants were asked to rate goal accomplishment since being discharged from the program.
Pain program satisfaction questionnaire
The PPSQ has 11 questions rated on a 4-point Likert scale ranging from 1 (not at all satisfied) to 4 (extremely satisfied) and 2 open-ended questions (for comments) to assess patient satisfaction.11,13,14 The PPSQ is a valid and reliable measure.11,14 Comments were organized into themes by three researchers (CH, VBD, JA), one of whom is an expert in qualitative analysis (VBD), and reviewed by a fourth researcher (EGH). Only one researcher (EGH) is a clinician and has treated some participants. Data were anonymized, and the researcher was blind to participant identity.
An inductive, narrative method of thematic analysis was used. Comments were first reviewed and organized into themes by three researchers, in batches of 10 at a time, to assess for sampling saturation using Microsoft Excel (Microsoft Corp., Redmond, WA). The researchers independently categorized comments into themes, then met to discuss the themes and arrive at a consensus. Another researcher reviewed comments and themes for corroboration after the first three researchers completed a batch of 10. Sampling saturation was determined when there was repetitiveness in comment sentiments and themes began to solidify.
All surveys were saved in REDCap in a password-protected portal accessible only by the research coordinator. If participants completed surveys online, responses were saved directly in REDCap and managed by the coordinator. If participants completed surveys on paper, responses were input into REDCap, and the paper copies were securely locked in the patients’ files.
| Demographics and psychosocial characteristics | Mean (SD)* | ||
|---|---|---|---|
| Commenters (n = 39, 58.2%) | Non-commenters (n = 28, 41.8%) | ||
| Sex, n (%) | |||
| Male | 17 (43.6) | 20 (71.4) | |
| Female | 22 (56.4) | 8 (28.6) | |
| Age, years | 47.38 (13.06) | 48.64 (11.68) | |
| Veteran status, n (%) | |||
| Veteran | 16 (41.0) | 15 (53.6) | |
| Civilian | 23 (59.0) | 13 (46.4) | |
| Place of birth, n (%) | |||
| Canada | 32 (82.1) | 23 (82.1) | |
| Other | 7 (17.9) | 5 (17.9) | |
| No. years in Canada | 44.74 (15.57) | 45.82 (12.93) | |
| No. years of education | 14.13 (4.33) | 13.79 (4.94) | |
| Pain duration in months | 110.69 (135.98) | 142.15 (132.19) | |
| No. months since discharge | 25.82 (13.46) | 21.43 (11.79) | |
| No. of children | 1.74 (1.48) | 1.61 (1.23) | |
| Marital status, n (%) | |||
| Married, common law | 29 (74.4) | 19 (67.9) | |
| Not married | 10 (25.6) | 9 (32.1) | |
| No. of injuries related to work or service | 2.31 (3.62) | 3.77 (5.50) | |
| Mean no. of injuries for other reasons (e.g., car accident) | 1.93 (1.87) | 1.42 (1.54) | |
| No. visits to family physician | 16.72 (6.22) | 15.52 (6.83) | |
| No. visits to other specialists | 7.67 (6.49) | 5 | .28 (3.77) |
| No. visits to the emergency room | 2.69 (2.87) | 1.37 (2.04) | |
| Employment status at follow- up, n (%) | |||
| Employed | 4 (10.3) | 8 (28.6) | |
| Unemployed | 35 (89.7) | 20 (71.4) | |
*
Unless otherwise indicated.
RESULTS
Quantitative
Table 1 presents demographic and psychosocial characteristics of the study sample.
Participants in the follow-up study consisted of 31 Veterans and 36 civilians who did not differ in age (p > 0.05). In the Veteran group, there were more men (n = 24) than women (n = 7), whereas in the civilian group the proportion of men (n = 17) and women (n = 19) was equivalent (χ21 = 6.4, n = 67, p = 0.011). A higher percentage of Veterans (87.1%) than civilians (63.9%) were unemployed (χ21 = 4.7, n = 67, p = 0.03). Veterans had higher pain chronicity (t61 = 51.9, p < 0.001), more emergency room visits (t59 = 6.5, p = 0.01), and a greater number of work or service injuries (t59 = 20.61, p < 0.001).
When comparing those who provided comments with those who did not, two significant differences emerged. First, the association between commenter status and sex (χ21 = 5.1, n = 39, p = 0.02) showed that more women provided comments than not (22 vs. 8, respectively). Second, a difference between commenter status and number of emergency room visits (t60 = 2.02, p = 0.05) was found, with commenters reporting more visits on average (mean = 2.69, SD = 2.87) than non-commenters (mean = 1.37, SD = 2.04) at program admission.
The SES and the PPSQ scores of Veterans and civilians had similar means at follow-up: 3.19 (SD = 1.05) and 3.30 (SD = 0.92) for the SES and 36.53 (SD = 4.65) and 35.22 (SD = 6.20) for the PPSQ, respectively. The scores of those who provided comments versus those who did not also had similar means: 2.97 (SD = 1.09) and 3.23 (SD = 1.14) for the SES and 35.06 (SD = 6.19) and 34.96 (SD = 5.46) for the PPSQ, respectively. The scores of men and women who provided comments had similar means: 3.16 (SD = 1.04) and 3.35 (SD = 0.93), and 36.47 (SD = 6.11) and 37.21 (SD = 5.41), respectively (p > 0.05 for all).
| Themes | No. of comments | |||
|---|---|---|---|---|
| Veterans (n = 16) | Civilians (n = 23) | Men (n = 17) | Women (n = 22) | |
| Theme 1: gratefulness for treatment and program | 8 | 8 | 7 | 9 |
| Theme 2: improvement in ability | 4 | 10 | 4 | 10 |
| Theme 3: new sense of resiliency, ability to cope, new confidence | 5 | 12 | 5 | 12 |
| Theme 4: empowered over recovery | 2 | 5 | 2 | 5 |
| Theme 5: on the path to rehabilitation and recovery — a process and journey | 5 | 5 | 4 | 6 |
| Theme 6: need for support groups | 1 | 4 | 1 | 4 |
| Theme 7: some patients are doing well, but some still struggle | 5 | 6 | 6 | 5 |
| Theme 8: patients need continued follow-up to ensure they are on track and they do not regress | 4 | 2 | 2 | 4 |
| Theme 9: timeliness of program — needed earlier in course of chronic pain | 1 | 3 | 0 | 4 |
| Theme 10: program merits recommendation | 4 | 3 | 2 | 5 |
Qualitative
Of the 67 participants, 39 (58%) provided comments describing experiences in the program, 16 (41%) of whom were Veterans. Ten themes emerged: 1) gratefulness for treatment and program, 2) improvement in ability, 3) new sense of resiliency, ability to cope, new confidence, 4) empowered over recovery, 5) on the path to rehabilitation and recovery — a process and journey, 6) the need for support groups, 7) some participants are doing well, but some still struggle, 8) participants need continued follow-up to ensure they are on track and do not regress, 9) timeliness of program — needed earlier in the course of chronic pain, and 10) program merits recommendation. Table 2 presents the number of comments by theme for Veterans and civilians.
Gratefulness for treatment and program
In this very common theme, participants provided positive comments about the program, commending the staff, their professionalism, and program activities, the welcoming and helpful attitude of staff, and how information learned in the program was enjoyable and beneficial. Most simply said, “It’s a great program.” A male Veteran wrote, “I would like to thank all of the beautiful people at the Clinic for everything they have done and continue to do for those of us living with persistent pain.” A female Veteran wrote, “This was such a wonderful program and I really felt like it brought all the pieces of the puzzle together.” A male civilian wrote, “I’m very much better for taking the four week clinic. Thank you!”
A female civilian wrote:
How do I put into words my gratefulness to the clinic and every employee involved with the clinic and programft The program was a life changer for me. Even though I was a registered nurse, I still needed the program to use my knowledge … Yoga, meditation, I try to do daily. So amazing!
Improvement in ability
A very common theme was improvement in ability. The program teaches many skills that participants apply after discharge. A male Veteran said:
I have done several renovations since completing the program and by using the skills I have learned, I was able to put a lot of it in action and motion. Things that normally would have taken let’s say 3 weeks to finish took me over a month to completed but was well worth it.
A male civilian wrote:
The pain management program changed the trajectory of my life. It took me from being completely unaware of how to help myself, to being able to understand and adapt to my pain. It allowed me to make changes that brought improvements in nearly every area of my life. As my pain changes, for better or worse, the things I learned at the clinic have allowed me to find ways to improve gradually … I have regained a lot of mobility and I attribute it entirely to the strategies of this program.
A female civilian wrote, “I could drive to Barrie to help give child care to my granddaughter, care for my father.”
New sense of resiliency, ability to cope, new confidence
Many participants reported a new sense of resiliency, ability to cope, and new confidence. They wrote about how the program provided them with a positive attitude toward their progress and future, how they saw improvements emotionally and physically, and how the program allowed them to be happier and enjoy a better quality of life, in spite of pain. A male Veteran wrote, “Using the information I gained in the program, I have been able to further develop pain control and reduction measures which have made it easier for me to cope with pain.” A female Veteran wrote, “The program has helped me significantly. It taught me coping techniques.” A male civilian commented, “It has given me freedom and confidence that have been vital to rebuilding my life.” A female civilian wrote:
This program gave me hope for the future! Prior to that I had no hope. I now have short-term and long-term goals for my future. I have learned to be patient with myself and not feel guilty resting in between chores etc. My self-esteem improved. I exercise almost daily whether I feel pain or not.
Empowered over recovery
Participants stated that the program empowered them to manage pain and allowed them to resume previously valued activities (e.g., playing sports, having children, socializing) and overcome limitations and barriers previously associated with pain. A female Veteran stated:
I learned new tricks of the trade and the repetition of some of the exercises (meditation, for example) really helped instill in me the habit to continue on. I’ve gone on to have children with much less fear about my pain and how it would interfere and am constantly adjusting and continuing on rather than simply stopping out of discomfort and pain. … I also have been walking much, much more and now look forward to it every day. … I always feel better after-ward, even if I’m in pain.
A male Veteran wrote:
I have realized that I do not have to succumb to the model of “social” that the world considers healthy. For me, due to the tragedies of war, social has come to mean responsibility to a much smaller more specific group of people. Sometimes it’s okay to be alone.
A male civilian wrote:
A positive attitude and the discipline to use the skills acquired through the Program provides the self-worth to keep going. … Attending the program has elevated my post-accident self-esteem, confidence and gives me purpose to enjoy life.
A female civilian wrote:
The program was the best thing that happened to me, it really did change a lot of negative things and thoughts I had about everything … after completing the program I felt I was a completely different person: looking after myself more, eating healthy, sleep improvement, positive energy, sharing what I learned in the program with others.
On the path to rehabilitation and recovery — a process and journey
A common theme was how the program led participants on a path to rehabilitation and recovery and that managing pain is a process and journey. A female Veteran wrote, “Although I’m transitioning as I’m on the list for next hip replacement and right knee which will happen in the following year … I feel I still have a journey ahead.” A male civilian wrote:
I am more acutely aware of my pain threshold, which has allowed me to engage in everyday life knowing that only I am solely in control of managing my pain. This awareness and recognition has facilitated me to try many pre-accident activities in sports, leisure, and home life which were a very important part of my life pre-accident. I do so in moderation and with respect for my body.
A female civilian wrote, “I have to change my attitude before I can make real changes. … I know that someday I will have the strength mentally to help myself and enjoy life again.”
Need for support groups
This theme emphasized the value of the group program to provide participants with a support system and reduce feelings of isolation. Another concern reflected in these comments was the need for support after discharge to continue applying new skills in everyday life. A male Veteran stated, “I feel that when away from the program, it’s hard to keep applying what was taught, so felt alone not grounded enough.” A female civilian said, “I would like to have seen a support group set up that you could join on the Internet that has gone through the program.”
Some participants are doing well, but some still struggle
Although the overwhelming majority of comments demonstrated a positive patient experience, this theme indicated some required further interventions after the program. A male Veteran wrote, “Since taking the course my back has gotten worse, and am trying to cope with it. I have been seeing a doctor for [posttraumatic stress disorder] I did not know I had. A female civilian commented, “I continue to struggle with pain, balance, depression and focus, which all frustrates me. … I will never be the person I was, not physically or mentally, which is hard to accept still.”
Participants need continued follow-up to ensure they are on track and do not regress
Several participants requested follow-up programs to support transition into everyday life; they needed continuous support and progress tracking to maintain benefits. A female Veteran wrote, “It would be beneficial to have a refresher after I have completed all the replacement surgeries.” A male Veteran stated:
After a year or so I was ready to do another course as I got lost. I know the program helped but needed more, as being in the military we were taught to ignore pain for many years and to keep going, so it became a way of life.
A female civilian commented:
I am disappointed I did not have a follow up … coming into class after the program was finished maybe 1/month or so to see how I was doing, if I was on the right track, and if I need more class that would be an option.
Timeliness of program — needed earlier in the course of chronic pain
Some participants felt the program would have been even more beneficial had they attended earlier. These comments were made exclusively by women. A Veteran stated, “I wish I attended the pain clinic before my pain started getting worse,” and a civilian wrote, “The program changed my life. I wish I was made aware of it earlier after my accident.”
Program merits recommendation
Participants felt the program warranted a recommendation to others. A male Veteran wrote, “I will always tell comrades to take this program as soon as possible when they start suffering from chronic pain.” A female civilian commented, “Definitely recommending the program.
You guys are real people but what you do is unreal. God bless you all for all that hard work you provide to others.”
As seen in Table 2, a preponderant theme for Veterans is theme 8, with four Veterans (two male, two female) versus two female civilians, and themes 2–4, 6, and 9 have both a civilian and female preponderance. Themes 1 and 5 have an identical number of Veterans and civilians and an approximately equivalent number of men and women (albeit different percentages). Theme 7 and 10 have approximately the same number of Veterans and civilians.
DISCUSSION
This study evaluated Veteran and civilian experiences four months to four years post-discharge from an interdisciplinary chronic pain management program. To the authors’ knowledge, this is one of very few follow-up qualitative analysis studies of Veterans and civilians. Veterans’ comments were categorized into all 10 themes, providing a perspective on their needs in managing chronic pain. The finding of similar goal accomplishment since program discharge and satisfaction with services for Veterans and civilians and commenters and non-commenters supports the similarity of themes in the two groups. Demographic differences support those previously reported in this program.15
The majority of themes demonstrated a large positive impact of the interdisciplinary program long term (four months to four years). Themes elicited in this study support those of Hapidou and Horst obtained at discharge from this program several years ago. For example, “impact of a strong interdisciplinary team” is similar to “gratefulness for treatment and program.”5 Likewise, “the program as a stepping stone” is similar to “on the path to rehabilitation and recovery — a process and journey,”5 both of which indicate that pain management starts with the program and continues long after discharge. The similarity in themes between the two studies suggests that benefits of the program are consistent and continue after discharge.
A most common theme in this study is gratefulness for treatment and program. Many participants expressed gratitude toward staff, stating that staff were understanding of patient experiences with chronic pain. Patients also expressed that staff were professional and well trained, indicating that the program meets the needs of patients across the domains encompassed by the interdisciplinary approach. This is an important finding because health-professional-related barriers were shown to affect management of chronic pain.16 Hadi and colleagues found that patients express frustration when they feel there is a lack of communication among health care professionals.16
Positive change in participant cognitions, as shown through “new sense of resiliency, ability to cope, new confidence” and “empowered over recovery,” is consistent with the findings of Jensen and colleagues of reductions in pain-related disability and pain intensity, along with increased beliefs in ability to control pain.17 Many participant comments also reflected beliefs in being better able to control pain and thus developing a better outlook on life and ability to overcome new challenges. Moreover, empowering patients to become active participants in their health care is paramount to improving quality of care and reducing costs.18–21 Self-management of chronic pain via education and supportive interventions reduces health care utilization and leads to clinical improvements and better quality of life.18
Theme 6 on the need for support groups aligns with the findings of Holmner and colleagues on the importance of group interventions and social support in dealing with chronic pain and the realization of not being alone while living with pain and sharing experiences with others who have similar pain problems.7
Many Veterans described being on the path to rehabilitation and recovery — a process and journey. Holmner and colleagues identified a similar theme among Veterans that accepting pain is an ongoing process and that having obtained redress, learning about chronic pain, being with others sharing the same condition was helpful in the acceptance process.7 To accept pain was described as not allowing it to control their lives and as how they adjusted to pain. Some participants said the program helped them become aware of how pain limited their lives, affecting participation in work and leisure.7 Likewise, Veterans in this study expressed the same thoughts regarding pain management and the need for continued follow-up to ensure they are on track and do not regress. Penney and Haro found that a small group of Veterans described no improvements or changes since leaving the program,9 and some expressed frustration with their pain conditions because of the overwhelming barrier to post-program benefits of lack of support and the need for follow-up interventions.
Differences between the sexes were suggested by the findings. For most themes, the majority of comments were provided by women; for Theme 9, all comments were by women. Differences in the frequency with which women endorsed the themes cannot be accounted for by satisfaction or goal accomplishment ratings, for which no sex differences were found. Sex differences have been reported for pain sensitivity and socialization but not for why women provide more comments than men in qualitative analysis.22,23 This may require exploration.
Strengths and limitations
A major strength of this study is that, through the process of sampling saturation, anonymization, and member checking, the authors ensured quality, credibility, and integrity of data analysis. Another strength is the fact that themes in this study demonstrate that follow-ups, refresher courses, and continued support after the program would be highly valuable, thus further supporting the importance of interdisciplinary programs.
Limitations include that civilians primarily had chronic pain associated with a motor vehicle accident or work-related injury and were not representative of the population at large. The self-selection process of data collection may also have contributed to biased results, because patients who do better in treatment may also be more likely to respond to follow-up surveys.24 However, no differences were found in goal accomplishment or program satisfaction between responders and nonresponders and commenters and non-commenters. Moreover, the large range in time to follow-up (four months to four years) may have biased results in terms of distribution of themes. One could ask whether some of the themes came primarily from those who were three to four years from discharge versus four months. However, visual inspection of the data revealed that themes were evenly distributed throughout the follow-up period.
A future improvement in reducing response rate bias may include considering why people do not respond to follow-up surveys. To increase response rate, participants can be contacted before releasing surveys, following up with them after sending a survey, or sending the survey to non-respondents a second time.25 Reducing the length of a survey may improve response rate, especially regarding the probability of responders adding comments to open-ended questions.
Future implications
In the United States, the number of interdisciplinary programs has decreased over the years, from 210 in 1998 to 84 in 2005.26 This study emphasizes and adds to the growing body of research on the importance of interdisciplinary programs in managing chronic pain in diverse patient populations. Such programs should be a priority for health care organizations and policy makers. Results of this study have implications for clinicians and administrators of interdisciplinary programs. The theme of “some patients are doing well, but some still struggle” portrays diversity among patients and program experiences. Some participants stated that they needed other interventions, such as surgery, after leaving the program. Driscoll and colleagues also identified that some Veterans wanted non-pharmacological alternatives, alone or in conjunction with medication, to manage pain, with some accessing other interventions, such as pain self-management.27 Future implications can include developing the provision of support services for patients after leaving the program and maintaining a group support system for patients at follow-up. The increasing use of telehealth services to support patients in chronic pain management shows promise for accessibility and cost and time effectiveness.28,29
Conclusion
This qualitative analysis study speaks to the sustained benefit of an interdisciplinary chronic pain program for both Veterans and civilians, months to years after discharge, as well as the importance of more follow-up and support.
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REGISTRY AND REGISTRATION NO. OF THE STUDY/TRIAL
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ANIMAL STUDIES
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PEER REVIEW
This manuscript has been peer reviewed.
Information & Authors
Information
Published In
Journal of Military, Veteran and Family Health
Volume 8 • Number 2 • June 2022
Pages: 51 - 61
Copyright
For permission to share, copy, or redistribute, contact [email protected].
History
Received: 30 June 2021
Revision received: 5 September 2021
Accepted: 22 September 2021
Published ahead of print: 3 February 2022
Published in print: June 2022
Published online: 13 June 2022
Key Words:
Mots-clés :
Authors
Contributors
Conceptualization: EG Hapidou and S Altena
Methodology: EG Hapidou, C Hanna, and V Borg Debono
Validation: EG Hapidou
Formal Analysis: EG Hapidou, C Hanna, V Borg Debono, E Pham, and J Anthonypillai
Investigation: EG Hapidou
Resources: EG Hapidou, C Hanna, S Altena, and L Patterson
Data Curation: EG Hapidou, C Hanna, V Borg Debono, E Pham, and J Anthonypillai
Writing — Original Draft: EG Hapidou and C Hanna
Writing — Review & Editing: EG Hapidou, C Hanna, V Borg Debono, E Pham, J Anthonypillai, S Altena, and R Zacharias
Visualization: EG Hapidou
Supervision: EG Hapidou
Project Administration: EG Hapidou and J Anthonypillai
Competing Interests
The authors have nothing to disclose.
Funding
This project received funding from the Chronic Pain Network through the Strategy for Patient Oriented Research and the Michael G DeGroote Institute for Pain Research and Care.
Ethics Approval
This study was approved by the Hamilton Integrated Research Ethics Board, Hamilton, Ontario, Canada, on Nov. 26, 2019 (clearance no. 7845).
Informed Consent
The authors confirm that informed patient consent was obtained from all patients.
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Journal of Military, Veteran and Family Health 2022 8:2, 51-61
Journal of Military, Veteran and Family Health 2022 8:2, 51-61