Pain, 49 (I 992) 22 I-230 221

0 1992 Elsevier Science Publishers B.V. All rights reserved 0304-3959/92/$05.00

PAIN 02000

Efficacy of multidisciplinary pain treatment centers:

a meta-analytic review *

Herta Flor a,b,Thomas Fydrich ’ and Dennis C. Turk ’

“ Department of Clinical and Physiological Psychology, University of Tiibingen, Tiibingen (Germany), ” Fachhereich Psychologie,
Unirxersityof Marhurg, Marburg (Germany), ’ Department of Psychology, Ukersity of Heidelberg, Heidelberg (Germany),
and ’ Pain El,aluation and Treatment Institute, Departments of Psychiatry and Anesthesiology, Unir,ersity of Pittsburgh School of Medicine,
Pittsburgh, PA, (USA)

(Received 2 April 1991, revision received 9 July 1991, accepted 12 September 1991)

Summary Sixty-five studies that evaluated the efficacy of multidisciplinary treatments for chronic back pain
were included in a meta-analysis. Within- and between-group effect sizes revealed that multidisciplinary treatments
for chronic pain are superior to no treatment, waiting list, as well as single-discipline treatments such as medical
treatment or physical therapy. Moreover, the effects appeared to be stable over time. The beneficial effects of
multidisciplinary treatment were not limited to improvements in pain, mood and interference but also extended to
behavioral variables such as return to work or use of the health care system. These results tend to support the
efficacy of multidisciplinary pain treatment; however, these results must be interpreted cautiously as the quality of
the study designs and study descriptions is marginal. Suggestions for improvement in research designs as well as
appropriate reports of research completed are provided.

Key words: Meta-analysis; Chronic back pain; Multidisciplinary treatment

Introduction
There has been a rapid proliferation in the number
of pain clinics since their inception over a quarter of a
century ago. Many questions have been raised as to the
relative efficacy and cost effectiveness of these clinics
(Stieg and Turk 1988; Cicala and Wright 1989). A
growing number of papers have appeared in the litera-
ture reviewing the relative effectiveness of these clinics
in treating patients with persistent pain. A number of
qualitative reviews (Block 1982; Aronoff et al. 1983;
Kerns et al. 1983; Turner and Roman0 1984; Linton
1986; Malone and Strube 1988) have generally sup-
ported the efficacy of pain clinic treatment (however,
see Trifiletti 19841, although methodological concerns
* This research was supported by Grants No. FI 156/l and F1 156/2
by the Deutsche Forschungsgemeinschaft to the first author.
Correspondence to: Dr. Herta Flor, Department of Clinical
Physiological Psychology, University of Tubingen, Gartenstrasse
W-7400 Tiibingen, Germany.
are always raised and each review concludes with the
old bromide - more and better research is needed
before definitive conclusions can be drawn.
In addition to methodological concerns raised, con-
clusions about the efficacy of pain clinic treatment also
have to be viewed with some caution as they have been
based on subjective impressions and personal opinions
regarding the efficacy of therapeutic approaches in
general and in comparison to alternative approaches.
Simply put, the usual approach consists of aggregating
the results of studies in a narrative manner sometimes
referred to as a box-score or vote-count approach
(Glass 1976).
There are a number of problems inherent in the
box-score approach. The narrative reviewer attempts to
‘make sense’ out of an array of studies and reports his
or her conclusions usually without articulating the rules
by which evidence was evaluated. The standards for
deciding such things as which studies to include, which
and
dependent measures should be given greatest weight,
29, how to reconcile differences in outcome on different
dependent measures, and how to abstract the evidence
222
from them may shift from study to study and from
reviewer to reviewer (Mintz 1983). Furthermore, the
adequacy of the box-score approach is limited because
it ignores the magnitude of effects across all available
studies and across all variables. This approach uses
only a fraction of the available data.
Because of the subjective nature of qualitative re-
views, two reviewers can examine the same studies and
come to very different conclusions. For example, two
sets of reviewers examined the utility of the MMPI in
predicting response of pain patients to different treat-
ments. One United States commission, Social Security
Administration Commission on the Evaluation of Pain
(US Dept. Hlth Hum. Serv. 19871, concluded that “...
the MMPI also has not yet demonstrated the kind of
predictive validity essential to precise measurements
about pain, nor has it yet yielded precise predictors of
success in treatment or rehabilitation program has
not as yet progressed to where it can serve as an
acceptable measure for the assessment of clinical pain
as it relates to disability” (p. 84). By way of contrast,
another reviewer of the same literature arrives at a
conclusion that appears to be diametrically opposed,
namely, “The collective findings of empirical studies ...
lend strong support to inclusion of the MMPI in the
assessment of patients being treated for chronic pain”
(Snyder 1990). To illustrate further how the nature of
reviews can lead to different conclusions, we can con-
sider the recent meta-analytic review conducted by
Fernandez and Turk (1989). These investigators
demonstrated how completely opposite conclusions can
be drawn based on reviewing the same studies examin-
ing the efficacy of different pain coping strategies but
using qualitative versus quantitative (meta-analytic)
methods.
In pursuit of greater objectivity in the review pro-
cess, a set of statistical techniques known collectively as
‘meta-analysis’ was developed (Glass et al. 1981).
Meta-analyses consist of the integration and synthesis
of research through statistical analysis of individual
studies. Perhaps the most innovative aspect of meta-
analytic applications is that they afford the use of
inferential statistics in a domain where conclusions
were formerly tested on simple summation and opinion
and thereby did not control for the subjective interpre-
tation of the reviewer. Meta-analyses reduce (but do
not totally eliminate) the subjectivity that is inherent in
traditional narrative reviews.
The effect size of a study is given by a basic formula
that incorporates the difference in mean outcomes of
the experimental (treated) group and control (un-
treated) group, divided by the standard deviation of the
control group. Computations based on this formula
result in the determination of the effects of treatment
in standard deviation units. Thus, for example, an
effect size of 0.50 reveals that one treatment condition
exceeded another by one-half of a standard deviation.
This result can be interpreted as a specific treatment
performing one-half of all standard deviations better
than an alternate treatment or no treatment.
A valuable feature of the computed effect size is
that it is comparable to a standardized Z score and
thus can be converted to percent improvement. Thus,
an effect size of 0.50 for a treatment indicates that the
average treated patient fared better than 69% of the
untreated patients. Individual effect sizes can be aver-
aged across studies to provide a global portrait of the
relationship or they can be further examined as depen-
dent variables moderated by type of treatment in ques-
tion or a host of other methodological variables (e.g.,
pertinent demographic data, quality of study) or mod-
erator variables such as patient demographics, diagno-
sis, compensation status (Wolf 1986).
Meta-analysis has begun to be widely accepted in
medicine (Jenicek 1989; Mann 1990) and has received
attention in the pain treatment outcome literature for
different pain problems (e.g., headaches: Blanchard et
al. 1980; Holroyd and Penzien 1986, 1990), the efficacy
of preparatory information for surgery (e.g., Hathaway
1986; Suls and Wan 1989), coping strategies (e.g., Fer-
nandez and Turk 1989), and the efficacy of specific
pain treatments (e.g., acupuncture: Blanchard et al.
1980; Pate1 et al. 1989) for diverse pain problems (e.g.,
Malone and Strube 1988).
The number of dependent measures, diversity of
patient characteristics, and criteria of success of pain
clinic outcome studies that have appeared in the litera-
ture make both narrative and meta-analytic reviews
especially difficult. Some of the problems with these
box-score approaches were noted earlier. However,
advances in the use of quantitative review methods
(meta-analyses) seem to offer a number of advantages
and should contribute to a more systematic under-
standing of the effectiveness of pain clinics. The pri-
mary purpose of this paper is to use meta-analytic
methods to determine the relative effectiveness of mul-
tidisciplinary treatment for patients with chronic low
back or heterogeneous pain, two of the largest groups
of patients treated in pain clinics.
Methods
Studies included
Studies were identified by searching data bases including MED-
LARS and PSYCHINFO. reviewing relevant journals (e.g., Archkes
of Physical and Medical Rehabililarion, Pain, Journal of Consulting
and Clinical Psycholom), and tracing publications by searching the
reference sections of relevant reviews and papers. Studies were
included if they used an interdisciplinary treatment approach in a
multidisciplinary pain clinic, included empirical data. and were pub-
lished from 1960 to 1990. A thorough review of the literature from
1960 to 1990 revealed more than 300 pain outcome studies that
 223

TABLE I control groups were not reported. Additionally, within-group effect

sizes permitted a standardized control between different studies.
STUDY CHARACTERISTICS
Furthermore, within-group effect sizes reveal to what extent the
change in treatment groups exceeds the change in control groups.
Mean S.D. Range N
Following the suggestion of Nicholson and Berman (19831, in cases
Number of comparisons 12.09 11.61 l-60 65 in which the results were reported as non-significant and no other
Internal validity 1.20 0.59 o- 3 65 information was available, effect size was conservatively estimated as
Percentage excluded 16.12 20.05 o-54 12 0.
Percentage declined 14.01 IS.07 3-65 18 Following computation of effect sizes for each individual depen-
Percentage dropouts dent variable, mean effect sizes for each study were computed. The
in experimental group 14.98 13.68 O-48 37 study effect sizes were derived by averaging all variables for which
Percentage dropouts effect sizes were reported. Study effect sizes were used because the
in control group 9.64 16.58 o-47 10 utilization of several, potentially highly correlated measures from
Percentage loss of subjects one study has been criticized (Wortman and Bryant 1985; Bangert-
in experimental group 28.50 22.36 O-87 44 Drowns 1986). In addition to computing effect sizes the studies were
Percentage loss of subjects evaluated and coded on a number of criteria.
in control group 25.53 21.31 O-60 14 General information. This information included the study identi-
fication number, the journal, and the year of publication.
For the coding of internal validity see text. N = number of studies
Sum& information. The site of pain was coded according to the
included.
classification of the International Study for the Association of Pain
(Merskey 1986). Additional categories added were back pain, hetero-
geneous pain, and predominantly back pain ( > = 50%). The dura-
included a host of multidisciplinary interventions. Of these studies, a
tion of pain was coded in months. In addition, subject recruitment
majority dealt with recurrent headaches which have been extensively
strategy (clinic, advertising, solicited by experimenter, referred, com-
reviewed elsewhere (Blanchard et al. 1980; Chapman 1986; Holroyd
bination of the above) was coded. Patient characteristics including
and Penzien 1986, 1990; Keefe et al. 1986). One-hundred-and-sixteen
(a) age, (b) marital status, (cl education level, fd) SES, (e) employ-
studies were found that included some kind of psychological treat-
ment status, if) compensation, (g) litigation, (hf number of previous
ment for chronic back or heterogeneous pain. Twenty-six of these
surgeries and (i) medication use were also coded. Furthermore, the
treatment studies made use of one or more psychological treatment
basis for the exclusion or inclusion of patients was noted.
paradigms, for instance biofeedback (e.g., Nouwen 1983; Bush et al.
Design-related irzjbrmufion. Experimental design information was
1985) or they were not conducted in a pain clinic settting (cf., Turner
used in determining the methodological quality of the study. It
1982) and were therefore not included. An additional 25 publications
included the type of group assignment (random, matching, conve-
either did not provide any empirical data fn = 9), were single-case
nience sample). The internal validity of the study was coded accord-
presentations fn = 8) or were predictive studies with only one assess-
ing to 4 criteria (based on Glass et al. 1981): 0 = no statistical
ment at post treatment (n = 7). In summary, 65 of these 300 studies
analysis, highly non-equivalent groups, obvious bias; 1 = weak, non-
(22%) met inclusion criteria that qualified them for inclusion in the
existent matching, disproportionate mortality, inadequate statistics;
meta-analysis. The studies incorporated in the meta-analysis are
2 = random assignment but differential mortality, failed randomiza-
listed in the appendix. Table I displays descriptive information about
tion, well designed matching study; 3 = random assignment, mortality
the study population.
< 15% and same between groups, still good if data on terminators
are included or equivalence of dropouts and non-dropouts is estab-
Coding of series lished. The exclusion rates and the percentage of patients who
Each dependent variable of the 6.5 studies was coded by two declined to enter the study, the number of experimental and control
independent raters (H.F. and T.F.). Inter-rater reliabilities were groups, and the dropout rate per group were also recorded.
computed for a random sample of n = 13 studies and n = 50 effect Treatment-related information. The treatment-related informa-
sizes. Cohen’s kappa coefficient, based on Cicchetti (1976) ranged tion included the type of treatment experimental group. Because of
from 0.75 to 1.00 with a median kappa of 0.88. For the numerical great diversity and difficulties in differentiating some of the treat-
value of effect size a 94% agreement between raters was obtained. ments, type of treatment was not considered as a separate variable in
Disagreements in the studies were resolved by discussing the criteria this study. The comparison groups were coded as follows: (1) no
and refining them if necessary. treatment. (2) waiting list, (3) medical treatment, (4) placebo treat-
In order to have comparable effects for these studies, effect sizes ment, (5) second treatment, and (6) other. Further variables coded
were computed that relate the effects of the treatment groups with were the setting (inpatient, outpatient, combination of inpatient and
those of a control group. As noted, effect sizes can be seen as outpatient), the location of the treatment (pain clinic, university
analogous to standard deviations. They were calculated by subtract- department, other clinic, private practice), the primary department
ing the experimental groups post-treatment mean from that of the of the treatment provider (psychiatry, psychology, other medical), the
control group and dividing by the control group’s standard deviation amount of family invoivement, the training of the therapist who
(between-group effect size: Smith and Glass 1980). If means and provided the psychological treatment, the treatment format (individ-
standard deviations were not available, effect sizes were computed ual or group), the duration of the treatment, type and duration of
by using available F or r values or by estimating the data from concurrent medical treatment.
graphic displays or P values, as described by Glass et al. (Glass et al. Dependent variables. Overall. 704 dependent variables were coded
1981). by type: somatic, psychophysiological, behavioral, and verbal-subjec-
In addition, effect sizes for within-group changes over the course tive. Within the verbal-subjective modality pain intensity, interfer-
of the treatments, and - if data on control groups were available - ence, mood. and other measures (such as MMPI, SCL-90) were
within-group effect sizes for the control groups were calculated by differentiated. The behavioral variables included return to work, use
subtracting the post-treatment mean from the pretreatment mean of the health care system, medication intake, observable pain behav-
and dividing by the pretreatment standard deviation. This strategy iors, and activity levels.
permitted computation of standardized values for change on depen- The quality and reactivity of the outcome measures were coded
dent variables even if control groups were not used or data on following the suggestions of Glass et al. (iY81). A variable received a
723

quality rating of I if the measure showed low reliability and validity TABLE 11
or if the measure was specifically designed for the study without data
PATIENT CHARACTERISTIC‘S
on reliability and validity. A quality rating of 2 was assigned if
reliability and validity were adequately described or if a measure
Mean Median S.D. Range N
with known reliability and validity was used. Reactivity was coded
according to the three following categories: (I) all physiological Mean age in years 44.Y3 44.91 4.46 34.5- 56.0 56
measures, laboratory data, blinded ratings or behavioral assessments. Percent female 50. II) 52.00 IX.14 0 - X6 57
medical record data: (2) standardized measures with little connection Pain duration in months X5.43 60.00 113.h’) I3 -7% 46
with the treatment or therapist (e.g.. diary data): (3) patient self-re- Percentage working 34.17 25.25 32.1 I 0 -100 2x
port of improvement, therapist improvement ratings. instruments Percent married 77.f15 77.00 0.20 56 100 27
with obvious relationship to treatment outcome. Twenty-nine per- Average years in school I I.98 IZ.lO 0.70 IO - I3 IO
cent received a good quality rating, 36q a low quality rating, and for Percentage with
the remainder the quality could not be determined. The reactivity of litigation 2t1.53 x.20 24.45 0 - 63 20
the measures was generally high (58%); only 3% received a low Percentage ou
reactivity rating, and the remainder was considered to be moderately compensation 5 I .hJ 53.00 24.5’) 0 63 20
reactive. Percentage with
Eff;‘c’t size.\. Effect sizes were compared along a number of ;’ = I sui-gery 54.50 50.00 lY.33 28 -IO0 23
dimensions. First, the mean effect size for each of the treatments Mean number of
under review was computed to determine the overall effect of the surgeries 1.76 I .50 0.86 0.4- 4.60 74
treatment provided. The long-term effects of the treatments were Pcrcentagc mcd-
evaluated by computing separate effect sizes for the time from the cation use x4.5 I X6.00 12.12 53 ~100 17
completion of treatment up to 6 months and the period ranging from
N = number of studies included.
7 months to 7 years post treatment. Next. the changes for each type
of dependent measure (e.g.. verbal-subjective, behavioral) were ana-
lyzed. For these computations, effect sizes based on individual out- of hl patients per study. Table II presents important demographic
come measures rather than study effect sizes were used. Additional and clinical characteristics of the patients. These data show that
analyses were performed for selected variables, such as return to those patients for whom information was available were severely
work and use of the health care system. Finally, the effect sizes were disabled with high rates of unemployment, a large number of com-
correlated with sample and design characteristics as well as study pensation and litigation cases. many previous surgeries. and high
characteristics to determine predictors of the effect sizes for the medication use. In most of the studies (85%) regular pain clinic
various treatments. patients not specifically referred for a study served as subjects.

Treatment characteristics
Characteristics of studies included The majority of the treatments included a combination of psycho-
The number of dependent variables per study ranged from I to logical interventions, medical treatments. and physical or occupa-
3. Between I and 60 effect sizes or percentage change measures tional therapy. The average duration of the treatments was 7 weeks
were obtained per study with an average of 12. The number of (SD. = 6.42. N = 52) with a range from I to 31 weeks. The average
experimental groups ranged from I to 3 (92% of the studies had only number of hours spent in treatment ranged from 4 to 264 h. with an
one) and the number of control groups from 0 to 2 (with 65% having average of Yh h (S.D. = 7X. N = 51). For inpatient programs which
no control group). lacked information on the exact number of treatment hours. an
The most common type of treatment provided was multimodal average of 6 treatment hours/day for 7 days/week was assumed.
(60%); the most frequent type of control group was one composed of Approximately 80% of the treatments were conducted by multidisci-
patients whose insurance company refused to pay or who could not plinary treatment teams. The majority of the studies (50%) were
pay for other reasons (28%). The typical assignment to the experi- performed in inpatient settings; 289; were in an outpatient setting
mental and control groups was that a convenience sample consisting and I3V were mixed. The remainder of the studies (N = 6) provided
of patients treated was chosen (75%). Thus, the internal validity of no information on the type of setting.
the studies using the Glass et al. (1981) criteria was relatively low.
with only 8% of the studies receiving a rating of 3 (high internal
validity) and 86.5% receiving a low validity rating. Results

Or~erall treatment effects

Patient characteristics
Overall 3089 patients were included in the meta-analysis. The The overall effect sizes for the studies without dif-
number of patients per study ranged from 5 to 467, with an average ferentiating between type and quality of measure and

TABLE 111

MEAN EFFECT SIZES BY TIME OF ASSESSMENT

Follow-up Treatment group ES Control group ES Between-group ES Treated group Control group
(within-group) (within-group) (Cr, change) t% change)

Mean S.D. Range N Mean SD. Range N Mean SD. Range N Mean SD. N Mean S.D. N

Short term t < = 6 mo.)

I.51 1.4’) 0.25-7.98 34 0.03 0.19 - 0.2OHJ.42 7 0.62 0.47 -0.46-I.24 I3 47 27 46 6 I8 II
Long term (> 6 mo.)
I.31 1.06 0.23-5.79 24 0.44 0.47 0.08-I 4 0.x1 O.hh 0.04-2.43 I2 4x 21 2’) 24 21 IO

N = number of studies included

 225

TABLE IV The mean percentage change at short-term follow-up

EFFECT SIZES BY TYPE OF CONTROL GROUP was 40.07 (S.D. = 27.36, N = 46) for the experimental
and 6.11 (S.D. = 17.77, N = 46) for the control groups.
Mean S.D. Range N At long-term follow-up these percentages changed to
Treatment denied 0.90 0.71 0.12-2.43 8 48.34 (S.D. = 20.60, N = 29) for the treated and 23.65
Waiting list 0.62 0.31 0.17-1.14 6 (S.D. = 20.72, N = 10) for the control groups (but note
Pure medical treatment 0.83 0.56 -0.12-1.24 5
the small N for the control group). These results sug-
Placebo 0.97 0.13 0.88-1.06 2
Physical therapy 0.41 0.30 0 -0.73 6
gest that the groups treated in a multidisciplinary pain
clinic demonstrate at least twice the change reported
N = number of studies included. by control groups.

other study parameters, are presented in Table III. In

order to determine short-term and long-term effects of
the treatments, assessments were divided in up to 6
months after completion of treatment (short-term fol-
low-up) and longer than 6 months post treatment
(long-term follow-up).
Table III displays three types of overall effect sizes
for the study population. Examination of this table
reveals that both the between-group and the within-
group effect sizes are large and are maintained at the
short-term and long-term follow-ups. The effect sizes
at both follow-ups are smaller when compared to con-
trol groups than within treatment; however, they re-
main substantial. The majority of the control group
effect sizes do not differ significantly from zero.
An effect size of 0.62 for the between-group com-
parison at short-term follow-up (mean: 5 weeks post
treatment) indicates that a treated patient is function-
ing on the average 0.60 standard deviations or 30%
better than a patient from the control group (per-
centage based on a binomial effect size display: cf.,
Rosenthal and Rubin 1982). The effect size of 0.81 at
follow-up (on the average 95 weeks post treatment)
amounts to an improvement of 38%. If this value is
compared to the within-group effect size, the effect
size increases to 1.51 at short-term and 1.31 at long-
term follow-up, respectively. Expressed in average im-
provement, these results translate to an improvement
of 60% at short-term follow-up and 55% at long-term
follow-up.
Computations of percentage improvement were pos-
sible for more studies than computations of effect size.
Comparison to different control groups
When treatment effects were compared to different
types of control groups it became evident that those
patients who declined treatment differed most from
the treated patients with an average effect size of 0.90
(see Table IV). When compared to unimodal non-
medical or conventional medical treatments the exam-
ined multimodal programs seem to be superior, allow-
ing the tentative conclusion that combined treatments
in general are superior to the use of single-treatment
components. Differences in effect size between the
various control groups, however, were not significant.
Treatment effects by outcome measure
The frequencies of utilization of the five different
categories of dependent measures show that behavioral
and verbal-subjective measures of pain are most widely
used. The pattern of the within-group effect sizes re-
veals that patients show the greatest improvement on
self-report measures of pain (Table V>. Importantly,
however, they demonstrate substantial effects on the
more objective physical and behavioral measures as
well.
A more detailed analysis of the behavioral class of
outcome variables revealed that there were substantial
effects of the treatments on such important measures
as return to work and use of the health care system.
For example, the between-groups effect size of 0.67 for
return to work indicates that the treated patients have
a much greater likelihood (68% vs. 32%) to return to
work than the untreated patients. Comparable effects

TABLE V

EFFECT SIZES BY OUTCOME MEASURES

Within-group ES Between-group ES Treated (% change) Controls (%) change)

Mean S.D. N Mean S.D. N Mean S.D. N Mean S.D. N

Somatic 0.94 0.50 37 - - 58 29 44 _ _ _
Psychophysiological 2.04 1.26 5 0.84 0.26 4 47 10 5 11 10 4
Behavioral 1.19 0.99 158 0.65 0.70 115 54 47 216 10 26 52
Pain 1.59 1.91 97 0.70 0.66 73 37 23 116 4 18 44
Interference 0.50 0.43 20 1.10 0.67 12 23 14 23 -7 6 3
Mood 1.91 3.11 10 0.63 0.33 3 20 22 12 12 23 4
Other subjective 0.76 0.82 104 0.47 0.48 61 24 21 139 10 17 38

N = number of studies included.

226

were evident for use of medication, overall pain behav- there was, however, a small significant negative corre-
iors, and activity levels (all 65% vs. 35% improvement). lation between reactivity of a measure and between-
group effect size (r (271) = - 0.14, P < 0.05).
It might be assumed that longer treatment times
Correlation of study characteristics with effect sizes
lead to greater improvement. However, the correlation
An interesting question is the determination of vari-
between duration of treatment and effect size was not
ables associated with effect size (Table VI>. Several
significant (r (12) = - 0.11). Thus, longer treatments
variables have been associated with poor outcome, for
do not necessarily produce stronger effects.
example, chronicity (Swanson et al. 19791, age (Holroyd
and Penzien 19861, litigation or compensation (Block et
al. 1980; Guck et al. 1985). Correlations between effect
size and age, duration of pain, litigation or compensa-
Discussion
tion were not significant (r (23) = -0.24 for between-
group effect size and age; r (19) = -0.31 for between-
group effect size and duration; r (8) = -0.23 for be- Overall the results of this meta-analysis provide
tween-group effect size and compensation, and r (7) = support for the conclusion that multidisciplinary pain
- 0.25 for- between-group effect size and litigation). clinics are efficacious. Even at long-term follow-up,
Caution is needed in interpreting the non-significant patients who are treated in such a setting are function-
effects for these variables as they are based on a small ing better than 75% of a sample that is either un-
number of studies. Despite the few studies, the low treated or that has been treated by conventional, uni-
correlations between treatment success and litigation modal treatment approaches. Although the largest ef-
and compensation suggest that these factors may not. fect sizes were obtained when treated patients were
as has been suggested, show serious impediments to compared to those whose insurance company declined
successful treatment in pain clinics (Turk and Rudy payment or who could not pay themselves, effect sizes
1990). based on these comparison groups were not signifi-
Other variables thought to be of relevance for the cantly different from effect sizes based on the compari-
evaluation of treatment outcome studies are the num- son of treatments with waiting list or purely medical
ber of dropouts per study as well as the overall attri- treatments. Conventional physical therapy is somewhat
tion rate (which includes dropouts, those excluded better than no treatment or medical treatment but
from treatment, and those who do not return to for inferior to multidisciplinary approaches (commonly a
follow-ups). Neither the percentage of dropouts, r (12) combination of medical, physical therapy, and psycho-
= 0.01, NS, nor the overall attrition rate, r (15) = logical approaches).
- 0.30, NS, were significantly related to between-group Importantly, the effects for pain clinics are not
effect sizes. As noted, the small sample sizes preclude simply limited to the subjective perception of the pa-
firm conclusions. tients but also extend to objective behavioral variables
Somewhat surprisingly, the quality of the studies such as return to work or decreased use of the health
was not significantly related to treatment outcome (r care system. For example, patients treated in a multi-
(23) = 0.14 for the correlation between group effect disciplinary pain clinic are almost twice (68% vs. 36%)
size and internal validity). However, the type of group as likely to return to work than the untreated or
assignment was marginally related with non-random unimodally treated patients. Similarly impressive are
assignment yielding higher between-group effect sizes the data on the pretreatment to post-treatment change:
(r (25) = 0.32, P < 0.10). The quality of the dependent an overall effect size of 1.35 can be interpreted as an
variables was not significantly related to effect size: improvement of 56%. This figure is closely paralleled

TABLE VI
EFFECT SIZES ON SPECIFIC BEHAVIORAL LEVELS

Within-group ES Between-group ES Treated (% change) Untreated (‘% change)

Mean S.D. N Mean S.D. N Mean S.D. N Mean S.D. N

Work 1.35 0.71 30 0.67 0.55 17 43 28 43 2s 32 9
Medication 1.78 1.19 48 0.61 0.63 30 63 27 54 21 21 7
Health care use 0.44 0.29 16 0.47 0.5 1 15 35 16 21 4 1x 3
Activity 0.92 0.66 27 0.63 0.87 16 53 66 49 13 32 14
Pain behavior 0.59 0.44 29 0.61 0.85 13 62 67 34 0 4 x

N = number of variables included in the analysis.


by the average 43% improvement (meaning 43% more
patients are working after as compared to before treat-
ment) computed from the return to work data noted in
the studies for which effect size could not be com-
puted. The findings on return to work are especially
important.
Although it might be argued that over one-half of
the patients treated in pain clinics do not return to
work, the duration of pain (over 7 years), the magni-
tude of the problem, extent of disability of patients
included in these studies, and the tremendous cost of
disability payments suggest that a 43% saving for this
intractable pain population would save third-party pay-
ers billions of dollars not to mention the incalculable
reduction in suffering of the patients and their fami-
lies.
The conduction of this meta-analysis was signifi-
cantly hampered by the fact that most studies failed to
provide means and standard deviations for the relevant
outcome measures. In a large percentage of cases they
had to be determined from proportions or had to be
estimated from graphic displays.
There are several qualifications that must be noted
in interpreting the results based on to this meta-analy-
sis. First, the majority of the studies were conducted
without appropriate control groups. Even when control
groups were used, they were rarely appropriate and
most often composed of a convenience sample. Typi-
cally, patients who dropped out of treatment, whose
insurance company refused to pay or patients who did
not enter treatment for other reason were used as
controls. There might be significant differences be-
tween patients who accept treatment and those who
decline, for whatever reason. This type of non-random
control group is likely to inflate effect size, as is evi-
dent from the positive correlation of non-random as-
signment and effect size. Thus, the appropriateness of
using those who decline treatments as a comparison
group is open to question and needs greater considera-
tion and discussion. Other limitations include the qual-
ity of studies and the reactivity of measures. Moreover,
only a minority of studies provided descriptions of the
patient sample, and information on study design and
analysis. The advantages of meta-analysis are severely
reduced by inadequate study descriptions, dissimilar
dependent measures and diagnostic groups (cf., Hol-
royd and Penzien 1989).
Another issue to note is the substantial attrition of
subjects observed over the course of the treatments
and especially at long-term follow-up. In some studies,
as many as 87% did not complete the entire study. It is
not clear how these high attrition rates affect outcome
(cf., Turk and Rudy 1990). The lack of a significant
correlation between effect size and attrition in this
study sample would, however, suggest that the effect of
dropout may not be significant. Unless further data are
227
forthcoming, this issue must be considered as unre-
solved at this time.
Several issues discussed in the meta-analysis by Mal-
one and Strube (Mann 19901 were not addressed in
this review. In order to minimize problems created by a
small number of studies with very heterogeneous pain
problems, this study was limited to patients who at-
tended a multidiscipinary pain clinic, i.e., patients who
suffered predominantly from chronic back pain. Gen-
eralizations to other types of pain should, therefore,
not be made. We refrained from an analysis of the
comparative efficacy of different types of multidisci-
plinary interventions because the number of studies
included would preclude statistical analysis. As Hol-
royd and Penzien (1989) noted, merely ocular compar-
isons of means based on a sample for which type of
treatment, type of pain, and type of outcome measure
are confounded, will not yield meaningful information
on the efficacy of multidisciplinary pain treatments.
Further evaluation of treatment outcome studies
would be facilitated if authors adhered to the following
guidelines: (a) comprehensive patient sample descrip-
tions according to the criteria detailed in the Method
section of this article; (b) use of adequate control
groups, preferably with random assignment; (cl use of
well-established outcome measures on all levels rele-
vant for pain; and Cdl provision of means, standard
deviations, and sample sizes for all outcome measures.
Despite the limitations noted, several conclusions
can be drawn from this meta-analytic study. First,
multidisciplinary pain treatments are superior to uni-
modal treatments and no treatment. Second, the bene-
ficial effects from pain clinics are maintained over an
extended period of time. Importantly, the improve-
ments documented are not only reflected on subjective
ratings of pain but also more objective measures such
as return to work and use of the health care system.
These results are quite impressive and add credence to
the relative and incremental validity of multidisci-
plinary pain clinic treatment.
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