It is time for using adequate assessment and new designs to improve the effectiveness of treatment in chronic musculoskeletal pain

Abstract

’ t know who benefi ts most from what type of treatment – or sometimes even combining types of CBT that might also be contra productive, for example gradually increasing activities by using operant principles on a time contingent basis and teaching the patient to rebalance activity – rest using a pain-contingent approach. Results of randomized, controlled trials (RCTs) in which multidisciplinary treatments are being studied show only low to moderate effect sizes and at least half of the patients do not even show a clinically relevant improvement of personal relevant activities and participation (6). It should be mentioned that many trials do not even use personal relevant outcome measures. But why are the results so moderate? Shouldn ’ t we fi rst perform an adequate assessment of each patient on the basis of his/her goals and a hierarchy of factors that maintain the chronicity of disability to decide what treatment modalities should be provided? I do think that is what we commonly do in clinical practice, but it is diffi cult to study within an RCT design (7). By applying newer techniques using sophisticated statistical analyses, such as randomization testing in single case design (SCD) studies (8), we can make signifi cant progress. This type of study really resembles our daily clinical practice, and by multiple sampling of each patient provides much data to ensure suffi cient power to test whether the hypothesis that the selected treatment modality works can be confi rmed or rejected. Unfortunately, most journals, and especially communities involved in meta-analysis such as the Cochrane collaboration, still view this type of study as being of low quality. I do think it is time to change this view. Another important topic of intervention studies is the description of the content of the treatment and the check as to whether the provided treatment is similar to the treatment protocol, the so-called process evaluation. Many studies still only briefl y discuss the content and treatment rationale (underlying theory) and hardly ever present data on the process evaluation. Regrettably, an extensive description of the diagnostic process, selection of treatment and EDITORIAL