An interdisciplinary virtual group program addressing the FINER points of chronic pain management: an exploratory analysis of functional outcomes

Abstract

Objectives:

Chronic pain is multifactorial and has large social and economic costs. Comprehensive pain management through an interdisciplinary approach addressing the biopsychosocial model of pain is beneficial. The purpose of this study was to assess the feasibility and functional outcomes following participation in the 8-week virtual interdisciplinary Functional Integrative Restoration (FINER) program.

Design:

Cohort study.

Setting:

Virtual platform (Zoom) utilized by participants and clinicians within a large academic institution.

Subjects:

44 individuals with chronic pain meeting study criteria who participated in the virtual FINER program from September 2021 to April 2023 were included in final analysis.

Methods:

Participants attended twice weekly seminars and group sessions focused on pain education, lifestyle medicine, integrative medicine, and psychological therapies virtually and completed pre- and post-program surveys. Outcomes included the Pain Catastrophizing Scale (PCS), Tampa Scale of Kinesiophobia (TSK) and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29). Qualitative feedback was also obtained.

Results:

From September 2021 to April 2023, 44 adult FINER participants with chronic low back and/or neck pain completed pre- and post-intervention surveys. We observed significant improvements in PCS, TSK, and various domains of the PROMIS-29, including pain interference, participation, physical function, and sleep, with modest effect sizes.

Conclusions:

The FINER program reduced self-reported functional outcomes related to the participants’ chronic pain. Positive qualitative feedback from FINER participants suggested mental and physical health benefits. Future investigation will include a larger cohort and will deploy active (patient-reported outcomes) and passive (mobility and sociability) digital measures to further characterize functional changes.

Introduction

Chronic pain affects one in five adults in the United States as of 2019.¹ Chronic low back and neck pain are leading causes of disability worldwide and their prevalence has increased markedly over the past few decades.² In 2015, more than half a billion people had chronic low back pain and more than a third of a billion had chronic neck pain.² Chronic low back and neck pain may result in significant impairments in functional status, mood, social life, and ability to work.³ When accounting for direct costs to the health care system and the cost of lost productivity due to pain, the estimated annual societal cost of chronic pain ranges from $560 to $635 billion, higher than the cost of diabetes and cancer combined.⁴

While decades of research have sought to identify effective pharmacologic and non-pharmacologic treatments for chronic back pain, no singular therapy has proven effective in treating the entirety of a patient’s pain experience or in preventing pain’s recurrence.^5,6 As such, the biopsychosocial model of pain has emerged as a framework for organizing the complex interplay of sociocultural, behavioral, and psychological factors that combine with traditional biological causes of pain.⁷ The biopsychosocial framework acknowledges that, in addition to the distinct nociceptive, inflammatory, or pathologic basis of pain, each patient’s pain can vary as a function of emotional stress, maladaptive self-care habits, poor support networks, cultural differences, level of education, and income.⁸ Specific evidence-based interventions include promoting nutrition,^9,10 quality sleep,¹¹ physical activity,¹² mindfulness and stress management,¹³ resilience,¹⁴ and social connections.¹⁵ Additional research suggests that educating patients about the neurophysiologic mechanisms that underpin their pain may improve their pain and function.¹⁶

Mounting evidence supports a multimodal, interdisciplinary approach that incorporates education, exercise, and psychotherapy plus traditional pain management strategies to effectively treat chronic back pain ^7,17 and improve outcomes such as pain catastrophizing.¹⁸ Darnall et. al¹⁹ showed that a single-session pain management intervention like Empowered Relief^® was non-inferior to cognitive behavioral therapy (CBT) and superior to health education for improving pain catastrophizing. Pain catastrophizing has shown to be a predictor of quality of life and highly correlated with pain intensity. Pain catastrophizing—measured with the Pain Catastrophizing Scale (PCS) in individual patients— is the tendency to focus excessively on pain, magnify its impact, and feel helpless in controlling it. ^20–22 Studies have demonstrated that pain catastrophizing is associated with decreased quality of life and increased pain intensity in patients with chronic pain conditions, suggesting that a person’s quality of life is more associated with their beliefs about pain than with the pain intensity itself.²³

Functional restoration programs address the biological, psychologic, and social components of pain and have demonstrated considerable efficacy worldwide, dating back to the 1980’s.^24,25 Functional restoration programs typically employ an interdisciplinary team of clinicians including physicians, therapists, nurses, and psychologists or psychiatrists to offer longitudinal comprehensive and holistic biopsychosocial pain care.^24,25,26 From the perspective of a healthcare operations, when viewed at the individual patient level, interdisciplinary pain management programs are costly due to the time demand on the clinical team; however, at the population and societal level, this cost may be offset as such programs may reduce healthcare expenditure and promote return to work.^25,26

The coronavirus (COVID-19) pandemic posed unique challenges to patients with chronic pain. In many cases, telehealth adoption provided a necessary means for safe and accessible pain evaluation and management.^27,28 The Functional Integrative Restoration (FINER) program was developed at our institution, in 2020 to help meet the need for interdisciplinary pain management virtually and continues to date. Our program was inspired by the concepts of functional restoration programs, particularly the interdisciplinary nature and biopsychosocial focus, but the FINER program has a different format and is not considered to be a formal functional restoration program. FINER is an 8-week program facilitated by a team of physicians specializing in pain and spine care, pain psychologists, and physical therapists. The program consists of twice weekly virtual seminars and group sessions focused on pain neuroeducation, plus a wide range of evidence-based integrative, psychologic, and lifestyle factors that play a role in chronic pain. We hypothesized that the pilot virtual FINER program would improve participants’ self-reported functional status.

Methods

Design

This exploratory prospective cohort study was conducted within the MassGeneralBrigham hospital system. Approval was granted through the MassGeneralBrigham Institutional Review Board. All subjects signed a written informed consent prior to the start of this study. This manuscript was prepared in concordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.²⁹

Participants

Participants were recruited in cohorts to participate in the FINER virtual program by two board-certified physiatrists specializing in pain medicine, DS and JK, across clinical sites within a large academic institution. Potential subjects were screened for eligibility and invited to voluntarily participate in the study. Inclusion criteria included age over 18 years, chronic (>six months) back and/or neck pain, visits with multiple physicians or specialties for the same pain region within a three-month period, imaging workup within three years, history of failed conventional care with at least two therapies, and agreement to initial evaluation and subsequent attendance at virtual FINER sessions. Exclusion criteria included red flags warranting more urgent evaluation and management, scheduled surgery, mental health disorders requiring urgent or inpatient psychiatric care, non-English speaking, and missing pre- or post-intervention questionnaires. A detailed list of inclusion and exclusion criteria can be found in Supplemental Table 1. Participant data were reviewed for the purposes of this analysis from September 2021 to April 2023. Demographic and clinical background information was extracted from the electronic medical record. Information on opioid prescriptions was obtained via the prescription drug monitoring program.

The FINER Virtual Program

The FINER virtual program is an eight-week mind-body curriculum meant to serve as an adjunct to standard outpatient management for chronic pain. Each week is comprised of two live virtual (Zoom) sessions: 1) a large group session/ one-to-two-hour webinar that is available to all of our patients and 2) a small group one-hour session that is open to those who officially registered for the program and consented to the FINER study. Weekly live webinars focus on evidence-based chronic pain therapeutic concepts, including pain neuroscience education, lifestyle medicine (exercise, nutrition, sleep, stress management, social connections, avoidance of risky substances), integrative therapies (mindfulness, meditation, yoga, acupressure, Qigong, Tai Chi) and psychological therapies (Pain Reprocessing Therapy (PRT), Cognitive-Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), clinical hypnosis, and positive psychology). The small group sessions include a 40-minute discussion and practice of topics learned during the previous weekly webinar, facilitated by the physicians and pain psychologist, 15 minutes of gentle exercises led by a physical therapist, and five minutes of meditation, guided by a physician. Existing literature suggests that group therapies face several recruitment barriers, including the number of sessions, scheduling of sessions, and the availability of facilitators.³⁰ Each 8-week program had an average of 11 participants in the small groups, which facilitators felt was the optimal range for effective group dynamics. Additionally, we reasoned that the smaller group size made participants feel more confident that they were in a safe space to express their experiences without judgment. For purposes of the below analyses, we counted attendance in the live smaller group sessions as “FINER participation. There were a total of eight small group sessions. The personalized weekly group session involves active participant engagement to practice the learned concepts in a supportive group environment. This session is facilitated by an interdisciplinary team of board-certified pain medicine physicians, pain psychologists, and physical therapists. Participants were also oriented to free resources such as video recordings, articles, books, and mobile applications available via our website, finerprogram.org.

Outcome Measures

We collected survey data prior to and following FINER program participation using REDCap electronic data capture tools hosted at Mass General Brigham.³¹ Adherence to the FINER program was defined as having completed 6 or more weekly personalized group sessions. Outcomes collected included the Pain Catastrophizing Scale (PCS), the Tampa Scale of Kinesiophobia (TSK), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29). PCS was considered the primary outcome.

The PCS is a 13-item measure designed to explore the thoughts and feelings surrounding an individual’s pain experience. Specific individual domains include rumination, magnification, and helplessness. Responses are measured on a scale from 0 (not at all) to 4 (all the time) and the assessment is then scored by the sum of individual items with a range of 0 to 52 for the total score.³²

The TSK is a 17-item self-report measure developed to detect fear of movement or re-injury due to perceived pain. Each item is scored on a scale from 1 (strongly disagree) to 4 (strongly agree), with a range of 17 to 68 with higher scores indicating greater activity avoidance and somatization of pain experience.³³

The PROMIS-29 tool is a non-disease-specific measure of domains including physical functioning (higher score: less difficulty), pain intensity and interference (higher score: more interference), sleep disturbance (higher score: worse sleep), social participation (higher score: more participation), depression (higher score: more depressed), anxiety (higher score: more anxiety), and fatigue (higher score: more fatigue).³⁴ Pain intensity is scored on a 0–10 numerical rating scale. Each additional domain is scored on a multi-item five-point scale. The sum of the responses is converted to T-scores and compared with the general US population.³⁵

We additionally collected narrative qualitative feedback from participants via online survey following the FINER program.

Statistical Analysis

A descriptive data analysis was performed for baseline demographics. Means and standard deviations or median and quartile data were calculated for continuous variables depending on normality assumption, and frequencies and percentages for categorical variables. Each PROMIS-29 subscale score was converted to a T-score using standardized conversion tables, with a global mean of 50 and standard deviation of 10.³⁵ Shapiro-Wilk tests were used to examine the distribution of the data. A paired t-test or Wilcoxon signed-rank test was applied to estimate significance depending upon whether the data was normally or non-normally distributed. Cohen’s d was used to calculate the effect size of the pre/post changes in each PROMIS-29 subscale score. ANOVA, t-test, and linear regression were used to study the effects of demographic variables of interest [age, gender, body mass index (BMI), income level, current opioid use, current PT, history of surgery, and duration of symptoms] on the dependent variables (PCS, TSK, PROMIS-29 subscales) as correspondent. For feasibility, outcomes were compared between adherent and non-adherent participants using t-tests. Adherence was defined as participants who had attended at least 6, or 75% of smaller group sessions. To test the correlation between the number of sessions and the outcomes, Pearson or Spearman was used as applicable. Benjamini-Hochberg (BH) false discover rate <0.05 for 10 tests was applied. The significance level was set at a p-value <0.05. No missing data was found in the questionnaires of PCS, TSK and PROMIS-29 questionnaires assessing the effect of the FINER program. R studio (version 4.2.2.) was used for the analysis. Dose-response plot was made with Python 3.10.12.

Results

Demographics

Of 79 eligible participants initially enrolled for participation in the study, 44 participants were included in final analysis. Twenty-five had missing either pre- or post-intervention questionnaires, eight had previously completed a FINER session prior to the beginning of this study’s inclusion date, and two participated in more than one eight-week FINER session (Figure 1).

Figure 1. Study inclusion flowchart.

FINER, Functional Integrative Restoration program.

The majority (77%) of participants were female. The average age of participants was 55.6 years. The average BMI of participants was 26.9. Complete demographic information is detailed in Table 1.

Table 1.

Demographics.

	All patients N = 44
Age, mean (SD)	55.6 (15.6)
Gender, %
Female	77.3
Male	22.7
Nonbinary	0
Race, %
Asian	3.2
Black	4.5
Native American	2.3
White	86.4
Other	4.5
Ethnicity, %
Hispanic or Latino	6.8
BMI, %
Underweight (<18.5)	0.0
Normal Weight (18.5–24.9)	50.0
Overweight (25–29.9)	25
Obesity
Class I (30–34.9)	18.2%
Class II (35–39.9)	2.3%
Class III (≥40)	4.5%
Disability, %
Yes
Invisible	31.8
Visible	0.0
No	54.6
Prefer not to answer	13.6
Sexual Orientation, %
Heterosexual	88.6
LGBTQIA+	9.1
Unspecified	2.3
Type of Insurance, %
Private	50.0
Medicare	47.7
Medicaid	2.3
Household Income, %
Under 29,999	11.4
30,000–49,999	11.4
50,000–74,999	6.8
75,000–99,999	20.4
100,000–149,999	20.4
150,000–199,999	9.1
200,000 or more	18.2
Unspecified	2.3
Marital Status, %
Divorced	11.4
Domestic partner/civil union	4.5
Married	68.2
Single, cohabitating	2.3
Single, never married	13.6
Level of Education, %
Some college	18.3
Bachelor’s degree	38.6
Advanced degree	38.6
Vocational/trade/technical school	4.5

Detailed information regarding participants’ symptomatology, including pain duration, location, and diagnoses can be found in Table 2. Primary pain was in the cervical spine, lumbar spine, or both. Participants carried multiple primary pain diagnoses, including radiculopathy, spondylosis, stenosis, scoliosis, and myofascial pain. Participants had multiple concomitant sites of pain across the body. Some (31.7%) participants had underlying painful systemic conditions, such as fibromyalgia, rheumatologic disease, hypermobility, Lyme disease, and long-COVID-19.

Table 2.

Pain characteristics.

	All patients N = 44
Duration of symptoms, %
≥ 3 months but< 1 year	2.3
1 – 4.99 years	25
5 – 9.99 years	22.7
≥10 years	50
Primary site of pain, %
Cervical spine	20.4
Lumbar spine	40.9
Both	38.7
Diagnoses, %
Radiculopathy	45.4
Myofascial pain	54.5
Spondylosis	45.4
Spinal stenosis	11.4
Degenerative scoliosis	2.3
Concomitant sites of pain, %
None	22.7
Head/jaw	4.5
Hand	2.3
Shoulder	11.4
Thoracic/ribs	4.5
Sacroiliac joint	6.8
Pelvis	2.3
Hip	13.6
Knee	6.8
Leg/ankle	4.5
Systemic pain conditions
Fibromyalgia	13.6
Rheumatologic disease	4.5
Hypermobility	9.1
Post-infectious (Lyme, long-COVID-19)	4.5

A summary of prior nonsurgical treatments can be found in Figure 2. Nine participants (20.5%) had previously undergone spine surgery. Seventeen (38.6%) participants were receiving formal physical therapy concomitantly during the FINER program. Eleven (25%) participants were concurrently using opioids to manage their pain.

Figure 2. Prior treatments.

NSAID, non-steroidal anti-inflammatory drug. Prior treatments included physical therapy (93.1%), axial injection (e.g., epidural steroid injection, medial branch block and/or radiofrequency lesioning, 61.4%), muscle relaxer (e.g., cyclobenzaprine, tizanidine, baclofen, valium, 47.7%), neuropathic agents (e.g., gabapentin, pregabalin, 45.5%), trigger point injection (43.2%), acupuncture (38.6%), NSAID and/or acetaminophen (36.4%), opioids (27.3%), antidepressants (e.g., tricyclic, selective serotonin reuptake inhibitor, serotonin-norepinephrine reuptake inhibitor, 25%), topical agents (e.g., lidocaine patch, diclofenac gel 18.2%), chiropractor (18.2%), and oral steroids (6.8%).

Outcomes

Compared to baseline (mean=20.1, SD 11.24), there was a significant decrease in pain catastrophizing after the FINER program (mean=13.2, SD 10.50). This decrease showed a moderate effect size (Cohen’s d=−0.71) with a difference from pre- and post-values of −6.9 (p<0.001) with adjusted p-value by BH of 0.0002. Overall, 16 out of our 44 patients (36.4%) reported at least an 8 point improvement in pain catastrophizing, which has been defined as a Minimal Important Change in a study by Monticone et al. Patients showed a significant reduction on kinesiophobia after the FINER program with a mean difference −4.5 points (p<0.001), a moderate effect size (Cohen’s d=−0.69) with and adjusted p-value by BH of 0.0002. These outcomes are summarized in Figure 3 and Table 3.

Figure 3. Pain catastrophizing and kinesiophobia significantly decrease with FINER program.

3a.) Pain catastrophizing score significantly improved from pre-FINER (blue, 20.1 ± 11.2) to post-FINER (red, 13.2 ± 10.5). 3b.) Tampa Scale for Kinesiophobia score significantly improved from pre-FINER (blue, 38 ± 11.3) to post-FINER (red, 33.5 ± 10.5).

Table 3.

Summary of FINER impact across multiple standardized clinical instruments.

	Pre	Post	p-value	Cohen’s d
Pain Catastrophizing Scale (†)	20.1±11.2	13.2±10.5	<0.0001	−0.71
The Tampa Scale of Kinesiophobia (‡)	38±11.3	33.5±10.5	<0.0001	−0.69
PROMIS-29
Physical score (‡)	37.9±7.5	39.2±10.2	0.025	0.35
Anxiety score (†)	59.1±10.1	56.8±8.5	0.081	−0.27
Depression score (‡)	57.3±14.9	55.7±11.9	0.221	−0.19
Fatigue score (†)	56.9±9.3	56.1±7.7	0.355	−0.14
Sleep score (†)	55.2±7.5	52.9±7.9	0.010	−0.41
Participate score (†)	42.4±9.2	44.5±10.4	0.010	0.4
Pain interference score (†)	63.3±8.5	59.4±8.9	0.001	−0.53
Pain average (0–10) (‡)	6±4	5.5±4	0.090	−0.25

N=44. PROMIS, Patient-Reported Outcomes Measurement Information System.

^(†)indicates normally distributed data with data as mean ± SD, and compared using paired t-test,

^(‡)indicates skewed data with data as median ± IQR, and compared using Wilcoxon signed-rank test. Effect size measured as Cohen’s d.

Secondary outcomes included the PROMIS-29 scale with significant improvements in the following domains: physical function from baseline (mean difference=1.3, p=0.025, p-adjusted = 0.045), ability to participate in social activities (mean difference=2.1, p=0.01, p-adjusted= 0.021), sleep (mean difference=−2.2, p=0.01, p-adjusted = 0.021), and pain interference in an individual’s usual activities (mean difference=−3.9, p=0.001, p-adjusted = 0.004). Other domains including anxiety, depression, fatigue, and average pain measured on a 0–10 scale did not show significant results. However, 11 patients (25%) achieved a pain reduction of at least 10%−30%, 6 (13.6%) achieved a reduction 30–50% and 7 (15%) a reduction of more than 50%. Figure 4 and Table 3 summarize these results. Supplemental Figure 1 details individual participant scores before and after participation in FINER, which highlight important participant-specific outcomes that could allow for a better understanding of individual phenotypes that may derive success in the FINER program in the future, beyond our aggregate data.

Figure 4. Physical function, sleep, and participation improve with FINER program.

Significant improvements were observed from baseline (blue) to after completion of FINER program (red) in physical function, sleep, and participation. No statistically significant difference was observed in anxiety, depression, fatigue, pain interference, or pain score (0–10).

In the analysis of demographic variables and outcome measures, we observed a significant difference in the PROMIS-29 fatigue subscale between men and women, with men showing improved fatigue following the FINER program (Δ−4.7 versus Δ0.3, respectively, p=0.02). All other demographic variables of interest showed insignificant correlations with outcome measures, including age, BMI, income level, opioid use, current PT, history of surgery, and duration of symptoms (Table 4).

Table 4.

FINER improves function, largely independent of demographic variables.

	Age (†)	Sex (‡)	Income (§)	BMI (†)	Current opioid use (§)	Current PT (§)	History of surgery (§)	Duration of symptoms (‡)
TSK	0.57	0.75	0.65	0.65	0.42	0.88	0.48	0.65
PCS	0.67	0.47	0.41	0.95	0.29	0.19	0.91	0.79
PROMIS-29
Physical	0.84	0.28	0.77	0.91	0.55	0.42	0.47	0.09
Anxiety	0.17	0.37	0.49	0.58	0.27	0.82	0.78	0.30
Depression	0.71	0.71	0.26	0.34	0.19	0.57	0.61	0.63
Fatigue	0.70	0.02*	0.56	0.06	0.57	0.91	1.00	0.17
Sleep	0.15	0.62	0.99	0.42	0.38	0.30	0.33	0.43
Participation	0.33	0.80	0.55	0.93	0.81	0.26	0.41	0.20
Pain interference	0.59	0.85	0.55	0.76	0.47	0.38	0.98	0.88
Pain average	0.71	0.26	0.35	0.17	0.34	0.45	0.54	0.42

P-values for linear regression (†), t-test(‡), or ANOVA (§) models comparing the effect of demographic variables (age, sex, BMI, income level, current opiate use, current PT, history of surgery and duration of symptoms) on dependent variables (pain catastrophizing, TSK, PROMIS subscales) as correspondent. An asterisk denotes the significant difference noted in fatigue following FINER participation in males (mean difference = −4.7) compared to females (mean difference = 0.3). TSK, Tampa Scale of Kinesiophobia; PCS, Pain Catastrophizing Scale; PROMIS-29, Patient-Reported Outcomes Measurement Information System.

Feasibility

Participants completed a mean of 6.18 (SD 1.78) sessions. 68.2% were considered adherent to the FINER program. There were no significant differences between the demographic makeup of adherent and non-adherent patients (Supplemental Table 2). In the exploratory analysis for PROMIS-29 subscales, participants who attended 6 or more sessions had a significant increase from baseline in physical function (p=0.039), a decrease in anxiety (p=0.006), and better sleep (p=0.0031), compared to nonadherent participants. Dose-response plots showing mean difference in outcome measures by sessions attended are shown in Figure 5. Correlation analyses between PROMIS-29 functional subscales and number of sessions attended showed significant negative correlation with sleep (R=−0.35, p=0.021), depression (R=−0.31, p=0.038) and anxiety (R=−0.34, p=0.024) (Supplemental Figure 2). Furthermore, qualitative feedback obtained from survey data following FINER suggested that participants found the sessions beneficial by validating their pain experience, altering their perception of pain, building a social network, integrating physical activity, providing pain-related education, and setting goals toward lifestyle changes (Supplemental Table 3).

Figure 5. Multiple functional domains show dose-dependent improvement with FINER participation.

Dose response plots with y-axis showing the mean change per session number according to the test, and x-axis the number of sessions (1–8). The size of each dot represents the number of people per session.

Discussion

We report that our 8-week, virtual, interdisciplinary Functional Integrative Restoration (FINER) program benefits a complex population of participants with chronic neck and/or back pain who had persistent pain despite a variety of prior treatment strategies. FINER showed an overall positive impact across multiple functional domains including pain catastrophizing, kinesiophobia, PROMIS-29 subscales (social participation, physical function, sleep, and pain interference). Our results are in line with prior studies supporting multimodal, interdisciplinary programs for patients with chronic pain.^24,25,36 Consistent with previous reports from other group programs, we did not observe significant improvement in overall pain score on a 0–10 scale.^36,37 However, 54.5% of the participants accomplished a decrease of at least 10% on pain average corresponding to the minimal clinically important change in chronic pain according to the IMPACCT guidelines.³⁸ These findings could suggest that FINER participants were able to reframe their perception of chronic pain, thereby allowing for improved function despite relatively modest reduction in overall perceived pain on a numeric scale.

This was an exploratory analysis that showed significant improvement in our primary outcome, the Pain Catastrophizing Scale. A study found that the minimal important change for pain catastrophizing was approximately eight points,³⁹ and at least 16 out of the 44 patients (36.4%) accomplished this result. The program focuses on mindfulness, self-care, cognitive and emotional coping strategies, and introduces a variety of psychological therapies that address some appraisal mechanisms like rumination and helplessness, supporting previous studies.⁴⁰ Also, FINER is a group program that shares common experiences and motivation improving concepts as communal coping; previous studies have shown the importance of sharing a community and being part of a safe space.^41,42 Mindfulness techniques combined with pain reprocessing therapy and CBT might be able to target acceptance and self-regulation skills.^43–45 Overall a multidisciplinary program as FINER improve pain catastrophizing thinking that leads to an overall improvement of quality of life. We further note that a promising study by Ziadni et al⁴⁶ found that a single 2-hour Zoom-delivered Empowered Relief class significantly reduced pain catastrophizing, pain intensity, pain bothersomeness, and sleep disturbance in adults with chronic pain compared to a waitlist control group, with effects lasting up to 3 months post-treatment.

The ideal dose and duration of a group program for chronic pain is unclear. Our pilot data suggested significant improvements in physical function, anxiety, and sleep for individuals who attended at least six of eight FINER sessions compared to those who did not. Likewise, there was an overall negative correlation between the number of sessions attended and sleep, depression, and anxiety, suggesting that greater attendance may provide benefits in these domains. This observed effect could result from additional education, greater exposure to coping strategies, or increased community support from others in the group. Future work should address the ideal treatment dose and duration for maximum functional gains following a functional restoration program.

The variability in patient-specific demographic factors, diagnoses, and response to various medical and psychological treatments for chronic pain poses a significant challenge to effective pain management.⁴⁷ The biopsychosocial model attempts to recognize the biological, psychological, and sociodemographic mediators that underpin a person’s pain experience.⁸ Our exploratory data in this heterogeneous group of individuals suggested that men demonstrated greater improvements in fatigue than women. However, this data should be cautiously interpreted given our limited sample that consisted predominantly of women. We further note that our sample had substantial gender imbalance. Gender imbalances in chronic pain are well established: a 2019 study showed that of patients with localized chronic pain, 44% were men and 56% were women while in patients reporting widespread chronic pain, 40% were men and 60% were women.⁴⁸ Our previously published research further noted a gender imbalance in research participation, reporting nearly two to one women to men recruitment and completion (Recruited: 51F, 26M; Completed: 25F, 13M).⁴⁹ Notwithstanding this imbalance, we note that outcomes were not dependent on age, BMI, income, duration of symptoms, opioid use, concomitant PT regimen, or history of spine surgery. Further research in a larger sample may aid in the detection of patient-specific factors that may be associated with favorable responses to the FINER program.

Six significant qualitative themes were identified via patient feedback following the FINER program and may help explain the mechanism of FINER’s positive impact on the experience of chronic pain. These were validation of the pain experience, physical integration via group integrative therapies, altered perception and re-framing of pain, support from a chronic pain community, improved understanding of the definition and mechanism of pain, and empowerment to implement lifestyle changes. Specific participant feedback toward each of these themes is included in Supplemental Table 3. This positive qualitative feedback further supports that a virtual group program could be a feasible means of implementing interdisciplinary care for individuals with chronic pain.

The rapid expansion of virtual healthcare necessitated by the COVID-19 pandemic challenged physicians to find ways to continue to offer patient-centered care for patients with chronic pain.²⁷ While often falling short of a more thorough in-person assessment, virtual clinical consultation remains a convenient option for clinicians and patients alike, even after the shift back to in-person visits.²⁸ In our experience, the educational, group-based structure of the FINER program makes it particularly suitable for a virtual platform. Given the complex patient population we were able to engage, offering a virtual program (allowing participants to attend without leaving their home) proved to be not only appreciated, but an effective way of reaching patients where they were. Studies during COVID-19 like Hollyfield et. al 2023 showed the transition of in-person to a virtual ACT, supporting a high intensity of virtual ACT had significant but small effects in chronic pain.⁵⁰ Critically, we report preliminary data that even with our virtual interdisciplinary program, participants made meaningful self-reported functional gains across multiple physical and psychological domains. Additionally, the virtual platform may alleviate the additional costs associated with the infrastructure, travel costs, and potentially missed time at work that would be inherent to an in-person program. Further research is warranted to understand the economic implications of virtual interdisciplinary pain care.

Limitations

While our study demonstrated the potential benefits of the virtual FINER program, we also recognize its limitations. We had a relatively small sample size which may have been underpowered to detect meaningful differences in pre- and post-FINER secondary outcome measures. There was no control group to assess whether the outcomes we observed can be fully attributed to the FINER program. Our study also did not follow patients longitudinally after the 8-week study period to assess for long-term efficacy of the FINER program. Finally, this sample was comprised of majority white individuals, and we were limited in our ability to expand the FINER program to non-English speaking patients which may limit its generalizability to other populations. In the future we hope to expand the program to promote accessibility to a more diverse, gender balanced patient population including racial and ethnic minority groups, non-English speaking participants, and greater outreach to men.

Future Directions

We plan to continue to recruit participants to the FINER program as a means of interdisciplinary biopsychosocial pain management. In the future, we hope to integrate active (e.g., patient reported outcome measures) with passive (e.g., GPS location and accelerometer-based measures) outcome measures to further characterize changes in functional status related to participation in the FINER program.

Conclusions

We report that our virtual, interdisciplinary Functional Integrative Restoration (FINER) program significantly improved the management of chronic pain patients. Over the course of the 8-week program, we observed dose-dependent improvements across several self-reported domains related to the pain experience, including reduced pain catastrophizing and kinesiophobia, improved social participation and physical function, better sleep quality, and decreased pain interference. Future research will aim to expand the program to a larger population and evaluate its long-term effectiveness.