{"id":8095,"date":"2026-04-03T11:20:29","date_gmt":"2026-04-03T11:20:29","guid":{"rendered":"https:\/\/www.proefschriftmaken.nl\/portfolio\/jose-geurts\/"},"modified":"2026-04-23T09:02:58","modified_gmt":"2026-04-23T09:02:58","slug":"jose-geurts","status":"publish","type":"us_portfolio","link":"https:\/\/www.proefschriftmaken.nl\/en\/portfolio\/jose-geurts\/","title":{"rendered":"Jose Geurts"},"content":{"rendered":"","protected":false},"excerpt":{"rendered":"","protected":false},"author":8,"featured_media":14122,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"us_portfolio_category":[45],"class_list":["post-8095","us_portfolio","type-us_portfolio","status-publish","has-post-thumbnail","hentry","us_portfolio_category-new-template"],"acf":{"naam_van_het_proefschift":"Chronic Pain","samenvatting":"Er is geen Nederlandse samenvatting beschikbaar. De Engelse samenvatting vind je <a href=\"https:\/\/www.proefschriftmaken.nl\/en\/portfolio\/jose-geurts\/\">hier<\/a>.","summary":"General Discussion\n\nNearly 20% of adults in Europe suffer from one or more chronic pain conditions. 1 Burden of disease research showed that chronic pain syndromes score globally in the 2 top 10 when years living with disability are concerned. This thesis describes the impact of chronic pain on patients, on society and on pain treatment, and it shows that the burden of chronic pain is high both for the individual patient and for society. A large 3 part of the burden of chronic pain for patients is the search for a pain relieving treatment, and partly because of this long quest for pain relief, costs for patients and society are high. Chronic pain treatment can be challenging because often the cause of the chronic pain is not exactly known. If a precise diagnosis is lacking, classification of symptoms becomes essential. It is important to specify subgroups of patients within the chronic 4 pain population who could be helped with a specific pain treatment and on the same level of importance, to identify those patients for whom such treatment would not be helpful. Costs of healthcare are high and neither patient nor society benefits from incorrect targeted treatment. Subgrouping or classification creates the opportunity to avoid unnecessary treatment and to develop specifically targeted effective treatments and treatment pathways for each subgroup. Besides, consideration of patients\u2019 expectations is essential as a discrepancy between patients\u2019 expectations and treatment choices may add to additional patient and societal burden.\n\nAims and Outcome\n\nThe first aim of this thesis was to explore the burden of chronic pain for patients and society. Low back pain is the most prevalent chronic pain syndrome, therefore we started this thesis to explore the amount of the burden by studying the incidence of chronic low back pain (LBP) one year following patients visiting their general practitioner for acute LBP (chapter 2). This systematic review regarding the course of low back pain showed that in the first 3 months recovery is observed in 33% of patients and one year after onset 65% of patients still report pain. The findings of this study indicate that the assumption that spontaneous recovery occurs in a large majority of acute low back pain patients, is not justified. Chapter 3 shows that patient burden and societal burden for patients with chronic discogenic low back pain (CDP) is high. We found that average pain severity was 6.5 (0-10) and 46% suffered from severe pain (\u22657\/10). All patients had physical limitations, mean limitations rate was 43.7 (100% = totally disabled), and 13.5% of the patients were very limited to disabled (60 to 100% disabled). QALY loss compared to a healthy population was 64%. Healthcare costs were mainly related to pain treatments. Using the friction costs approach, we found that the annual costs for society are \u20ac7,912 per CDP patient; 51% healthcare costs and 49% societal. When using the human capital approach total costs were \u20ac18,940; 22% healthcare and 78% societal costs. The friction cost approach is recommended in the Dutch guidelines but internationally 5 the human capital approach is commonly used.\n\nThe second aim was to explore potentially (cost-)effective treatments for chronic pain syndromes. Chapter 4 shows the design of a cost-effectiveness analysis parallel to a randomized controlled trial investigating the potential value of a low cost minimally invasive interventional treatment option to relieve discogenic pain. The treatment group receives an intradiscal injection with methylene blue (IMBI), lidocaine, and contrast; the control group receives intradiscal isotonic saline with lidocaine and contrast. Because diagnostic criteria for discogenic pain are not well established inclusion and exclusion criteria were very strict and include a positive provocative discography. Evidence-based effective pain treatments are rare for intractable discogenic low back pain. This minimally invasive treatment option is relatively cheap and, if clinically successful, could become the \u2018pain treatment of choice\u2019 for a selected group of patients with chronic discogenic low back pain for whom non-invasive treatment options failed.\n\nChapter 5 shows the results of the cost-effectiveness analysis explained in chapter 4. Thirty-five percent of the patients in the IMBI group responded with \u226530 pain relief to the pain treatment versus 27% in the control group. The base case cost-effectiveness analysis showed an incremental cost per QALY of \u20ac71,571, indicating that IMBI is more effective, but also more costly. The cost-effectiveness acceptability curve showed that the probability that IMBI is cost-effective ranged between 26% and 42% depending on the maximum willingness to pay (threshold value) for a QALY, indicating that IMBI is not cost-effective at the short term. Post hoc subgroup analyses gave an indication that cost-effectiveness of the IMBI treatment could be higher in a selected group of patients with more severe pain (<7 NRS), lower quality of life (<0.45 utility score), and with shorter disease duration (<5 years). In both the IMBI and control group, healthcare and societal costs decreased during the 6 months of follow-up, while quality of life increased.\n\nChapter 6 shows the results of a long term effectiveness study regarding conventional spinal cord stimulation (con-SCS) in Complex Regional Pain Syndrome type I (CRPS-I). Spinal cord stimulation (SCS) provides an effective long-term pain treatment for 63% of implanted CRPS-I patients. Forty-one percent of SCS treated patients had at least 30% pain reduction at measurement endpoint. Sixty-one percent of the patients had at least one re-intervention after implantation due to equipment related problems, battery changes, and complications, with a total of 122 re-interventions over 12 years of follow-up. Mean pain relief of at least 50% one week after the test stimulation is associated with long-term treatment success.\n\nChapter 7 is a topical review about current and future perspectives of SCS for treatment of chronic pain syndromes. This study evaluates the evidence of (cost)-effectiveness and complications and side effects for all currently used stimulation modalities. This study shows that there is evidence available for cost-effectiveness of conventional SCS for the treatment of CRPS-I and failed back Surgery syndrome (FBBS) and for High Frequency SCS in FBBS. For all other indications and 6-8 stimulation modalities cost effectiveness still needs to be established. This paper states 9 that when (cost)effectiveness is proven, in the future, tailoring stimulation solutions for each individual patient could be available and patients\u2019 preferences for stimulation type or system can be taken into account as well. This also implies that pain management with SCS becomes more complex because of the extended choice in systems, treatment modalities, and potential targets. SCS requires experienced physicians, a multidisciplinary approach to selection of patients, and ongoing care of patients. A point of concern is that, at present, cost-effectiveness of SCS is impeded by the high costs of the device and the high incidence of complications and side effects requiring re-intervention and surgery. The costs of SCS and the device related re-interventions are high (approximately $24,000). Consequently, SCS treatment is not accessible for everyone in the world and up to now is only available for selected indications. Goals for future development of SCS include collecting evidence for long-term effectiveness and (cost-)effectiveness of other indications and stimulation modalities, reduction of device cost, and improvements in technology leading to reduced complication rates and longer time effectiveness.\n\nThe third aim of this thesis was to explore what patients expect from chronic pain management. Chapter 8 shows the results of a systematic review on chronic pain patients\u2019 expectations for pain treatment. Because the term expectations is multidimensional this review provides a framework in which expectations are distinguished between structure, process, and outcome expectations. A further distinction was made between value expectations (like an ideal, norm, or necessity) and predicted expectation (like a probability of an outcome). This review found that assessment of patients\u2019 expectations for treatment is mostly limited to outcome expectations. Patients generally have high expectations regarding pain reduction after treatment if expressed as a predicted expectation (44-64% pain relief), but considerably higher when expressed as an ideal expectation (81-93% pain relief). It is concluded that asking the right question regarding patients\u2019 expectations is important for shared-decision-making in pain management and related research. As patients generally have high expectations regarding pain treatment, health care professionals should discuss reachable treatment goals with their pain patients.\n\nDiscussion and recommendations\n\nTo improve healthcare performance it is important to have a shared goal that unites interests and activities of all stakeholders. Achieving high value for patients must be the overarching goal of health care delivery, with value defined as health outcomes achieved per dollar\/euro spent. Considering patients\u2019 expectations regarding chronic pain management in a shared decision making process is key in achieving this. 10\n\nBurden of chronic pain\n\nThe results of the systematic review about the clinical course of low back pain indicates that the current paradigm that the prognosis of acute low back pain is mostly favorable, is probably false. The belief that \u2018the outcome of low back pain is mostly favorable\u2019, might lead to conservatism in pain management and could be contra productive for innovations in pain treatment. There should be more focus on intensive follow-up and coaching of patients who have not recovered within the first three months to prevent pain chronification. The burden of disease study in this thesis shows that Dutch society spends \u20ac7,911.95 (friction costs approach) or \u20ac18,940.58 (human capital approach) annually per patient with chronic discogenic low back pain. Health care resources are mostly used for pain therapies. Despite the pain treatment efforts, chronic discogenic low back pain patients continue to suffer from severe pain, are physically limited, and experience serious loss of quality of life. These results indicate the need for treatment options with timely and long-term favorable outcome.\n\nTreatment options for chronic pain\n\nChronic pain typically begins as acute pain that is difficult to control and transforms into a persistent pain condition. Chronic pain often has neuropathic features that in general are in the long term unresponsive to pharmacological options. Trials regarding 11 pharmacology in neuropathic pain show generally modest outcomes even for effective drugs, with numbers needed to treat (NNT) of >6, for strong opioids the NNT shows >4. Research into how and why the transition from acute to chronic pain occurs has 12 led to a stronger appreciation of opioid-induced hyperalgesia (in which a patient receiving opioids for the treatment of pain becomes more sensitive to painful stimuli), use of more effective and safer opioid-sparing analgesic regimens, and non-pharmacological interventions for pain management. 13 An overreliance on opioids has impacted all types of pain management, making it undoubtedly a root cause of the \u201cepidemic\u201d of prescription opioid abuse in the United States (US). However, this problem is not limited to the US. After discharge from 14 elective surgery, overprescription of opioids, in particular oxycodone, is common in Europe as well. One of the current challenges in specialized chronic pain management 15 centers is to diminish chronic pain patients\u2019 opioids use after earlier prescription for acute (postoperative) pain. 16,17 Opioids weaning is particularly important in chronic pain management because of the former mentioned opioid-induced hyperalgesia. When contemplating interventional pain treatment options healthcare providers involved in pain management should include reduction or elimination of opioid use as part of the treatment plan. The large NNT of pharmacological options provide an extra argument to consider the use of minor invasive interventional pain treatment options early in the course of the disease like the rather low-cost option intradiscal methylene blue injection (IMBI) studied in this thesis in patients with discogenic pain.\n\nResearch into cost-effectiveness of pain therapies\n\nCost-effectiveness analyses can supply healthcare decision-makers with information about the relative value of each intervention per euro spent. The 2 interventional treatment options described in part 2 of this thesis are spinal cord stimulation (SCS) and intradiscal methylene blue injection (IMBI). Costs of the intervention for the 2 treatment options described in this thesis (IMBI versus SCS) are located on the low end of the \u2018cost ladder\u2019 (costs of IMBI treatment is \u00b1 \u20ac500) as well as on the high end (spinal cord stimulation costs approximately $24,000). A single center prospective clinical trial that studied SCS 18 in patients with discogenic pain was published recently with promising results. However, 19 if after treatment the value gained is equal for the discogenic pain suffering patient, patients who could have been helped with a \u20ac500 costing intervention should not be treated with a higher cost treatment like spinal cord stimulation. Cost effectiveness analyses evaluating pain interventions are scarce up till now, although the costs of the interventions should be important for healthcare providers and decision makers. This thesis shows that besides establishing the costs of treatments, cost effectiveness studies can also help in the decision which pain treatment could be suitable for which patient population. The cost-effectiveness study in this thesis indicated that prediction analysis could also be of interest in cost effectiveness analyses, to target which patient is likely to gain from the treatment at acceptable costs. For example, in chapter 5 the cost per QALY ratio showed dominance for the IMBI intervention in patients with high pain severity (\u22657). In patients with very low quality of life (<0.45) costs per QALY was \u20ac11,828 for the IMBI treatment, which is below the lower threshold of \u20ac20,000\/QALY. Although post hoc and lacking sufficient power for firm conclusions, the finding that IMBI is cost-effective in patients with these patient characteristics suggest that IMBI might be an interesting treatment option for discogenic pain suffering patients with severe pain and low quality of life. Therefore, further research into (cost)effectiveness of the IMBI treatment in a specific pain population is still needed. Alternatively, data from sufficiently large and comparable patient groups that have received IMBI treatment would allow for multivariate regression analysis, which can be helpful in identifying subgroups of patients for which treatment is (cost)effective.\n\nResearch into personalized pain treatment options\n\nIn chronic pain it has been suggested that pain phenotype based on putative pain mechanisms may predict response to treatment. Correct patient selection for pain 20 treatments is still challenging because a generally acknowledged evidence-based classification of chronic pain has not been established yet and diagnostic criteria are still mostly ineffective. In interventional pain research it is therefore important to specify for which patient population the treatment could be of interest to prevent incorrect targeting of treatment and as a consequence reject the treatment for all patients. Classifications of chronic pain syndromes are generally directed at anatomy (like low back pain and more specifically: facet pain or discogenic pain), or classifications encompass pain types such as nociceptive or neuropathic pain. 21-23 Recently, the IASP taskforce constructed a classification framework for the World Health Organization (WHO) International Classification of Diseases (ICD)-11. In this framework etiology 24 and pathophysiology have been combined. This means that the pain types are specifically included in the classification. It could be that this combination, using both an anatomy-oriented and a pain type classification, can be helpful to identify the right patient for each treatment option.\n\nExpectations for chronic pain management.\n\nThe systematic review in this thesis about patients\u2019 expectations for chronic pain treatment provides a framework for understanding types of expectations. Expectations were categorized as value expectations expressed in ideals, in norms and necessities; and predicted expectations in which patients express expected outcome. These type of expectations were further categorized within the Donabedian\u2019s healthcare model of structure, process and outcome. This review showed that overall patients\u2019 expectations of pain reduction after treatment are high, which is specifically true for value expectations of patients. These high value expectations can lead to dissatisfaction with pain management even if the clinical outcomes are met. Therefore, health care 25 professionals should actively inquire about the (type of) expectations that chronic pain patients hold, and discuss reachable treatment goals. Furthermore, focusing on improvement of outcome alone is not the answer, as patients\u2019 satisfaction with care is also dependent on structure and process aspects of care. There is some evidence that structure and process expectations are even stronger predictors of pain management satisfaction in chronic pain patients than outcome. 26 Value expectations refer to hopes and wishes while predicted expectations are the more realistic expectations. Association between high expectations and a better outcome is present when assessing predicted (i.e., more realistic) expectations. In contrast no association was found between high ideal expectations and better outcome. Patients\u2019 expectations for a specific treatment can furthermore be altered by information from the professional about evidence for potential benefits and harms of the intended treatment. Management of expectations before and during pain management could be an important contribution to patients\u2019 satisfaction by lowering predicted expectations that are too high or heighten predicted expectations that are too low. Differentiating between types of expectations could also be important if patients are in the process of accepting the pain. The pain management challenge should be to provide a personalized pain management program without obstructing the patient\u2019s pain acceptance process. In shared decision making, it is likely that the process of pain acceptance is supported if predominantly predicted expectations are discussed. We also found that most quantitative papers did not use validated expectation scales. This could be due to the fact that applied research into patients\u2019 expectations is still in its infancy. An instrument which assesses expectations before the first consultation, could be a useful tool to discover genuine patients\u2019 needs, predicted expectations, and treatment goals so as to incorporate them into the treatment plan. Developing and validating expectation scales that comprise structure, process, and outcome as well as the different types of expectations, would be helpful for shared decision making and could provide a useful tool for expectations management during pain therapies. Furthermore, such an instrument could also help to discover and discuss realistic expectations for treatment, so as to avoid disappointment and dissatisfaction with care.\n\nConclusion\n\nCarefully designed comparative long-term follow-up studies accompanied with cost-effectiveness analyses assessing pain treatments can help policymakers to select and reimburse those treatments that add value for money at the macro level. To achieve value based healthcare at the individual pain patient level, the key challenges for chronic pain management are to develop and search for effective treatment options, personalized pain treatments i.e. correctly select patients for each treatment, and to anticipate on patients\u2019 expectations and incorporate those into the shared decision making process.","auteur":"Jose Geurts","auteur_slug":"jose-geurts","publicatiedatum":"11 december 2019","taal":"EN","url_flipbook":"https:\/\/ebook.proefschriftmaken.nl\/ebook\/josegeurts?iframe=true","url_download_pdf":"","url_epub":"","ordernummer":"FTP-202604031116","isbn":"978 94 6380 597 1","doi_nummer":"","naam_universiteit":"Universiteit Maastricht","afbeeldingen":14122,"naam_student:":"","binnenwerk":"","universiteit":"Universiteit Maastricht","cover":"","afwerking":"","cover_afwerking":"","design":""},"_links":{"self":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/8095","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio"}],"about":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/types\/us_portfolio"}],"author":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/users\/8"}],"replies":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/comments?post=8095"}],"version-history":[{"count":1,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/8095\/revisions"}],"predecessor-version":[{"id":8096,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/8095\/revisions\/8096"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/media\/14122"}],"wp:attachment":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/media?parent=8095"}],"wp:term":[{"taxonomy":"us_portfolio_category","embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio_category?post=8095"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}