Multimodal Interventions to Improve the Management of Chronic Non-Malignant Pain in Primary Care Using Participatory Research

Round 1

Reviewer 1 Report

This is an interesting paper that studies how to improve management of pain, a significative social and public health problem, using a PAR process. This manuscript presents critical problems in its current form that will have to be improved before being accepted for publication.

One of the problems is that the Results sections appears to describe exclusively part  2.2.4. Procedure of  2.2. Phase 2: Interaction. 

Authors do not provide any Results of the "exhaustive review of the literature" or how they reached "recommendations based on levels of evidence". Those steps are critical and thorough and precise details of that process and results is necessary to be included in this manuscript. Authors will have to include search strategy and major findings, and what method was used to grade levels of evidence.

Authors will also have to clarify what an "exhaustive review of the literature" is, and why they decided not to conduct a "systematic review of the literature".

Next step is a variant of the Delphi Method. A clear description of what was discussed and Results obtained is necessary.

Authors later indicate that a "clinical trial was carried" to "assess the effectiveness of the application". No mention in the Methods or in the Results section is provided regarding what exactly this "clinical trial" was.

Results section includes a Table 6 which is titled "Multimodal intervention". One may assume this is the final output of this project, but not clear whether based on what is presented one may understand what the intervention really consists.

Discussion section has to be completely modified. As the indications for Authors indicate "Authors should discuss the results and how they can be interpreted in perspective of previous studies and of the working hypotheses. The findings and their implications should be discussed in the broadest context possible and limitations of the work highlighted. Future research directions may also be mentioned. This section may be combined with Results." What they provided is a reflection on pain and pain management but they don't discuss their own findings. Limitations of their Methods and Results are necessary.

Author Response

Author's Reply to the Review Report (Reviewer 1)

Author Response File: Author Response.pdf

Reviewer 2 Report

In this article, the authors analyse the recommendations for the management of CNMP with the use of participatory methodology. Even if this topic is quite interesting, many elements should be addressed in order to improve the manuscript:

The introduction seems redundant and I invite the Authors to resume key concepts.

English revision should be provided (i.e. line 62 “are needed”, line 66-67 phrase reconstruction: Combined therapy programs……should be developed to improve……)

The Authors selected 15 clinical and scientific experts from different field to select final recommendations divided in four groups (pharmacological therapy, psychoeducational therapy, physical exercise, and health assets). I understand the meaning of the discussion between expert and the group, however, the level of evidence must be reported in a scientific paper. If it is impossible to assess this, they should use “suggestions” in spite of "evidence".  

Some methodological questions should be clarified:

Why did the Authors select 15 expert, how was this sample calculated?   

How many people comprised the nominal group?

Which was the pain diagnosis of patients selected for the expert patients group? The inclusion criteria are excessively vague. Why did you contact 30 experts, how was this number selected?  

How was the questionnaire agreement between the 4 groups? There was a role of the 2 professional experts included in the groups as moderator? Their experience/knowledge influenced the results? Seven professional experts were not involved in the discussion with groups as moderators? Why?   

These data should have been analysed and reported into the paper.

In the discussion (line 303), the Authors stated “this study obtained the best evidence….” It is difficult to support this thesis since this paper cannot assess a true level of evidence. Moreover as stated at line 307, opinions and demands were collected.

The findings of this paper were compared to reviewed literature as stated by the Authors. Unfortunately, no clear comparison was provided between author’s findings and literature and no adequate discussion was provided. I suggest to improve this key element. It is also important to summarise the literature key concepts and provide adequate references.  

Line 326 “no cure for pain syndromes” what did the authors mean with this sentence? It is very confusing and not understandable.

Line 341: why did the authors cite ibuprofen instead of citing COX-1 and COX-2 inhibitors?

In this paper the Authors reported only pharmacological, non-pharmacological and psychological therapies for the management of CNMP. However, interventional and surgical pain management should be cited since these approaches are gaining in importance.   

A limitations of this study should be added at the end of the discussion.

Author Response

Author's Reply to the Review Report (Reviewer 2)

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

The manuscript has improved significantly with the changes.

Section 2.3. with Phase 3: Modeling should be eliminated from Methods. A paragraph may be included in the Discussion.

A Section 5. Conclusions could help to wrap up the main findings and implications of this paper.

English editing will be necessary.

Author Response

Section 2.3. with Phase 3: Modeling should be eliminated from Methods. A paragraph may be included in the Discussion.

 In agreement

A Section 5. Conclusions could help to wrap up the main findings and implications of this paper.

 In agreement

Reviewer 2 Report

The paper was much improved from the last original version. 

It can be accepted in the present form. 

Author Response

The paper was much improved from the last original version. 

It can be accepted in the present form. 

 In agreement Thank you very much for your review

Round 3

Reviewer 1 Report

The manuscript has improved significantly.

English editing may be necessary.