Prediction and assessment of the severity of post-operative pain and of satisfaction with management

Are there reliable predictors of postoperative pain?

BACKGROUND

The purpose of this study was to identify the preoperative determinants of severe postoperative pain.

METHODS

Potential predictors were assessed using a questionnaire submitted on the day before surgery. Pain at rest, and pain during coughing/mobilization, were measured using visual analog scales on the day of surgery and on the following 2 days. The type of postoperative pain management was not standardized and was prescribed by the anesthesiologist in charge. Multivariate logistic regression models explaining postoperative pain were developed in Group I, comprising 304 consecutive patients undergoing orthopedic or intraperitoneal surgery, and validated in Group II, comprising 145 independent patients.

RESULTS

Of the 62 variables examined by univariate analysis, only five were found to increase the risk of severe postoperative pain in Group I at rest and six factors during cough/mobilization. In the multivariate model for pain at rest, general anesthesia, expectation of postoperative pain, and chronic sleeping difficulties increased the risk of severe postoperative pain. In Group II, only chronic sleeping difficulties remained (OR: 3.97, 95% Cl: 1.69-9.29). In the multivariate model during cough/mobilization, intraperitoneal surgery, fear of postoperative pain, and having a relative with a history of pain increased the risk of severe postoperative pain in Group I. Intraperitoneal surgery OR 2.45 (95% Cl = 1.01-4.50) and having a relative with a history of pain OR 2.06 (95% Cl = 1.005-4.50) remained in Group II.

CONCLUSION

Of the many factors that may influence postoperative pain, chronic sleeping difficulties emerge in this population of patients as the strongest determinant of pain at rest. Intraperitoneal surgery and having a relative with a history of pain are the strongest determinants of pain during cough/mobilization. These findings make physiological sense and deserve more attention by anesthesiologists.

Postoperative pain management on surgical wards—impact of database documentation of anesthesia organized services

Postoperative pain management (POPM) should be based on an organization exploiting existing expertise and documenting the outcome of the POPM in each individual patient. The aims of the present study were to evaluate the adequacy of database documentation of POPM of an anesthesia organized, nurse-based, anesthesiologist-supervised acute pain service (APS) on surgical wards and to assess to what extent the information obtained was continuously used to improve practice. From 2890 registered cases in the database (patient controlled analgesia, n = 1975; epidural analgesia [EDA], n = 915), a homogeneous two-year sample of documentation charts from use of EDA for POPM in connection with major, open, abdominal surgical procedures (n = 381) was chosen for detailed analysis. The data charts contained information on patient data, drug dosage, total amount of infused drug, duration of EDA treatment, occurrence of side effects, and patient's level of satisfaction. The database information was easily accessible making assessment of relevant aspects of the routines, including associations between analgesic technique, patient related factors, and satisfaction with the services, immediately available. Only 58% of the data charts were properly completed and fed into the database but the clinical safety of the missing nondatabase documented sample was not found jeopardized. Although the database documentation routines were considered to fulfill basic requirements of data collection and monitoring of the appropriateness of POPM, they were not found to function optimally. The reason seemed to be inadequate feedback of information between the parties involved in the POPM services. The present study stresses the importance of establishing routines for adequate, continuous feedback of recorded audit data from the APS team to the surgical wards for the maintenance of a high level of compliance with accepted guidelines.

Factors affecting intravenous analgesic requirements after colectomy

BACKGROUND

The purpose of this study was to determine factors that influence postoperative IV analgesic use after colectomy.

STUDY DESIGN

We retrospectively evaluated patients who underwent colectomy between January 1997 and December 2000 at our medical center and calculated the amount of postoperative IV narcotics needed in morphine equivalents. Statistical differences (p < 0.05 considered significant) were measured using the Wilcoxon rank-sum test. Correlations were performed using Spearman correlation coefficients, and linear regression analysis was also performed.

RESULTS

Four hundred eighty-one patients (235 men, 246 women) underwent colectomy; patients had a mean age of 60.6 years (range, 17 to 96 years). Procedures performed included total/subtotal colectomy (10%, n = 49), right colectomy (42%, n = 200), transverse colectomy (3%, n = 12), left/sigmoid colectomy (40%, n = 195), and low anterior resection (4%, n = 17). Laparoscopic colectomy was performed in 53 (11%) patients. Mean postoperative morphine equivalent use was 160.2 mg. Narcotic analgesic use was significantly less for women (p = 0.02), diagnosis of cancer (p = 0.02), and laparoscopic colectomy (p = 0.0001). Patients undergoing a right colectomy required less postoperative narcotics than patients having other types of colectomies (p < 0.02). There was a positive correlation between postoperative narcotic use and operative time (r = 0.14, p = 0.007) and a negative correlation with patient age (r = -0.37, p = 0.0001). Linear regression analysis demonstrated that age (p = 0.0001), female gender (p = 0.04), and laparoscopy (p = 0.001) were independent predictors for decreased narcotic use.

CONCLUSIONS

Postoperative IV narcotic analgesic use is affected by gender, patient age, indication for colectomy, operative time, type of procedure, and operative technique.

Assessment of postsurgical recovery after discharge using a pen computer diary*

We assessed patients after their return home following gynaecological surgery, using a daily electronic diary. Thirty-two females aged 27-77 years took part. After a hospital stay of 1-6 days (mean 2.3), they were given a pen-based electronic diary and asked to record symptoms and other data over one month. They also completed a questionnaire at the end of the study. Substantial effects on quality and duration of sleep, pain during both the night and day, interference with daily activities, energy, and ability to concentrate were recorded, mostly during the first week of treatment. Symptoms reported in the final questionnaire correlated significantly with diary data. Most patients found the electronic diary easy to use, and none found it difficult. Daily electronic diaries are an acceptable method of obtaining better information on the extent and duration of symptoms and other difficulties after discharge following surgery.

Preoperative prediction of severe postoperative pain

We developed and validated a prediction rule for the occurrence of early postoperative severe pain in surgical inpatients, using predictors that can be easily documented in a preoperative setting. A cohort of surgical inpatients (n=1416) undergoing various procedures except cardiac surgery and intracranial neurosurgery in a University Hospital were studied. Preoperatively the following predictors were collected: age, gender, type of scheduled surgery, expected incision size, blood pressure, heart rate, Quetelet index, the presence and severity of preoperative pain, health-related quality of life the (SF-36), Spielberger's State-Trait Anxiety Inventory (STAI) and the Amsterdam Preoperative Anxiety and Information Scale (APAIS). The outcome was the presence of severe postoperative pain (defined as Numeric Rating Scale > or =8) within the first hour postoperatively. Multivariate logistic regression in combination with bootstrapping techniques (as a method for internal validation) was used to derive a stable prediction model. Independent predictors of severe postoperative pain were younger age, female gender, level of preoperative pain, incision size and type of surgery. The area under the receiver operator characteristic (ROC) curve was 0.71 (95% CI: 0.68-0.74). Adding APAIS scores (measures of preoperative anxiety and need for information), but not STAI, provided a slightly better model (ROC area 0.73). The reliability of this extended model was good (Hosmer and Lemeshow test p-value 0.78). We have demonstrated that severe postoperative pain early after awakening from general anesthesia can be predicted with a scoring rule, using a small set of variables that can be easily obtained from all patients at the preoperative visit. Before this internally validated preoperative prediction rule can be applied in clinical practice to support anticipatory pain management, external validation in other clinical settings is necessary.

Tolerance, Hospital Stay, and Recovery after Uterine Artery Embolization for Fibroids: The Ontario Uterine Fibroid Embolization Trial

PURPOSE

Uterine artery embolization (UAE) is gaining popularity as an alternative to hysterectomy for the treatment of fibroids. Although minimally invasive treatments such as UAE offer the potential of fewer complications, shorter hospital stay, and quicker recovery than surgery, there have been few published data on tolerance and recovery in patients undergoing UAE.

MATERIALS AND METHODS

This was a multicenter prospective single-arm clinical treatment trial involving the practices of 11 interventional radiologists in eight Ontario university-affiliated and community hospitals. Between November 1998 and November 2000, 555 women underwent UAE for symptomatic uterine fibroids. Follow-up included ultrasound examinations and telephone interviews. UAE was performed under conscious sedation. Polyvinyl alcohol particles (355-500 micro m) were the primary embolic agent, and the procedural endpoint involved stasis in the uterine arteries. Pain protocols included antiinflammatory medications and narcotics and a planned overnight hospital admission. Tolerance and recovery were measured by patient-reported pain intensity (10-point numeric rating and five-point descriptor scale), hospital length of stay (LOS), and time until return to work.

RESULTS

Intraprocedural pain was reported by 30% of patients and postprocedural pain was reported by 92% of patients (mean pain rating +/- SD, 7.0 +/- 2.47). The mean hospital LOS was 1.3 nights. Postprocedural pain was the most common indication for an LOS greater than 1 night (18%) or 2 nights (5%). Return visits to the hospital (10%) and readmissions (3%) were primarily for pain. The overall postprocedural complication rate was 8.0% (95% CI: 5.9%-10.6%). Of the 44 complications, 32 (73%) were pain-related. The mean recovery time after UAE was 13.1 days (median, 10.0 d).

CONCLUSION

The majority of patients had a 1-night LOS after UAE and recovered within 2 weeks. Postprocedural pain varied considerably and was the major indication for extended hospital stay and recovery.

What pain scales do nurses use in the postanaesthesia care unit?

BACKGROUND AND OBJECTIVE

The visual analogue scale (VAS) is considered as the gold standard method for postoperative pain assessment. Nevertheless, in some clinical situations, this method may not be reliable. We performed an observational study to assess the use of the VAS and other pain scales by nurses in the postanaesthesia care unit.

METHODS

We studied the reasons for not using the VAS and asked if it may be less appropriate in certain age groups.

RESULTS

Among 600 patients included in the study (16% = 70 yr), nurses used the VAS in 53%, the numerical rating scale in 30%, the verbal rating scale in 12% and the behavioural scale in 5%. In 43% of the assessments, nursed did not use the VAS; the most frequently cited reason was related to their preference for other methods. In 54% of the assessments, the reason for not using the VAS was related to the patients, mainly when they were in too much pain to use it (22%). When the patient was in too much pain, the numerical rating scale was chosen in 54% and the behavioural scale in 27%. There was no difference between young patients and elderly patients.

CONCLUSIONS

Although the VAS is the standard method to assess pain, the nurses preferred using the numerical rating scale, both spontaneously or when VAS assessment was not possible.

Gender bias in the observation of experimental pain

The aim of this study was to examine how men and women observe experimentally induced pain in male and female participants and to specifically determine the accuracy of observed pain ratings, the possible interactions between the sex of the viewer and the sex of the individual being observed, and the influence of gender role expectations on observed pain ratings. The sample comprised 29 participants (15 females). They each completed a battery of psychological questionnaires and viewed a presentation of 10 randomly ordered video clips. Each presentation consisted of 10 video clips, lasting 30s, of a participant (five males and five females) in the cold pressor task. The participants viewing the videos were asked to provide several ratings, including observed pain intensity and gender role related characteristics of the individual in the video. In terms of sex of the video participant, results indicated that viewers rated male videos as having less pain than female videos although the effect was small. Regarding sex of the viewer, results indicated that for both male and female videos, female viewers rated observed pain intensity significantly higher than did male viewers. In terms of accuracy, results indicated that on average, female video participants' pain was underestimated by 14 points, while male videos participants' pain was underestimated by 22 points (on a 0-100-point scale). Pain intensity ratings and pain tolerance from the participants in the videos did not differ significantly with respect to sex, though women had shorter tolerance times and higher pain ratings than men. Hierarchical regression analyses indicated that expectations of gender related 'endurance of pain' significantly predicted ratings of both male and female videos. When endurance expectations were controlled, sex of the viewer no longer significantly predicted observed pain ratings. The 'willingness to report pain' variable was not a significant predictor of observed pain ratings. Our results show that women are perceived to have more pain than men, that there was a tendency by both sexes to underestimate pain in others, but men showed even greater underestimation, and that gender role expectations of pain endurance given by the video observers accounted for substantial variance in their ratings of pain in the videos.

Sex differences in analgesic responses: evidence from experimental pain models

BACKGROUND AND OBJECTIVE

Sex-related influences on the experience of pain have received considerable empirical attention. Women are at greater risk for several forms of clinical pain and exhibit greater perceptual responses to experimental pain. In recent years, investigators have turned their attention to the influence of sex-related factors on analgesic responses. The purpose of this review is to examine the literature on sex differences in analgesic responses, emphasizing findings from experimental studies.

METHODS

First, important methodological issues in laboratory pain research are presented, and sex differences in responses to experimentally-induced pain are briefly addressed. Next, previous data from non-human animal research and human experimental and clinical research related to sex differences in analgesia are discussed. Also, preliminary results are presented from an ongoing study in our laboratory examining analgesic responses in women and men.

RESULTS AND CONCLUSIONS

Both previous research and preliminary findings from our laboratory suggests that opioids produce greater analgesic responses in women than men. Potential mechanisms underlying sex differences in analgesia are proposed, and important directions for future research are suggested.

Prevalence and characteristics of pain induced by percutaneous liver biopsy

Percutaneous needle liver biopsy is an important procedure for the diagnosis and evaluation of liver disease and is frequently associated with pain. In this prospective study, we investigated the prevalence and characteristics of this pain syndrome. Fifty-four subjects, who underwent liver biopsy under ultrasound guidance, received 5 mg of diazepam orally 1 h before the procedure and local infiltration with 10 mL of 2% lidocaine just before needle insertion. Outcome measures included the visual analog scale for measuring pain intensity over 24 h, pain localization on a body scheme, and the Spielberger questionnaire for measuring anxiety levels. Forty-seven (84%) of the 54 respondents reported pain 30 min after the biopsy (visual analog scale, 4.2 +/- 0.5; mean +/- SEM), and 21 (39%) reported pain at the 24-h time point. Biopsy site pain was reported by 9 subjects, right shoulder pain by 14, and pain at both sites by 24. Higher pain intensities were reported by women and by subjects with higher anxiety levels. This study indicates that liver biopsy is a painful condition in most patients. Mild anxiolytic treatment plus local anesthetic infiltration seem to produce insufficient analgesia, thus indicating that a more profound analgesic treatment is required for better control of this pain.

IMPLICATIONS

Percutaneous liver biopsy is a painful procedure in most patients. Mild anxiolytic treatment plus local anesthetic infiltration seem to produce insufficient analgesia. A more profound analgesic treatment is required for better control of this pain.

Distraction therapy with nature sights and sounds reduces pain during flexible bronchoscopy: a complementary approach to routine analgesia

STUDY OBJECTIVES

To determine whether distraction therapy with nature sights and sounds during flexible bronchoscopy (FB) reduces pain and anxiety.

DESIGN

Randomized controlled trial.

SETTING

Teaching hospital in Baltimore, MD.

PATIENTS

Consecutive adult patients (n = 80) undergoing FB with conscious sedation.

INTERVENTION

Nature scene murals were placed at the bedside, and patients were provided a tape of nature sounds to listen to before, during, and after the procedure. Patients assigned to the control group were not offered either the nature scene or the sounds.

MEASUREMENTS AND RESULTS

The primary outcomes were patient ratings of pain control (a 5-point scale ranging from poor to excellent) and anxiety. In a multivariate ordinal logistic regression model, the odds of better pain control were greater in the intervention patients than in the control patients (odds ratio [OR], 4.76; 95% confidence interval [CI], 1.35 to 16.7), after adjustment for age, gender, race, education, health status, and dose of narcotic medication. Older patients and patients with better health status reported significantly less pain. There was no difference in patient-reported anxiety between the two groups (OR, 0.87; 95% CI, 0.39 to 1.96).

CONCLUSIONS

Distraction therapy with nature sights and sounds significantly reduces pain in patients undergoing FB. Although the precise mechanism of this beneficial effect requires further investigation, clinicians should consider this nonintrusive strategy in addition to standard analgesic medications in patients undergoing painful, invasive procedures.

Postoperative pain management on surgical wards--do quality assurance strategies result in long-term effects on staff member attitudes and clinical outcomes?

Postoperative pain management (POPM) remains suboptimal on surgical wards in many countries despite the availability of effective analgesics, new technologies for drug administration, and clinical practice guidelines for pain management. The aim of the present study was to assess remaining long-term effects on pain management routines, patient experiences, and staff member attitudes in surgical wards more than 3 years after introduction of a quality assurance program for POPM and compare the findings to those of an organization where a corresponding systematic, entire hospital, quality assurance program had not been completed. A descriptive and comparative design, based on survey data from both patients (N = 110) and staff members (N = 51) on urologic surgery wards, was used. Significant (p <.05 to p <.0002) overall relationships were observed for identified shortages in pain management routines (lack of preoperative information, inadequate preoperative discussions on pain management, wait for pain killer) and reported experience of pain, nausea, or vomiting in the postoperative period. The quality assurance program, anesthesia-based pain services using a nurse-based anesthesiologist-supervised model, resulted in more adequate pain management routines, better patient satisfaction with POPM, and increased confidence in pain management among nurses on the surgical wards. On the basis of the present study it may be concluded that more than 3 years after the introduction of a quality assurance program for POPM in surgical wards, the pain management routines, patient experiences, and staff member attitudes have remained markedly improved and in accordance with the aims of accepted clinical practice guidelines for surgical pain management.

Changing acute pain management outcomes in surgical patients

Patient outcome studies indicate that patients accept pain as part of hospitalization. The majority of hospitalized patients who report experiencing pain are recovering from surgical intervention. To achieve successful outcomes, a comprehensive multidisciplinary effort must begin preoperatively and continue through discharge. The perioperative period is an essential link in effective pain management, and perioperative nurses are key in helping direct the care of surgical patients before, during, and after surgical procedures. Pain relief and the patients satisfaction with care frequently are used to measure pain management outcomes. This article examines the results of a secondary analysis of a subset of surgical patients drawn from a larger data set that was collected during two studies in urban and rural hospitals. It focuses on two outcomes, namely characteristics of pain and patient satisfaction with pain management after surgery. These outcomes were measured using the American Pain Society patient outcome questionnaire and the pain management index. Correlational, descriptive, and regression analyses indicate that postoperative management of patients' pain in these studies was less than optimal. From this new understanding, strategies for effective pain management of surgical patients are recommended.

Clinical characteristics of chronic back pain as a function of gender and oral opioid use

STUDY DESIGN

A cross-sectional analysis of data derived from patients with chronic spinal pain undergoing evaluation at a multidisciplinary pain treatment center was conducted.

OBJECTIVE

To determine whether pain severity, psychological status, and physical disability differed as a function of gender and opioid use, and whether the clinical correlates of opioid use differed in women and men with chronic back pain.

SUMMARY OF BACKGROUND DATA

Gender differences in the experience of pain have been widely reported. For example, in the general population, several chronic pain conditions are more prevalent among women than among men, and many experimental studies demonstrate lower pain thresholds and tolerances among women. In addition, recent evidence from studies of experimental and acute clinical pain suggests that responses to analgesic medications may differ in women and men.

METHODS

The sample consisted of 240 patients (35% women) with low back, upper back, or neck pain undergoing evaluation for treatment at a multidisciplinary pain center. The patients were classified as opioid or nonopioid users on the basis of self-report and medical record review. All the patients completed a battery of clinical assessments, including measures of pain severity, psychological adjustment, self-reported disability, functional tasks, and pain tolerance. Analyses were conducted to examine clinical variables as a function of gender and opioid use.

RESULTS

The results indicated that opioid use was associated with greater self-reported disability and poorer function in both women and men. However, the association of opioid use with affective distress differed between women and men. The women using opioids showed lower affective distress, whereas the opioid-using men reported greater affective distress. Opioid use was not associated with pain severity, although the women reported greater pain than men.

CONCLUSIONS

These findings indicate that both opioid use and gender are significant predictors of clinical status of patients with chronic spinal pain. More interesting, these two variables interact because opioid use was associated with increased affective distress among the men, but the reverse was true for the women. In addition, the women reported greater pain severity, which is consistent with some previous findings. Potential explanations for these findings are presented, and the practical implications are discussed.

Observation of pain assessment and management--the complexities of clinical practice

Pain assessment and management are complex issues that embrace physiological, emotional, cognitive, and social dimensions. This observational study sought to investigate nurse-patient interactions associated with pain assessment and management in hospitalized postsurgical patients in clinical practice settings. Twelve field observations were carried out on Registered Nurses' activities relating to pain with their assigned patients. All nurses were involved in direct patient care in one surgical unit of a metropolitan teaching hospital in Melbourne, Australia. Six observation times were identified as key periods for activities relating to pain, which included change of shift and high activity periods. Each observation period lasted 2 hours and was examined on two occasions. Four major themes were identified as barriers to effective pain management: nurses' responses to interruptions of activities relating to pain, nurses' attentiveness to patient cues of pain, nurses' varying interpretations of pain, and nurses' attempts to address competing demands of nurses, doctors and patients. These findings provide some understanding of the complexities impacting on nurses' assessment and management of postoperative pain. Further research using this observational methodology is indicated to examine these influences in more depth. This knowledge may form the basis for developing and evaluating strategic intervention programmes that analyse nurses' management of postoperative pain and, in particular, their administration of opioid analgesics.

Preoperative predictors of moderate to intense acute postoperative pain in patients undergoing abdominal surgery

BACKGROUND

Pain is a sensory and emotional experience that is influenced by physiologic, sensory, affective, cognitive, socio-cultural, and behavioral factors. Consistent with the perspective to improve the postoperative pain control, the present study has the purpose of assessing the effect of presurgical clinical factors, psychological and demographic characteristics as predictors for reporting moderate to intense acute postoperative pain.

METHODS

A prospective cohort study was performed with 346 inpatients undergoing abdominal elective surgery (ASA physical status I-III, age range 18-60 years). The measuring instruments were Pain Visual Analog Scale, the State-Trait Anxiety Inventory, and the Montgomery-Asberg Depression Rating Scale. Multivariate conditional regression modeling was used to determine independent predictors for moderate to intense acute postoperative pain.

RESULTS

Moderate to intense acute postoperative pain was associated with status ASA III (odds ratio (OR) = 1.99), age (OR = 4.72), preoperative moderate to intense pain (OR = 2.96), chronic pain (OR = 1.75), high trait-anxiety and depressive mood moderate to intense (OR = 1.74 and OR = 2.00, respectively). Patients undergoing surgery to treat cancer presented lower risk for reporting moderate to intense pain OR = 0.39, as well as those that received the epidural analgesia and multimodal analgesia with systemic opioid (OR = 0.09 and OR = 0.16, respectively).

CONCLUSIONS

The identification of predictive factors for intense acute postoperative pain may be useful for designing specific preventive interventions to relieve patient suffering. Especially because few of these variables are accessible for medical intervention, which would improve the clinical outcomes and quality of life of patients at risk of moderate to intense acute postoperative pain.

Analgesic use for postoperative pain: differences arise when comparing departments of surgery

PURPOSE

The goal of the study is to analyse whether the analgesic therapy of postoperative pain during the first 2 days after surgery differs among the different surgical departments.

METHODS

Patients were randomly chosen from among all those who underwent elective surgery. Characteristics of analgesic treatment (drug, dosage, schedule) and pain intensity were determined at the postoperative anaesthetic care unit and in the first and second postoperative days on the ward. All comparisons were carried out by surgical departments.

RESULTS

Six hundred and twenty-three patients from six surgical departments were studied. Analgesic treatment orders varied greatly among the different departments, and these differences were statistically significant regarding number of drugs, type of drugs, analgesic schedule, and completeness of medical orders. Some differences were also observed regarding drug dosage. Patients from gynaecology and obstetrics, traumatology and orthopaedics and general surgery reported the most severe pain.

CONCLUSIONS

The treatment of postoperative pain differs among the surgical departments, especially regarding analgesic schedules and completeness of analgesic orders. Analgesic therapy may often be based more on customary habits than on the patients' pain intensity.

Internal health status belief and lower perceived functional deficit are related among anterior cruciate ligament-deficient patients

PURPOSE

Health locus of control has been shown to influence the recovery process after injury and surgery. This study attempted to determine relationships between patient perceptions of health locus of control and their perceived functional limitations after anterior cruciate ligament (ACL) rupture. An external health locus of control refers to the belief that one's outcome after injury or surgery is under the control of powerful others or is determined by fate, luck, or chance. An internal health locus of control refers to the belief that one's outcome is directly related to individual patient behaviors.

TYPE OF STUDY

Quasi-experimental, posttest only design.

METHODS

Over a 1-year time period, 70 consecutive patients with unilateral ACL deficiency (acute, <1 month after onset) agreed to participate in this study. All data were collected 1 week before ACL reconstruction. Subjects completed the Health Locus of Control Scale (HLC) and the physical function section of the Short Form 36 (SF-36) Health Survey. A Kruskal-Wallis 1-way analysis of variance was used to assess group differences (P <.05) based on SF-36 physical function score classification.

RESULTS

Subjects with minimal perceived functional limitations (SF-36 physical function group 3) displayed lower (more internal) HLC scores (29.6 +/- 4.4; range, 24-36) than subjects with moderate perceived functional limitations (SF-36 physical function group 2) (33.0 +/- 6.1; range, 22-44) or subjects with maximal perceived functional limitations (SF-36 physical function group 1) (33.9 +/- 2.8; range, 30-38).

CONCLUSIONS

Subjects with lower perceived functional limitations regarded their health status as being controlled more by internal factors. It is not proven whether there is a cause-and-effect relationship or which of these parameters is the antecedent. Related reports suggest that perception of control may positively influence functional outcome and disability levels. Patients who perceive preoperative pain and functional limitation to be excessive may have low tolerance for the stressors associated with surgery and postoperative rehabilitation. With these patients, a more conservative surgical and rehabilitation approach may be better. Alternatively, methods to change their perceptions, such as cognitive therapy, may have a positive role.

Health-related quality of life of unrelated bone marrow donors in Japan

To promote bone marrow donation, both the safety and well-being of healthy unrelated volunteer donors must be protected. This prospective cohort study evaluated donors' health-related quality of life (HRQOL) and identified factors associated with it. Using the Medical Outcomes Study Short Form 36 Health Survey (SF-36) before bone marrow harvesting (BMH), and again 1 week and 3 months after the donors' discharge, we evaluated HRQOL of 565 donors (329 men, 236 women) registered with the Japan Marrow Donor Program (JMDP). We also examined the data routinely collected by the JMDP, such as BMH-related problems and other demographic and medical variables, to determine whether such data could be used to predict donors' HRQOL after discharge. Mean scores of all pre-BMH SF-36 subscales showed better functioning than the national norm. One week after discharge, mean scores on physical functioning (PF) and role-physical (RP) subscales, indicative of physical states, and bodily pain (BP) were approximately 1 SD lower than the national norm; however, mental health (MH) and general health perception (GH) remained above normal; the most frequent BMH-related problems were pain at the donation site and lower back pain, which were associated with lower PF, RP, and BP scores. Female gender and duration of procedure predicted lower PF, RP, and BP. Three months after discharge, mean scores of all SF-36 subscales had returned to baseline levels. These data show that the adverse effects of BMH on donors' HRQOL are transient and can be minimized by better management of pain.

Influence of expectations and actual pain experiences on satisfaction with postoperative pain management

Experience of moderate or even severe postoperative pain has remained a clinical problem despite major progress in pain assessment and management. The aim of the present study was to assess any association between different pre- as well as postoperative factors, actual pain experiences in the postoperative period, and the overall patient satisfaction with the pain management. A random sample of surgical patients (n =191) responded to pre- and postoperative questionnaires detailing presence of preoperative baseline pain, expected and actually experienced postoperative pain levels and perceived adequacy of the pain relief provided. Patient satisfaction was assessed and factors of importance for satisfaction/dissatisfaction were analysed. It was found that 88% of the patients had previously undergone surgical procedures and that 53% of these patients claimed to have experienced moderate or severe pain at that time. Current pain prior to the present surgical procedure was reported by 61% of the patients. Most patients (91%) expected pain of moderate to severe intensity and 76% reported to have experienced such pain levels. In spite of this 81% of the patients claimed to be satisfied with the pain management while only 8% were dissatisfied. Sex, age, pre-operative expectation and actual experience of pain relief, and the overall pain experience were found to be factors associated with the probability of being satisfied/dissatisfied. Main characteristics of the dissatisfied patient were a younger age and female sex. It is concluded that patients commonly expect moderate to severe pain in the postoperative period and that the actual pain experience is mainly in accordance with the pre-operative expectations. Therefore, the validity of patient satisfaction as an optimal outcome variable in quality assurance processes of postoperative pain management may be questioned.

Risk factors for postoperative anxiety in adults

We identified risk factors for postoperative anxiety and quantified their effect on 712 adults between 18 and 60 years of age (ASA I-III physical status) undergoing elective surgery under general anaesthesia, neural blockade or both. The measuring instruments were a structured questionnaire, a pain visual analogue scale, the McGill Pain Questionnaire, the State-Trait Anxiety Inventory, the Montgomery-Asberg Depression Rating Scale, a Self-Reporting Questionnaire-20, and a Self-Perception of Future Questionnaire. Multivariate conditional regression modelling taking into account the hierarchical relationship between risk factors revealed that postoperative anxiety was associated with ASA status III (OR = 1.48), history of smoking (1.62), moderate to intense postoperative pain (OR = 2.62) and high pain rating index (OR = 2.35), minor psychiatric disorders (OR = 1.87), pre-operative state-anxiety (OR = 2.65), and negative future perception (OR = 2.20). Neural block anaesthesia (OR = 0.72), systemic multimodal analgesia (OR = 0.62) and neuroaxial opioids with or without local anaesthesia (OR = 0.63) were found to be protective factors against postoperative anxiety.

Age-related differences in pain perception and report

The clinical and laboratory-based evidence for age-related differences in pain perception and report are reviewed. Most clinical studies suggest a relative decrease in the frequency and intensity of pain symptoms associated with myocardial complaints, visceral infections, musculoskeletal conditions, and postoperative and malignant pain problems in adults of advanced age. The findings from experimentally controlled laboratory investigations are more equivocal and vary according to the type and intensity of noxious stimulation. Nonetheless, such studies also provide some additional support for the notion of an age-related decrease in pain perception and report. Evidence has not determined whether the observed changes are caused by the aging process or reflect other age-associated effects, including an increased presence of comorbid disease, biocultural cohort effects, or altered psychosocial influences.

The role of pain anxiety, coping, and pain self-efficacy in rheumatoid arthritis patient functioning

Anxiety about pain is increasingly recognized as one factor contributing to increased pain perception and pain behavior [McCracken, L. M., Faber S. D., & Janeck A. S. (1998) Pain-related anxiety predicts nonspecific physical complaints in persons with chronic pain. Behavior Research and Therapy, 36, 621-630; McCracken L., & Gross R. (1995). The pain anxiety symptoms scale (PASS) and the assessment of emotional responses to pain. Innovations in clinical practice: a source book, 14, 309-321]. To assess this emotional reaction to pain in chronic pain patients, McCracken, Zayfert and Gross [McCracken, L., Zayfert, C., & Gross, R. (1992). The Pain Anxiety Symptom Scale: development and validation of a scale to measure fear of pain. Pain, 50, 67-73] developed the Pain Anxiety Symptom Scale (PASS) composed of four subscales: Cognitive Anxiety, Fearful Appraisal, Escape Avoidance and Physiological Anxiety. The present study extended previous work by examining the relationship among pain anxiety dimensions, use of active and passive coping strategies and arthritis self-efficacy as predictors of functional status in 154 rheumatoid arthritis (RA) patients. Functional status was assessed using the Five-Factor Model of the Arthritis Impact Scale, 2nd ed., (AIMS2): Physical Functioning, Affective Experience, Symptoms, Social Interaction and Role Function. Hierarchical multiple regression analysis on each of the AIMS2 criterion variables showed that pain anxiety, pain and symptom self-efficacy, health status and coping strategies were able to explain between 9 and 38% of the variance in the five AIMS2 variables. The present results support the hypothesized role of pain anxiety along with previously established contributions of self-efficacy and coping strategies, in affecting physical, social, emotional and role functioning in chronic RA patients.

Predictors of pain control in patients undergoing flexible bronchoscopy

The purpose of this study was to assess the extent to which patients undergoing flexible bronchoscopy (FOB) experience pain and to identify patient factors and process of care factors that are associated with pain. We conducted a prospective cohort study on 481 patients undergoing FOB. Overall control of pain during FOB was the primary outcome. The mean age of the patients was 48 yr, 50% were male, and 32% required supplemental oxygen prior to FOB. Pain control was excellent in 36% of patients, but 10% considered it to be fair or poor. Patient factors associated with excellent pain control were excellent health (versus poor health, OR = 6.25 [95% CI, 2.28-16.67]), more education (college education versus high school education, OR = 1.72 [95% CI, 1.05-2.86]), and not having asthma (OR = 2.86 [95% CI, 1.09-7.14]). Process of care factors associated with excellent pain control were not being bothered by scope insertion (versus bothered, OR = 3.65 [95% CI, 1.99-6.98]), no memory of FOB (versus some memory, OR = 2.33 [95% CI, 1.24-4.44]), and higher ratings of information about the procedure (per 1-point increase on a 12-point scale, OR = 1.57 [95% CI, 1.41-1.78]). This is the first large-scale, prospective study to evaluate patient and process of care factors that influence pain control during FOB. It demonstrated that there are patient characteristics and process of care factors that need to be considered when evaluating pain during bronchoscopy. Improved preparation of patients with lower education, inferior health status, and asthma may lead to decreased pain during FOB. Bronchoscopists may be able to reduce pain during FOB by identifying methods to decrease pain on scope insertion, by improving the information provided to patients, and by achieving greater levels of amnesia during FOB.

Applying the American Pain Society's QA standards to evaluate the quality of pain management among surgical, oncology, and hospice inpatients in Taiwan

The purpose of this study was two-fold: first, to apply the American Pain Society (APS) outcome questionnaire to examine and compare the quality of pain management provided in surgical, oncology, and hospice inpatient units in the Taipei area of Taiwan, and second, to provide baseline data of pain management quality in advance of the implementation of national guidelines for cancer pain management. Data revealed that hospice patients had significantly lower levels of pain severity and higher satisfaction with pain management than did oncology or surgical patients. A majority of patients reported that they received pain medication within 15 min after they complained of pain. However, a large number of patients never asked for pain medication during hospitalization. Moreover, most of the patients never requested medication changes even when their perception was that their medication were not effective. The findings of this study may provide support for the effectiveness of hospices in Taiwan in pain management and provide important information on the validity of the APS quality standards.

The visual analog scale allows effective measurement of preoperative anxiety and detection of patients' anesthetic concerns

The advent of managed care, reduction of costs, and advances in medical technology place increasing demands on anesthesiologists. Preoperative anxiety may go unnoticed in an environment that stresses increased productivity. The present study compares different methods for measuring preoperative anxiety, identifies certain patient characteristics that predispose to high anxiety, and describes the quantity and quality of anxiety that patients experience preoperatively. Seven hundred thirty-four patients participated in the study. We assessed aspects of anxiety by means of visual analog scales (VAS) and the State Anxiety Score of the Spielberger State-Trait Anxiety Inventory (STAI). The mean STAI anxiety score was 39 +/- 1 (n = 486) and the mean VAS for fear of anesthesia was 29 +/- 1 (n = 539). Patients feared surgery significantly more than anesthesia (P < 0.001). The VAS measuring fear of anesthesia correlated well with the STAI score (r = 0.55; P < 0.01). Young patients, female patients, and patients with no previous anesthetic experience or a previous negative anesthetic experience had higher anxiety scores. Patients worried most about the waiting period preceding surgery and were least concerned about possible awareness intraoperatively. Factor analysis of various anxiety items showed three distinct dimensions of fear: 1) the fear of the unknown 2) the fear of feeling ill, and 3) the fear for one's life. Among these dimensions, fear of the unknown correlated highest with the anxiety measuring techniques STAI and VAS. The simple VAS proved to be a useful and valid measure of preoperative anxiety.

IMPLICATIONS

The study of qualitative aspects of anxiety reveals three distinct dimensions of preoperative fear: fear of the unknown, fear of feeling ill, and fear for one's life. Groups of patients with a higher degree of preoperative anxiety and their specific anesthetic concerns can be identified using the visual analog scale.

Rehabilitation complications following knee surgery

When pain and effusion have been minimized and patients assume appropriate knee posture at rest and during exercise, the extent of postinjury or postoperative quadriceps femoris neuromuscular inhibition and avoidance during locomotion is reduced. Restoring normal lower-extremity ROM and musculotendinous extensibility (with consideration for biarticular muscles) is foundational to the implementation of an exercise program that integrates the trunk, hip, and ankle muscles into dynamic knee-stabilization challenges while addressing isolated quadriceps femoris deficiencies. Cardiovascular conditioning should be addressed as early as feasible. Although programs generally address anaerobic and aerobic energy systems, increasing patients' fatigue resistance, as evidenced by prolonged maintenance of appropriate functional exercise techniques and body control without verbalized discomfort or observed movement-avoidance patterns, ensures therapists that neuromuscular responsiveness for dynamic knee stabilization is improving.