Predictors of response to pain management treatment. The role of family environment and changes in cognitive processes

Should Multidisciplinary Pain Management Programmes Attempt to Reduce Self-Reported Pain in Patients with Chronic Back Pain? The Experience of a Welsh Inpatient Unit

Given poor outcomes in pain reduction, It has recently been recommended in this Journal that the primary aim of multidisciplinary pain management programmes should be to improve physical functioning rather than attempting to reduce the experience of pain. This study evaluates the effectiveness of a pain management programme in reducing self-reported pain within the overall context of improvements in quality of life, as assessed by the SF36 Health Survey Questionnaire. Logistical and methodological problems in evaluating self-reported pain are discussed.

The results at discharge show a statistically significant reduction in reported pain for the group as a whole and a clinically relevant Improvement in 53.8% of patients. These benefits are maintained up to one-year follow-up, which suggests that pain management programmes should not abandon the attempt to reduce self-reported pain.

Arm ache

Both patients and providers hope for better management strategies for nonspecific activity-related upper limb pain (herein referred to as "arm ache"). The next innovation in the care of arm ache may arise from the strong evidence that mood, coping strategies (e.g., catastrophic thinking), and heightened illness concern-all very responsive to treatment with cognitive behavioral therapy-account for a large percentage of the variation in symptom intensity and magnitude of disability. This focus on treatments to reduce symptoms and disability represents a change in culture for patients and providers, both of whom are accustomed to the biomedical framework that anticipates a direct correspondence between illness (the state of being unwell) and disease (pathophysiology). Not all patients are ready for such an approach, but as a first step health providers can prioritize empathy; remain mindful that words, illness concepts, and treatments can reinforce ineffective coping strategies; and encourage curiosity about the human illness experience.

Participant Characteristics Associated with Symptomatic Improvement from Yoga for Chronic Low Back Pain

Context

Studies suggest that yoga is effective for moderate to severe chronic low back pain (cLBP) in diverse predominantly lower socioeconomic status populations. However, little is known about factors associated with benefit from the yoga intervention.

Objective

Identify factors at baseline independently associated with greater efficacy among participants in a study of yoga for cLBP.

Design

From September–December 2011, a 12-week randomized dosing trial was conducted comparing weekly vs. twice-weekly 75-minute hatha yoga classes for 95 predominantly low-income minority adults with nonspecific cLBP. Participant characteristics collected at baseline were used to determine factors beyond treatment assignment (reported in the initial study) that predicted outcome. We used bivariate testing to identify baseline characteristics associated with improvement in function and pain, and included select factors in a multivariate linear regression.

Setting

Recruitment and classes occurred in an academic safety-net hospital and five affiliated community health centers in Boston, Massachusetts.

Participants

Ninety-five adults with nonspecific cLBP, ages ranging from 20–64 (mean 48) years; 72 women and 23 men.

Outcome measures

Primary outcomes were changes in back-related function (modified Roland-Morris Disability Questionnaire, RMDQ; 0–23) and mean low back pain intensity (0–10) in the previous week, from baseline to week 12.

Results

Adjusting for group assignment, baseline RMDQ, age, and gender, foreign nationality and lower baseline SF36 physical component score (PCS) were independently associated with improvement in RMDQ. Greater than high school education level, cLBP less than 1 year, and lower baseline SF36 PCS were independently associated with improvement in pain intensity. Other demographics including race, income, gender, BMI, and use of pain medications were not associated with either outcome.

Conclusions

Poor physical health at baseline is associated with greater improvement from yoga in back-related function and pain. Race, income, and body mass index do not affect the potential for a person with low back pain to experience benefit from yoga.

Fear and Avoidance of Movement in People with Chronic Pain: Psychometric Properties of the 11-Item Tampa Scale for Kinesiophobia (TSK-11)

PURPOSE

To determine the psychometric properties of the 11-item Tampa Scale for Kinesiophobia (TSK-11) in patients with heterogeneous chronic pain.

METHODS

The study evaluated test-retest reliability (intra-class correlation coefficient), cross-sectional convergent construct validity (Pearson product-moment correlation between TSK-11 and the Pain Catastrophizing Scale [PCS] scores at admission), and sensitivity to change of the TSK-11 (area under the receiver operating characteristic [ROC] curve) in patients (n=74) with heterogeneous chronic pain. We used two data sets (retrospective, n=56; prospective, n=18). All patients attended the 4-week interdisciplinary chronic pain management programme at Chedoke Hospital, Hamilton Health Sciences, Hamilton, Ontario.

RESULTS

The test-retest reliability of the TSK-11 was 0.81 (95% CI, 0.58-0.93), the standard error of measurement was 2.41 (90% CI, 1.47-2.49), and the minimal detectible change score was 5.6. The correlation between TSK-11 and PCS at admission was 0.60 (95% CI, 0.43-0.73). The area under the ROC curve was 0.73 (95% CI, 0.57-0.88).

CONCLUSIONS

The study results provide evidence for the test-retest reliability, cross-sectional convergent construct validity, and sensitivity to change of the TSK-11 in a population with heterogeneous chronic pain.

Both early and late changes in psychological variables relate to treatment outcome for musculoskeletal pain patients at risk for disability

We know little about why some people get better after psychological treatments for pain disability, whereas other people do not. In order to understand differences in treatment response, we need to explore processes of change during treatment. It has been suggested that people with pain complaints who change early in treatment have better outcomes. Therefore, we aimed to investigate whether changes in psychological variables at different time points are related to outcome, and whether early or late changes are better predictors of outcome. We used the fear avoidance model as a theoretical framework. We followed 64 patients weekly over 6-7 weeks and then determined outcome. Our findings indicate that people who decrease in catastrophizing and function early in treatment as well as in depressive symptoms, worry, fear avoidance beliefs and function late in treatment have better outcomes. Early decreases in function, and late decreases in depressive symptoms and worry uniquely predict improvements in disability. While early and late changes covaried concurrently, there were no significant sequential relationships between early and late changes. Changes in the proposed process variables in the fear avoidance model, early as well as late in treatment, thus add valuable information to the explanation of outcome.

Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain

BACKGROUND

Unhelpful pain cognitions of patients with chronic low back pain (LBP) may limit physical performance and undermine physical assessment. It is not known whether a direct relationship exists between pain cognitions and physical performance.

AIMS

To determine if a relationship exists between change in pain cognitions and change in physical performance when chronic LBP patients participate in a single one-to-one education intervention during which they have no opportunity to be active.

METHODS

In a quasi-experiment using a convenience sample, moderately disabled chronic LBP patients (n=121) participated in a one-to-one education session about either lumbar spine physiology or pain physiology. Multiple regression analysis evaluated the relationship between change in pain cognitions measured by the survey of pain attitudes (SOPA) and the pain catastrophising scale (PCS) and change in physical performance, measured by the straight leg raise (SLR) and standing forward bending range.

RESULTS

There was a strong relationship between cognitive change and change in straight leg raise (SLR) and forward bending (r=0.88 and 0.79, respectively, P<0.01), mostly explained by change in the conviction that pain means tissue damage and catastrophising.

CONCLUSIONS

Change in pain cognitions is associated with change in physical performance, even when there is no opportunity to be physically active. Unhelpful pain cognitions should be considered when interpreting physical assessments.

Cognitive-Behavioral Perspective and Cognitive-Behavioral Therapy for People With Chronic Pain: Distinctions, Outcomes, and Innovations

This article reviews the cognitive-behavioral (CB) perspective on chronic pain and discusses the distinction between this perspective and cognitive and behavioral techniques. We describe the general efficacy of cognitive-behavioral therapy (CBT) in the treatment of people with chronic pain along with some of the limitations of published outcome studies. We discuss advances in moderation and mediation of treatment outcomes. Lastly, we discuss the need for research that takes into account growing interest in evidence-based medicine, methods that address responders and nonresponders, individual trajectories, how we might advance and refine CBT, and strategies related to relapse prevention, maintenance, and adherence enhancement taking advantage of evolving technological methods of service delivery. We provide recommendations on how to approach studies of CBT efficacy as a function of better understanding of patient characteristics and context. We advocate for the potential of the CB perspective for all healthcare providers regardless of discipline or training.

An exploration of the support person's perceptions and experiences of complex regional pain syndrome and the rehabilitation process

We explored the perceptions and experiences of those who support a relative or friend with complex regional pain syndrome (CRPS), a chronic pain condition of unknown aetiology usually affecting a single limb. Semi-structured interviews were analysed using interpretative phenomenological analysis, and four superordinate themes are presented here. These themes describe the efforts of carers to make sense of CRPS and the rehabilitation process, to be sensitive to the discomfort of the person with CRPS and to respond in an attuned and helpful way. CRPS had become integrated into the carers' lives as they sought to monitor, protect and motivate the person they supported. The themes are discussed in relation to each other and to extant literature, including work on social support and adjustment to chronic illness, and the clinical implications are explored.

Psychological perspective on hand injury and pain

NARRATIVE REVIEW: Pain is considered a fundamental ramification of hand injury and has been identified as one of the most acutely stressful aspects of traumatic injuries and their treatment. Both comorbid psychiatric conditions and psychosocial factors have been shown to affect medical treatment outcome in patients with hand disorders and pain, further complicating recovery and potentially leading to significant psychological, social, and economic consequences for the individual. The purpose of this article was to assist hand therapists in developing a greater understanding of psychological constructs, psychosocial variables, and comorbid psychiatric conditions and thereby facilitate the more effective identification of such factors. A case study is included to illustrate these concepts. Circumstances in which referral for a comprehensive psychological evaluation is necessary are discussed. Many of the principles reviewed are also applicable to other upper extremity and musculoskeletal conditions.

Psychosocial aspects of disabling musculoskeletal pain

Psychosocial factors are important determinants of pain intensity and disability in patients with disabling musculoskeletal pain. The psychosocial aspects of disabling musculoskeletal pain include cognitive (e.g., beliefs, expectations, and coping style), affective (e.g., depression, pain anxiety, heightened concern about illness, and anger), behavioral (e.g., avoidance), social (e.g., secondary gain), and cultural factors. The effectiveness of cognitive behavioral therapy and other treatments that address the psychosocial aspects of disabling musculoskeletal pain has been confirmed in numerous high-quality studies.

Behavioral medicine approaches to pain

Pain is a complex, idiosyncratic experience. When pain is the primary complaint for seeking medical attention, understanding of multiple factors is essential in guiding successful treatment. Behavioral medicine, a branch of psychology, has been an integral part of interdisciplinary/multidisciplinay care of pain patients. In this article, we provide an overview of behavioral medicine approaches to pain, including assessment and commonly used therapeutic methods. Particular attention is given to cognitive-behavioral therapy and motivational enhancement therapy.

One-year follow-up comparison of the effectiveness of McKenzie treatment and strengthening training for patients with chronic low back pain: outcome and prognostic factors

STUDY DESIGN

A randomized controlled trial with multivariable analyses of prognostic factors.

OBJECTIVE

To report the long-term outcome of McKenzie treatment compared with strengthening training. Further, to determine patient-related factors associated with poor outcome 14 months after completion of treatment.

SUMMARY OF BACKGROUND DATA

Exercise therapy is widely recommended for patients with chronic low back pain. However, reports vary considerably concerning characteristics of patients who will not respond to treatment. Knowledge of factors associated with poor outcome may assist identification of patients requiring special attention.

METHODS

A total of 260 patients with chronic low back pain were included in a previously reported randomized controlled trial of McKenzie therapy versus strengthening training. Outcome variables were: functional status, pain level, work status, and use of healthcare services during follow-up. Also, factors associated with withdrawal during the intervention were sought identified. The following factors of possible prognostic significance were determined: levels of pain and disability, pain-distribution, duration of symptoms, smoking habits, leisure activities, workload, job satisfaction, treatment preference, outcome expectations, treatment modality received, compliance with home exercises during follow-up, and demographic variables such as age, gender, work status, and application for pension. Association between variables was examined by multiple logistic regression analysis and odds ratios.

RESULTS

No differences in outcomes were found between the treatment groups at 14 months of follow-up. Low level of pain intensity and disability, sick leave at entry, low pretreatment expectations of future work ability, withdrawal during treatment, and discontinuance of exercises after the end of the treatment period were associated with poor outcome.

CONCLUSION

Poor long-term outcome of exercise therapy for chronic low back pain can be explained by a number of patient-related factors. Different prognostic factors were associated with different outcomes. These factors were more important in determining outcome than the exercise-programs studied.

Patients referred to a pain management clinic: beliefs, expectations and priorities

AIM

This paper is a report of a study to explore patients' pain-beliefs and emotions at the point of referral to a pain clinic, their expectations of the clinic and their priorities for improvement in aspects of their lives affected by pain.

BACKGROUND

Chronic pain is a common experience and, although the percentage of people with pain referred to pain clinics is increasing, they often experience complex journeys through the healthcare system. Patients' beliefs about pain have been shown to influence their experience of pain and treatment outcomes, with a focus on the organic cause of pain reported.

METHODS

Three focus groups were convened with 18 participants. Ten statements about pain were distributed to each participant and ranked according to their priorities. The data were collected in 2002-2003.

FINDINGS

The participants' beliefs were dominated by the search for a firm diagnosis and cure. Participants held three main beliefs; that the cause of the pain must be established; that other people do not believe in the pain of a person without a firm diagnosis; and that painkillers are a way of 'fobbing you off'. Participants had little knowledge and few concrete expectations of the pain clinic. Their main priorities for improvement were 'less pain', 'some pain free times', and being able to do more 'everyday things'.

CONCLUSION

Staff delivering pain management services must understand patients' beliefs and expectations and explain their own perspectives in order to provide a sound basis for working together.

Changes after multidisciplinary pain treatment in patient pain beliefs and coping are associated with concurrent changes in patient functioning

Little is known about how patient functioning changes after completion of multidisciplinary pain programs, and what factors are associated with such changes when they occur; for example, whether improvement or deterioration in functioning corresponds to changes in patient beliefs and coping during this period. The objective of this study was to examine the extent to which changes in patient pain and functioning were associated with changes in beliefs and coping after multidisciplinary pain treatment. Patients with chronic pain (N=141) completed outcome (pain, functioning) and process (beliefs, catastrophizing, coping) measures at the end of multidisciplinary pain treatment and 12 months posttreatment. On average, patients reported similar levels of pain at both times, but showed a small worsening in disability and depression outcomes between posttreatment and follow-up, which were associated significantly with concurrent changes in the process measures. In particular, increased belief in oneself as disabled by pain, catastrophizing, and increased use of resting, guarding and asking for assistance in response to pain were linked with increased disability and depression. Decreased perceived control over pain was also consistently associated with worsening of these outcomes. The results highlight the potential importance of specific pain-related beliefs and coping responses in long-term patient pain and adjustment. Research is needed to determine whether booster interventions after the end of intensive multidisciplinary treatment that target these beliefs and coping responses improve long-term outcomes.

Behavioral medicine approaches to pain

Managing pain patients can be a challenging task for many clinicians because of the complexity of the condition. Pain by definition is a multifactorial phenomenon for which biomedical factors interact with a web of psychosocial and behavioral factors. Behavioral medicine approaches for pain generally address specific cognitive and behavioral factors relevant to pain, thereby aiming to modify the overall pain experience and help restore functioning and quality of life in pain patients. Behavioral medicine focuses on patients' motivation to comply with a rehabilitative regimen, particularly those with chronic, disabling pain. Since patients' own commitment and active participation in a therapeutic program are critical for the successful rehabilitation, the role that behavioral medicine can play is significant. It is not unreasonable to state that success outcomes of the rehabilitative approach depend on how effectively behavioral medicine can be integrated into the overall treatment plan. Past research in general supports this assertion, demonstrating clinical benefit and cost-effectiveness of multidisciplinary interventions that include behavioral medicine. Some of the approaches listed in this paper can be incorporated into clinicians' practice regardless of specialties, and such practice will likely provide helpful venues for managing pain patients.

Prediction of Pain Outcomes in Korean Older Adults: Use of a Structural Equation Model

OBJECTIVE

To construct a structural equation model of pain adjustment outcomes (e.g., depression and fatigue) in Korean older adults based on the cognitive-behavioral model of chronic pain.

METHODS

Nonexperimental research design. Data were collected by questionnaires from 271 Korean older adults. Data analysis was conducted with SPSS 10.1 for descriptive statistics and a PC-LISREL program for covariance structural analysis.

RESULTS

In this study, based on the modifications, chi-square statistics were changed, the goodness-of-fit index was 0.97, the adjusted goodness-of-fit index was 0.93, the root mean square residual was 0.04, the normal fit index was 0.98, and the non-normed fit index was 0.98. Path coefficients and their statistical significance for the revised model were as follows: pain adjustment and pain beliefs were found to have a significant direct effect on pain coping. The variable directly related to pain beliefs was pain adjustment, and variables directly influencing fatigue were pain coping and pain beliefs. Lastly, pain adjustment, pain coping, and fatigue were found to have a significant direct effect on depression. Also, pain adjustment, pain coping, and pain beliefs were found to have a significant indirect effect on depression. In conclusion, pain adjustment, pain coping, pain beliefs, and fatigue all contributed to depression. Fifty-four percent of depression could be explained by these variables.

CONCLUSIONS

This modified model is considered appropriate for explaining and predicting pain adjustment outcomes in Korean older adults. Also, the findings support the development of an intervention strategy to improve pain coping, negative pain beliefs, fatigue, and depression caused by poor pain adjustment.

Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain

Although cognitive-behavioral therapies (CBT) have been demonstrated to be effective for a variety of chronic pain problems, patients vary in their response and little is known about patient characteristics that predict or moderate treatment effects. Furthermore, although cognitive-behavioral theory posits that changes in patient beliefs and coping mediate the effects of CBT on patient outcomes, little research has systematically tested this. Therefore, we examined mediators, moderators, and predictors of treatment effects in a randomized controlled trial of CBT for chronic temporomandibular disorder (TMD) pain. Pre- to post-treatment changes in pain beliefs (control over pain, disability, and pain signals harm), catastrophizing, and self-efficacy for managing pain mediated the effects of CBT on pain, activity interference, and jaw use limitations at one year. In individual mediator analyses, change in perceived pain control was the mediator that explained the greatest proportion of the total treatment effect on each outcome. Analyzing the mediators as a group, self-efficacy had unique mediating effects beyond those of control and the other mediators. Patients who reported more pain sites, depressive symptoms, non-specific physical problems, rumination, catastrophizing, and stress before treatment had higher activity interference at one year. The effects of CBT generally did not vary according to patient baseline characteristics, suggesting that all patients potentially may be helped by this therapy. The results provide further support for cognitive-behavioral models of chronic pain and point to the potential benefits of interventions to modify specific pain-related beliefs in CBT and in other health care encounters.

Validating the Use of Two-Item Measures of Pain Beliefs and Coping Strategies for a Veteran Population

Previous research has demonstrated that 2-item versions of subscales from the Chronic Pain Coping Inventory, Coping Strategy Questionnaire, and the Survey of Pain Attitudes appear adequately reliable and valid for use in studies with large sample sizes. It was suggested that use of the abbreviated scales might help to expand the testing and application of cognitive-behavioral models of pain to new settings and with new populations where assessment burden might be a key issue. This study explored the utility of these brief scales among veterans in a Veterans Affairs setting. Strong associations were found between the 2-item versions and their respective parent scales. In addition, the 2-item scales were found to be associated with other pain-related measures, supporting their predictive validity. The results of this study replicate previous findings and offer support for the use of the 2-item versions for both screening and research purposes in Veterans Affairs settings with a veteran population.

PERSPECTIVE

This article presents the psychometric properties of brief versions of 3 commonly used pain coping and belief questionnaires in a unique population. These measures could be used clinically for initial screening purposes, as well as for treatment monitoring.

Partner Responses to Pain Behaviors Are Associated With Depression and Activity Interference Among Persons With Chronic Pain and Spinal Cord Injury

This study investigated the extent to which psychosocial factors (partner responses to pain behaviors, social support) are associated with pain-related activity interference and depressive symptom severity among individuals with spinal cord injury (SCI) and chronic pain. Seventy adults (45 men, 25 women) with SCI and pain and 68 partners completed Part II of the West Haven-Yale Multidimensional Pain Inventory, a measure of partner responses to pain behaviors. Individuals with SCI and pain also completed the Social Support Questionnaire-6, a modified Brief Pain Inventory Pain Interference Scale, and the Center for Epidemiological Studies-Depression scale. SCI subject ratings of partner responses to pain behaviors, but not partner ratings, were associated significantly with pain-related activity interference and depressive symptom severity. Negative partner response to pain behaviors explained the most variance in these 2 outcome measures. The results provide preliminary support for the importance of partner responses to pain behaviors in outcomes of individuals with chronic pain and SCI.

PERSPECTIVE

Chronic pain is a significant problem for many persons with spinal cord injury. In this sample of individuals with spinal cord injury and pain, perceived partner negative responses to pain behaviors were associated positively with activity interference and depression. Decreasing negative partner responses to pain behaviors might be a potentially important clinical intervention in this population.

Further validation of the chronic pain coping inventory

Multidisciplinary treatment programs for chronic pain typically emphasize the importance of decreasing maladaptive and encouraging adaptive coping responses. The Chronic Pain Coping Inventory (CPCI), developed to assess coping strategies targeted for change in multidisciplinary pain treatment, is a 64-item instrument that contains 8 subscales: Guarding, Resting, Asking for Assistance, Relaxation, Task Persistence, Exercising/Stretching, Coping Self-Statements, and Seeking Social Support. A previous validation study with 210 patients in a Canadian academic hospital setting supported an 8-factor structure for the CPCI. The current study was undertaken to validate the CPCI among 564 veterans with a more extended history of chronic pain. Patients completed the study questionnaires before multidisciplinary treatment. A confirmatory factor analysis was used to examine the factor structure of the 64-item CPCI. A series of hierarchical multiple regression analyses were performed with depression, pain interference, general activity level, disability, and pain severity as the criterion variables and the 8 CPCI factors as the predictor variables, controlling for pain severity and demographic variables. The confirmatory factor analysis results strongly supported an 8-factor model, and the regression analyses supported the predictive validity of the CPCI scales, as indicated by their association with measures of patient adjustment to chronic pain.

PERSPECTIVE

This article validated the 8-factor structure of the CPCI by using a confirmatory factor analysis and a series of linear regressions. The results support the applicability and utility of the CPCI in a heterogeneous population of veterans with severe chronic pain treated in a tertiary teaching hospital. The CPCI provides an important clinical and research tool for the assessment of behavioral pain coping strategies that might have an impact on patient outcomes.

Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome

BACKGROUND

Myofascial pain syndrome (MPS) is one of the most common causes of chronic musculoskeletal pain. Several methods have been recommended for the inactivation of trigger points (TrP).

OBJECTIVES

This prospective, single-blind study was proposed to compare TrP injection with botulinum toxin type A (BTX-A) to dry needling and lidocaine injection in MPS.

METHODS

Eighty-seven trigger points (cervical and/or periscapular regions) in 23 female and six male patients with MPS were treated and randomly assigned to three groups: lidocaine injection (n=10, 32 TrP), dry needling (n=10, 33 TrP), and BTX-A injection (n=9, 22 TrP).

OUTCOME MEASURES

Clinical assessment including cervical range of motion, TrP pain pressure threshold (PPT), pain scores (PS), and visual analog scales for pain, fatigue, and work disability were evaluated at entry and the end of the 4th week. Additionally, depression and anxiety were evaluated with the Hamilton depression and anxiety rating scales, and quality of life was assessed using the Nottingham health profile (NHP). The subjects were also asked to describe side effects. INJECTION PROCEDURE: One milliliter of 0.5% lidocaine was administered to each TrP in the lidocaine injection group, 10-20 IU of BTX-A to each TrP in the BTX-A group, and dry needling to each TrP in the last group, followed by stretching of the muscle groups involved. The patients were instructed to continue their home exercise programs.

RESULTS

Pain pressure thresholds and PS significantly improved in all three groups. In the lidocaine group, PPT values were significantly higher than in the dry needle group, and PS were significantly lower than in both the BTX-A and dry needle groups. In all, visual analog scores significantly decreased in the lidocaine injection and BTX-A groups and did not significantly change in the dry needle group. Disturbance during the injection procedure was lowest in the lidocaine injection group. Quality of life scores assessed by NHP significantly improved in the lidocaine and BTX-A groups but not in the dry needle group. Depression and anxiety scores significantly improved only in the BTX-A-injected group.

CONCLUSIONS

Injection is more practical and rapid, since it causes less disturbance than dry needling and is more cost effective than BTX-A injection, and seems the treatment of choice in MPS. On the other hand, BTX-A could be selectively used in MPS patients resistant to conventional treatments.

Are changes in fear-avoidance beliefs, catastrophizing, and appraisals of control, predictive of changes in chronic low back pain and disability?

Interventions for chronic low back pain (CLBP) often attempt to modify patients' levels of catastrophizing, their fear-avoidance beliefs, and their appraisals of control. Presumably, these interventions are based on the notion that changes in these cognitive factors are related to changes in measures of adjustment. The aim of the present study was to explore whether changes on these cognitive factors were related to changes in CLBP and disability. Fifty-four CLBP patients completed a series of self-report measures prior to beginning a cognitive-behavioral based intervention and again upon discharge. Change scores (post-treatment score minus pre-treatment score) were calculated for each of the self-report measures. The study found that changes in the cognitive factors were not significantly associated with changes in pain intensity. In contrast, reductions in fear-avoidance beliefs about work and physical activity, as well as increased perceptions of control over pain were uniquely related to reductions in disability, even after controlling for reductions in pain intensity, age and sex. The final model explained 71% of the variance in reductions in disability.

Multidisciplinary Pain Center Outcomes in Washington State Workers?? Compensation

We conducted this study to evaluate the clinical and disability status of injured workers 4.6 years after undergoing multidisciplinary pain center evaluation, comparing subjects who received treatment to subjects who were evaluated only. Three hundred injured workers were selected for a telephone survey; 150 had received pain center treatment and 150 had been evaluated but not treated. The survey included the SF-12, and questions about subjects' pain intensity and current work status. A workers' compensation database indicated the disability status of subjects. The response rate was 50%. In multivariate analyses, treated and evaluated-only subjects did not differ significantly in disability status, pain intensity, SF-12 scores, or current work status. At 4.6 years follow up, there was no evidence that pain center treatment affects either disability status or clinical status of injured workers.

Pain self-management in the process and outcome of multidisciplinary treatment of chronic pain: evaluation of a stage of change model

For chronic pain patients, acceptance of a self-management approach for pain may influence success in treatment, and adopting such a perspective may be conceptualized as a stage of change model. For 65 chronic pain patients in multidisciplinary treatment programs, we examined whether pretreatment self-management stage, assessed with Pain Stage of Change Questionnaire subscales, affected improvements in outcomes, and whether changes in stage represented a therapeutic process factor. Results showed (a) low precontemplation, high contemplation, and high action attitudes at pretreatment predicted greater improvements in outcomes than the opposite pattern of attitudes; (b) pre- to midtreatment changes in precontemplation and contemplation attitudes predicted mid- to posttreatment changes in pain severity and interference, but not vice versa. Results support the usefulness of a stage model in conceptualizing patients' acquisition of a self-management approach to pain, and suggest that early-treatment progression across stages may lead to reductions in pain severity and lifestyle interference.

Cognitive factors influence outcome following multidisciplinary chronic pain treatment: a replication and extension of a cross-lagged panel analysis

Reducing maladaptive cognitions is hypothesized to constitute an active therapeutic process in multidisciplinary pain programs featuring cognitive-behavioral interventions. A cross-lagged panel design was used to determine whether: a) early-treatment cognitive changes predicted late-treatment pain, interference, activity and mood changes, but not vice versa; b) three cognitive factors made unique contributions to outcome; c) substantial cognitive changes preceded substantial improvements in outcome. Sixty-five chronic pain patients, participating in a 4-week multidisciplinary program, completed measures of pain helplessness, catastrophizing, pain-related anxiety (process factors), pain severity, interference, activity level and depression (outcomes) at pre-, mid- and posttreatment. Results showed that early-treatment reductions in pain helplessness predicted late-treatment decreases in pain and interference, but not vice versa, and that early-treatment reductions in catastrophizing and pain-related anxiety predicted late-treatment improvements in pain severity, but not vice versa. Findings suggested that the three process factors predicted improvements mostly in common. However, little evidence was found that large early-treatment reductions in process variables preceded extensive improvements in pain. Findings replicate those of a recent report regarding cross-lagged effects, and offer support that cognitive changes may indeed influence late-treatment changes in outcomes.

Contrasting emotional approach coping with passive coping for chronic myofascial pain

Passive or emotion-focused coping strategies are typically related to worse pain and adjustment among chronic pain patients. Emotional approach coping (EAC), however, is a type of emotion-focused coping that appears to be adaptive in some nonpain populations but has not yet been examined in a chronic pain population. In a sample of 80 patients (75% women, M = 48.67 years of age) with chronic myofascial pain, we contrasted how EAC (assessed with the Emotional Approach Coping Scale) and 5 passive pain-coping strategies (assessed with the Vanderbilt Multidimensional Pain Coping Inventory (VMPCI)) were related to sensory and affective pain, physical impairment, and depression. Passive coping strategies were positively correlated with one another, but EAC was inversely correlated with most of them. The VMPCI passive strategies were substantially positively related to negative affect, whereas EAC was inversely related to negative affect. Controlling for potentially confounding demographics, higher EAC was related to less affective pain and depression, even after controlling for negative affect. Using passive coping strategies, in contrast, was associated with more pain, impairment, and depression, although these relations were greatly attenuated after controlling for negative affect. When considered simultaneously, EAC, but not passive coping, was related to affective pain, and both EAC and passive coping were significant correlates of depression, although in opposite directions. In secondary analyses, we found that EAC was related to less pain (particularly sensory) among men and to less depression among women. Unlike the use of passive pain-coping strategies, which are associated with worse pain and adjustment, the use of EAC (emotional processing and emotional expression) with chronic pain is associated with less pain and depression. This suggests that some emotion-focused types of pain coping may be adaptive, and it highlights the need to assess emotional coping processes that are not confounded with distress or dysfunction.

Do changes in cognitive factors influence outcome following multidisciplinary treatment for chronic pain? A cross-lagged panel analysis

Changes in maladaptive cognitions may constitute therapeutic processes of multidisciplinary pain programs. A cross-lagged panel design was used to determine whether (a) early-treatment cognitive change predicted late-treatment outcome index change, but not vice versa; and (b) these effects remained significant with depression change controlled. Ninety chronic pain patients, in a 4-week multidisciplinary program, completed measures of catastrophizing, pain helplessness, depression, pain, interference, and activity level at pre-, mid-, and posttreatment. With depression changes controlled, early-treatment catastrophizing and pain helplessness changes predicted late-treatment outcome index changes, but not vice versa; early-treatment depression changes predicted late-treatment activity changes, but not vice versa. Findings advance understanding of pain treatment process and suggest that negative cognition changes may indeed affect improvements in treatment outcome.

Behavioral and cognitive-behavioral treatment for chronic pain: outcome, predictors of outcome, and treatment process

STUDY DESIGN

A literature review was conducted.

OBJECTIVE

To examine the outcome of behavioral (BT) and cognitive-behavioral treatment (CBT), collectively referred to as BT-CBT, for chronic pain, to identify the predictors of treatment outcome, and to investigate the change processes associated with these treatments.

SUMMARY OF BACKGROUND DATA

Numerous controlled clinical trials of BT-CBT for chronic pain, alone or more commonly in multidisciplinary treatment contexts, suggest that these treatments are effective. However, further study is needed to examine which outcome variables change, when, for whom, and how.

METHODS

Published literature was gathered from Medline, PsychLit, and searches of relevant journals.

RESULTS

Overall, BT-CBT for chronic pain reduces patients' pain, distress, and pain behavior, and improves their daily functioning. Differences across studies in sample characteristics, treatment features, and assessment methods seem to produce varied treatment results. Also, some patients benefit more than others. Highly distressed patients who see their pain as an uncontrollable and highly negative life event derive less benefit than other patients. Decreased negative emotional responses to pain, decreased perceptions of disability, and increased orientation toward self-management during the course of treatment predict favorable treatment outcome.

CONCLUSIONS

Current BT-CBT helps many patients with chronic pain. Continuing clinical research should improve the matching of treatments with patient characteristics and refine the focus of treatments on behavior changes most associated with positive outcome. Further study of fear, attention, readiness to adopt self-management strategies, acceptance of pain, and new combinations of interdisciplinary treatments may lead to improved interventions.

Psychological factors in chronic pain: evolution and revolution

Research has demonstrated the importance of psychological factors in coping, quality of life, and disability in chronic pain. Furthermore, the contributions of psychology in the effectiveness of treatment of chronic pain patients have received empirical support. The authors describe a biopsychosocial model of chronic pain and provide an update on research implicating the importance of people's appraisals of their symptoms, their ability to self-manage pain and related problems, and their fears about pain and injury that motivate efforts to avoid exacerbation of symptoms and further injury or reinjury. They provide a selected review to illustrate treatment outcome research, methodological issues, practical, and clinical issues to identify promising directions. Although there remain obstacles, there are also opportunities for psychologists to contribute to improved understanding of pain and treatment of people who suffer from chronic pain. The authors conclude by noting that pain has received a tremendous amount of attention culminating in the passage of a law by the U.S. Congress designating the period 2001-2011 as the "The Decade of Pain Control and Research."

Multimethod assessment of treatment process in chronic low back pain: comparison of reported pain-related anxiety with directly measured physical capacity

Although cognitive behavioural treatments (CBT) have proven efficacy in improving symptom management, pain-related distress, physical performance and return to work. few studies have examined the relationship between changes in behavioural process variables during treatment and improvement in outcome variables following treatment. We designed a multimethod assessment strategy to test the relative contribution of changes in physical capacity and pain-related anxiety to treatment outcome variables. Low back pain patients (n = 59) were treated with an intensive programme of physical exercise and CBT. Comparisons from pre- to post-treatment showed significant improvement in pain severity, interference, affective distress, activity level, and depression. Improvements in pain-related anxiety were associated with improvements in all outcome variables except interference. Of three physical capacity composite scores, improvement in only one (lumbar extension and flexion capacity) was associated with improvements in all outcome variables except interference. Further analyses demonstrated that the relationship between changes in pain-related anxiety and treatment outcome were independent of changes in physical capacity performance. Changes during treatment in pain-related anxiety may be more important than changes during treatment in physical capacity when predicting the effect of treatment on behavioural outcome measures. These results are discussed in the context of how to improve assessment of the chronic pain patient and improve the effectiveness of multidisciplinary CBT.

Analysis of the Physician Variable in Pain Management

BACKGROUND

The role of physician variability in pain management is unknown.

OBJECTIVE

To assess the role of physician variability in the management of pain and provide quantitative data regarding the status of pain management in Michigan.

DESIGN

A multi-item mail survey was used to determine the physician's perceived knowledge of pain management modalities, goals, satisfaction, and confidence with pain treatment. Participants. The focus of this report was a group of 368 licensed Michigan physicians who provide clinical care.

RESULTS

Overall, 30% of the study group reported no formal education in pain management, although younger physicians reported more education (correlation coefficient = -0.252, P <.001). The physicians reported greater confidence in their knowledge of meperidine than other Schedule II opioids (P <.001 ). In regards to the opinion that prescribing strong opioids would attract a medical review, the physician responses ranged from 1 (strongly disagree) to 5 (strongly agree). The median score for this scale was 4, accounting for 46% of the responses. The study group expressed less satisfaction with their treatment of chronic pain as well as lower goals for relief (mean: 3.8; 95% confidence interval: 3.7-3.9).

CONCLUSIONS

Lower expectations for relief and less satisfaction in its management may contribute to the undertreatment of chronic pain. Perceptions of regulatory scrutiny may contribute to suboptimal pain management. These preliminary data highlight physician variability in pain decision making while providing insights into educational needs.

Cognitive-Behavioral Factors in the Management of Chronic Low Back Pain: Conceptualization and Evidence of Treatment Efficacy

The biomedical and psychogenic models of chronic pain view chronic low back pain (CLBP) in terms too extreme to account for the many factors that contribute to its development and maintenance. A cognitive-behavioral model depicts CLBP not merely in terms of sensory information or psychiatric disturbance, but in terms of well-validated principles that govern perception and behavior. Evidence from correlation, prospective, and experimental studies shows that CLBP can be explained in large measure by 1) the manner in which noxious stimuli are attended to and interpreted; 2) the degree to which certain behaviors become conditioned stimuli for fear responses; and 3) how environmental contingencies increase and decrease the frequency of maladaptive and adaptive behaviors. From this basic research, interventions have been designed to alter maladaptive cognitions and problematic behavioral contingencies. These appear quite effective in alleviating pain, decreasing disability, and lifting mood; more effective perhaps than standard medical management. Although further work is still needed, the case for a cognitive-behavioral model for the conceptualization of CLBP is strong and grows stronger with emerging research.

Effects of coping on health outcome among women with gastrointestinal disorders

BACKGROUND

Studies have shown that the nature and quality of coping may positively or negatively affect health outcome; however, this relationship has not been well studied among patients with gastrointestinal (GI) disorders.

OBJECTIVES

The primary objective was to study the effect of different coping strategies on the health outcome of women with GI disorders and how these coping strategies may modify the effects of education, GI disease type, neuroticism, and abuse severity on health outcome.

METHODS

We followed 174 patients in a referral GI clinic for 12 months to assess their health status as a derived variable of daily pain, bed disability days, psychological distress, daily dysfunction, number of visits to physicians, and number of surgeries and procedures. We obtained at baseline their GI diagnosis (functional vs. organic), neuroticism score (NEO Personality Inventory), sexual and/or physical abuse history, and scores on two coping questionnaires. Regressions analyses were used to determine the relative effect of the coping measures on health outcome and their modifying effects on education, GI disease type, neuroticism, and abuse severity.

RESULTS

A higher score on the Catastrophizing scale and a lower score on the Self-Perceived Ability to Decrease Symptoms scale (Coping Strategies Questionnaire) predicted poor health outcome. Less education, a functional GI diagnosis, a higher neuroticism score, and greater abuse severity also contributed to poor health status. However, the effect of GI disease type and neuroticism on health outcome was significantly reduced by the coping measures.

CONCLUSIONS

Maladaptive coping (eg, catastrophizing) and decreased self-perceived ability to decrease symptoms may adversely affect health outcome and may modify the effect of GI disease type and neuroticism on health outcome.

Veränderung von Kognitionen in der psychologischen Schmerztherapie - Eine Metaanalyse zum kognitiv-behavioralen Modell

Zusammenfassung. Das kognitiv-behaviorale Modell postuliert einen Zusammenhang zwischen Änderungen des Erlebens und Verhaltens und Änderungen von Kognitionen. Ziel der vorliegenden Metaanalyse ist es, die Veränderung von Kognitionen im Rahmen kognitiv-behavioraler Therapien bei chronischen Schmerzen zu untersuchen. In die Analyse einbezogen werden Studien, die die folgenden Bedingungen erfüllen: prospektives kontrolliert-randomisiertes Studiendesign, kognitiv-behavioraler Therapieansatz, Einbezug kognitiver Variablen im Prä-Post-Design, Angaben von Mittelwerten und Standardabweichungen für Experimental- und Kontrollgruppen sowie Gruppengrößen für jedes Treatment von n ≥ 5. Diese Bedingungen erfüllen 14 Studien mit n = 569 Patienten, die an chronischen Kopf- bzw. Rückenschmerzen leiden. Für Kopfschmerzpatienten kann eine Effektstärke kognitiver Variablen von d+ = 0,88 (starker Effekt) und für Rückenschmerzpatienten von d+ = 0,30 (schwacher Effekt) ermittelt werden. Beide Effektstärken sind statistisch signifikant und klinisch - wenn auch in unterschiedlicher Weise - bedeutsam. Die Effektstärken kognitiver Variablen korrelieren bei Rückenschmerzpatienten mit denen der Depressivität und Beeinträchtigung. Die Ergebnisse stützen zwar das Modell, erlauben aber keine Aussage über die Interaktion von Kognition und Verhalten im therapeutischen Prozeß.

The relation between pain beliefs, negative thoughts, and psychosocial functioning in chronic pain patients

Cognitions and beliefs appear important in predicting adjustment to chronic pain. The current study examines how cognitions and beliefs are related to psychosocial functioning. One hundred and sixty-three chronic pain out-patients were assessed. Regression analyses were performed using scores on the Pain Beliefs and Perceptions Inventory and the Inventory of Negative Thoughts in Response to Pain as predictor variables and responses to the West Haven Yale Multidimensional Pain Inventory as criterion variables. Pain cognitions and pain beliefs were correlated. After controlling for demographics, employment status and pain severity, pain beliefs and cognitions accounted for a significant amount of the variance in general activity, pain interference, and affective distress. Negative cognitions, particularly negative self-statements, were more predictive of outcome than pain beliefs. Although these data are correlational, they provide additional support for a biopsychosocial model of adjustment to chronic pain.

The role of spouse responses to disability and family environment in multiple sclerosis

Research in the area of family issues and multiple sclerosis has mainly focused on the impact of multiple sclerosis on the spouse. The aim of the current study was to examine the relationship between patients' ratings of their spouses' responses to multiple sclerosis patient disability behaviors and the impact on patient psychological and physical functioning. Multiple sclerosis patients were interviewed over the telephone using standardized questionnaires to assess patient physical and psychological functioning, spouse responses to patient disability and well behaviors (i.e., how does the spouse respond when you're having difficulties related to multiple sclerosis?), and family environment factors. The study was set in a large university-based Multiple Sclerosis Clinical Center. Forty-four of 64 patients approached with definite multiple sclerosis participated in the study. Physical functioning was assessed by the Kurtzke-EDSS, SIP, SF-36, and psychological functioning was assessed by the CES-D and SF-36. Scores on the SF-36 were generally lower compared with a normative sample of individuals with major medical problems; however, mean Kurtzke scores of 5.60 reflected moderate to severe impairment. Exploring spouse responses to disability, correlation analyses revealed that solicitous spouse responses to patient disability behaviors were significantly associated with greater multiple sclerosis-related physical disability. This relationship was stronger for patients who were more depressed. Spouse negative responses to patient disability behaviors were associated with poorer mental health, whereas spouses' encouragement of patient well behaviors was associated with lower emotional distress. Poorer psychological functioning was found in patients with families who were reported to have higher conflict and/or who were more controlling. Higher levels of independence in families were associated with better psychological and physical functioning in the patients. These preliminary findings suggest that patients' perceptions of their families' responses to disability and family environment factors may be important areas for further research. The findings may also provide potential targets for clinical intervention in the future.

Pelvic pain following radical retropubic prostatectomy: a prospective study

OBJECTIVES

To evaluate subacute and chronic pelvic pain after radical retropubic prostatectomy (RRP) performed for clinically localized prostate cancer.

METHODS

Twenty-four consecutive patients undergoing RRP completed pain, quality-of-life, and incontinence questionnaires. They also wore pads for 24 hours to measure urine loss objectively before and after surgery.

RESULTS

Three patients had pelvic pain preoperatively. Thirteen, 7, and 5 patients had pelvic pain at 1, 3, and 6 months, respectively, after RRP. At 6 months, none of the 5 patients with pelvic pain required analgesic medication. There was a strong relationship between pain and cancer worry, as well as between pain and incontinence.

CONCLUSIONS

Many patients have subacute pelvic pain after RRP but improve over time. Severe chronic pain is unlikely after RRP.

Pain during hospitalization is associated with continued pain six months later in survivors of serious illness. The SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

PURPOSE

To determine the level of pain reported by survivors of serious illness 2 and 6 months after study enrollment and to identify variables associated with later pain.

PATIENTS AND METHODS

Observational cohort study of patients with interviews during hospitalization (5,652) and 2 (3,782) and 6 (2,984) months later admitted between June 1989 and January 1994 with 1 or more of 9 high mortality diagnoses admitted to 5 tertiary care academic centers in the United States. Patients' level of pain during the hospitalization and 2 and 6 months later was determined from interviews with patients and surrogates (most often family members). Separate ordinal logistic regressions were constructed with level of pain at months 2 or 6 as the dependent variable and 22 demographic, psychological, chronic, and acute illness measures at the time of hospitalization as independent variables.

RESULTS

Of patients reporting level 4 (moderately severe pain occurring most of the time or extremely severe pain occurring half of the time) or 5 (moderately severe pain occurring most or all of the time or extremely severe pain occurring at least half of the time) pain to 5 during hospital interviews, 39.5% and 39.7% reported level 4 or 5 pain 2 and 6 months later, respectively. Level of hospital pain was the variable most strongly associated with later pain. Compared with patients with level 1 hospital pain, those with level 2 (not at all severe pain or moderate, occasional) had a 2.91 (95% confidence interval [CI] 2.50, 3.37) and 1.75 (CI 1.48, 2.07) times greater adjusted odds of increased levels of pain 2 and 6 months later, respectively. Compared with patients with level 1 hospital pain, those with level 5 pain had a 9.20 (CI 7.27, 11.65) and 4.40 (CI 3.39, 5.71) times greater adjusted odds of increased levels of pain 2 and 6 months later, respectively. Age, number of dependencies in activities of daily living, depression, and type of comorbid illnesses were also independently associated with level of pain both 2 and 6 months later.

CONCLUSION

Survivors of the serious and common illnesses that we studied have a high level of pain during hospitalization and up to 6 months after hospitalization. Level of hospital pain was most strongly associated with later pain. Better pain control both during hospitalization and after discharge should be given a high priority. Pain during hospitalization should trigger future inquiries about pain and its treatment.

Pain and satisfaction with pain control in seriously ill hospitalized adults: findings from the SUPPORT research investigations. For the SUPPORT investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatmentm

OBJECTIVES

To evaluate the pain experience of seriously ill hospitalized patients and their satisfaction with control of pain during hospitalization. To understand the relationship of level of pain and dissatisfaction with pain control to demographic, psychological, and illness-related variables.

DESIGN

Prospective, cohort study.

SETTING

Five teaching hospitals.

PATIENTS

Patients for whom interviews were available about pain (n = 5,176) from a total of 9,105 patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were interviewed after study enrollment about their experiences with pain. When patients could not be interviewed due to illness, we used surrogate (usually a family member) responses calibrated to patient responses (from the subset of interviews with both patient and surrogate responses). Ordinal logistic regression was used to study the association of variables with level of pain and satisfaction with its control. Nearly 50% of patients reported pain. Nearly 15% reported extremely severe pain or moderately severe pain occurring at least half of the time, and nearly 15% of those patients with pain were dissatisfied with its control. After adjustment for confounding variables, older and sicker patients reported less pain, while patients with more dependencies in activities of daily living, more comorbid conditions, more depression, more anxiety, and poor quality of life reported more pain. Patients with colon cancer reported more pain than patients in other disease categories. Levels of reported pain varied among the five hospitals and also by physician specialty. After adjustment for confounding variables, dissatisfaction with pain control was more likely among patients with more severe pain, greater anxiety, depression, and alteration of mental status, and lower reported income; dissatisfaction with pain control also varied among study hospitals and by physician specialty.

CONCLUSIONS

Pain is common among severely ill hospitalized patients. The most important variables associated with pain and satisfaction with pain control were patient demographics and those variables that reflected the acute illness. Pain and satisfaction with pain control varied significantly among study sites, even after adjustment for many potential confounders. Better pain management strategies are needed for patients with the serious and common illnesses studied in SUPPORT.

Long-term follow-up of outpatient interdisciplinary pain management with a no-treatment comparison group

The long-term psychosocial and physical functioning impact of an outpatient interdisciplinary pain management program was evaluated by comparison of pain management completors and a no-treatment group. Although pain intensity did not change and there were no significant differences between groups in several aspects of daily activity, the group that completed the program reported a greater sense of control over pain, had a more hopeful outlook on the future, perceived pain as interfering less with their life, and used strategies that are considered adaptive for long-term management of pain. The results suggest that patients with chronic, complex pain problems can improve perceptions regarding pain control and reduce the interference of pain in their lives. Outlook regarding the future was identified as a critical assessment and treatment variable. Individuals who were more optimistic about the future perceived a greater control over pain and endorsed coping strategies that involve diverting attention, ignoring pain sensations, and making coping self-statements. Although pain intensity rating did not differ, individuals who had a more pessimistic outlook on life considered pain to interfere with their work activity, mood, relations with other people, and overall enjoyment of life to a greater extent than individuals who were more optimistic.

A psychoanalytic investigation to improve the success rate of spinal cord stimulation as a treatment for chronic failed back surgery syndrome

OBJECTIVE

The analysis of patient data concerning psychological structure and functioning produced an instrument to determine whether a neurostimulator ought to be implanted or not.

DESIGN

A questionnaire containing 24 items was developed by a psychologist and tested in 40 chronic failed back surgery patients for whom a spinal cord stimulation seemed to be the only therapeutic approach. This questionnaire was based upon some crucial psychological themes, on which the patient took a position. A predictive indication factor (I.F.; %) for implantation of the neurostimulator was obtained from the 24 items. Six months after the implantation of the neurostimulator, we correlated the evaluation factor (E.F.; %) with a six-point evaluation scale considering the pain reduction. The aim was to compare the I.F. and E.F. to verify the correlation between them. This comparison was intended to answer the question if psychological variables included in our scale improve the success rate of the therapy.

SETTING

Data were collected by a psychologist at the Pain Clinic of the University Hospital of Gent, Belgium.

RESULTS AND CONCLUSIONS

The correlation between the I.F. and the E.F. was calculated for the 40 patients by the Spearman correlation test. A coefficient value of 0.8083 (p = 0.000) was found, indicating the existence of a very close correlation between the predictive I.F. and the E.F. The indication scale appears to be a useful instrument for clinical psychologists to predict the success rate of a spinal cord stimulator in this group of patients.