J. Scott Richards

Assessing pain behavior: the UAB Pain Behavior Scale.

Abstract Review of the chronic pain literature reveals that there have been few systematic attempts to devise rating scales which reliably and/or validly quantify pain behavior. The UAB Pain Behavior Scale was designed so that it could be administered rapidly by a variety of pain team personnel without sacrificing interrater reliability. The scale is described along with initial reliability and validity data. A summary of its use with chronic pain patients is presented.

Interference due to pain following spinal cord injury: important predictors and impact on quality of life

&NA; Two studies were designed to examine important predictors of pain following spinal cord injury (SCI), and the impact of pain on self‐reported quality of life (QOL). Pain was defined as ‘interference in day‐to‐day activities secondary to pain’. In order to determine risk factors associated with the development of pain interference, Study 1 examined the predictive validity of multiple demographic, medical, and QOL variables at year 1 post‐SCI to self‐reported pain interference 2 years post‐injury. Results showed that middle age (30–59‐year‐olds), lower self‐reported mental health, and pain interference at 1 year post‐SCI were the most important unique predictors of pain interference 2 years post‐SCI. In Study 2, participants were separated into four groups; (1) those pain‐free at years 1 and 2, (2) those pain‐free at year 1 and in pain at year 2, (3) those in pain at year 1 and pain‐free at year 2, and (4) those in pain at years 1 and 2. Results showed that only those experiencing a change in pain interference status reported a change in QOL. More specifically, those developing pain interference (group 2) from year 1 to year 2 reported decreased life satisfaction, physical health, and mental health, whereas, those with resolving pain interference from year 1 to year 2 reported an increase in these same domains. Unexpectedly, change in pain interference status was unrelated to change in self‐reported handicap. Implications and future directions are discussed.

Pain after spinal cord injury: an evidence-based review for clinical practice and research. Report of the National Institute on Disability and Rehabilitation Research Spinal Cord Injury Measures meeting.

Abstract Background/Objectives: To examine the reliability, validity, sensitivity, and practicality of various outcome measures for pain after spinal cord injury (SCI), and to provide recommendations for specific measures for use in clinical trials. Data Sources: Relevant articles were obtained through a search of MEDLINE, EMBASE, CINAHL, and PubMed databases from inception through 2006. Study Selection: The authors performed literature searches to find articles containing data relevant to the reliability and validity of each pain outcome measure in SCI and selected non-SCI populations. Data Extraction: After reviewing the articles, an investigator extracted information utilizing a standard template. A second investigator reviewed the chosen articles and the extracted pertinent information to confirm the findings of the first investigator. Data Synthesis: Taking into consideration both the quantity and quality of the studies analyzed, judgments on reliability and validity of the measures were made by the two investigators. Based upon these judgments, recommendations were formulated for use of specific measures in future clinical trials. In addition, for a subset of measures a voting process by a larger group of SCI experts allowed formulation of recommendations including determining which measures should be incorporated into a minimal dataset of measures for clinical trials and which ones need revision and further validity and reliability testing before use. Conclusions: A 0-10 Point Numerical Rating Scale (NRS) is recommended as the outcome measure for pain intensity after SCI, while the 7-Point Guy/Farrar Patient Global Impression of Change (PGIC) scale is recommended as the outcome measure for global improvement in pain. The SF-36 single pain interference question and the Multidimensional Pain Inventory (MPI) or Brief Pain Inventory (BPI) pain interference items are recommended as the outcome measures for pain interference after SCI. Brush or cotton wool and at least one high-threshold von Frey filament are recommended to test mechanical allodynia/hyperalgesia while a Peltier-type thermotester is recommended to test thermal allodynia/hyperalgesia. The International Association for the Study of Pain (IASP) or Bryce-Ragnarsson pain taxonomies are recommended for classification of pain after SCI, while the Neuropathic Pain Scale (NPS) is recommended for measuring change in neuropathic pain and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) for quantitating neuropathic and nociceptive pain discrimination.

Depression After Spinal Cord Injury: Comorbidities, Mental Health Service Use, and Adequacy of Treatment

OBJECTIVE To provide data for depression rates and psychiatric comorbid conditions, mental health service use, and adequacy of depression treatment in depressed and nondepressed adults with spinal cord injury (SCI). DESIGN Cross-sectional survey as part of the Project to Improve Symptoms and Mood after SCI (PRISMS). SETTING Community setting. PARTICIPANTS Community-residing people with traumatic SCI (N=947). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Patient Health Questionnaire-9 (PHQ-9) Depression Scale, psychiatric history questionnaire, Cornell Service Index (mental health service use), and current medication use. RESULTS The prevalence of probable major depression (PHQ-9 score ≥10) was 23%. There was a high lifetime prevalence of other psychiatric conditions, particularly anxiety disorders. In depressed participants, 29% currently were receiving any antidepressant and 11% were receiving guideline-level antidepressant dose and duration, whereas 11% had been receiving any psychotherapy in the past 3 months and 6% had been receiving guideline-level psychotherapy in the past 3 months. Serotonergic antidepressants and individual psychotherapy were the most common types of treatment received, and there was a wide range of provider types and treatment settings. Demographic and clinical variables were not associated with receipt of mental health service or guideline-level care. CONCLUSIONS Findings from this study document the low rate of mental health treatment for persons with SCI and probable major depression. These findings have implications for improving the effectiveness of depression treatment in people with SCI.

Suicide following spinal cord injury

A study of 9135 persons injured between 1973 and 1984 and treated at any of 13 model regional spinal cord injury (SCI) care systems was conducted. Follow-up ended December 31, 1985, by which time 50 persons had committed suicide (6.3% of deaths). Based on age-sex-race-specific rates for the general population, 10.2 suicides were expected to occur. Therefore, the standardized mortality ratio (SMR) for suicide was 4.9. The highest SMR occurred 1 to 5 years after injury. The SMR was also elevated for the first post-injury year, but was not significantly elevated after the fifth year. The SMR was significantly elevated for all neurological groups, but was highest for persons with complete paraplegia. The SMR was highest for persons aged 25 to 54 years, but was also elevated for persons aged less than 25 years. Suicide was the leading cause of death for persons with complete paraplegia and the second leading cause of death for persons with incomplete paraplegia. The most common means of committing suicide was by gunshot. These figures demonstrate the need for increased staff, patient and family awareness of this problem, and improved follow-up assessment and psychosocial support programmes.

Family caregiver social problem-solving abilities and adjustment during the inital year of the caregiving role.

The authors examined the relation of social problem-solving abilities to trajectories of adjustment of family caregivers in the initial year of their caregiving role. Persons who recently assumed the caregiver role for a family member with a recent-onset spinal cord injury completed measures of problem solving, depression, anxiety, and health during the inpatient rehabilitation program and at 3 other times throughout the year. Hierarchical linear modeling showed that negative problem orientation explained significant variation in the rates of change in caregiver depressive behavior, anxiety, and health complaints. Caregivers with a greater negative orientation were at risk to develop psychological and health problems at a significantly higher rate over the year. Implications for psychological interventions and health policy concerning the needs of family caregivers and their care recipients are discussed.

Bladder management and quality of life after spinal cord injury.

Hicken BL, Putzke JD, Richards JS: Bladder management and quality of life after spinal cord injury. Am J Phys Med Rehabil 2001;80:916–922 ObjectiveThis study examines the quality of life among individuals with spinal cord injury requiring assistance for bowel and bladder management vs. those with independent control of bowel and bladder. DesignTwo groups of 53 individuals each were matched case for case on age, education, sex, race, and lesion level. Outcome measures included the Satisfaction With Life Scale, the Craig Handicap Assessment and Reporting Technique (CHART), and the SF-12. ResultsSatisfaction with life was significantly lower among dependent individuals with impaired bowel and bladder functioning as compared with individuals with independent bowel and bladder control. Similarly, dependent individuals reported greater self-reported handicap (CHART) than independent individuals in the areas of physical independence, mobility, and occupational functioning. However, dependent and independent individuals did not differ in the areas of social integration and economic self-sufficiency. Item analysis on the CHART item assessing number of social contacts initiated in the previous month suggested that dependent individuals may have difficulty initiating new social contacts. Independent individuals reported better overall physical health (SF-12) than dependent individuals. Mental health (SF-12), however, did not differ across groups. ConclusionsIndividuals with impaired bowel and bladder control reported lower quality of life on several domains compared with those with independent control of bowel and bladder. Though the two groups did not differ in self-reported social integration, dependent individuals may have greater difficulty creating new social relationships.

Outcomes of post-spinal cord injury marriages

The purpose of this study was to compare the divorce rate among persons who got married after spinal cord injury with that of the non-spinal cord-injured population of comparable age and gender and to identify factors associated with increased likelihood of divorce. The study included 622 persons enrolled in the National Spinal Cord Injury Statistical Center data set since 1973. These persons were followed between 1 and 15 years after their marriage (mean = 3.5 years). The status of each marriage was determined at the time of their most recent routine annual follow-up examination. Overall, 126 divorces occurred, whereas 74 were expected, based on 2,190 person-years of follow-up and age-sex-specific annual divorce rates for the United States population. Men and remarried persons had divorce rates 2.07 times and 1.80 times higher, respectively, than women and persons married for the first time. The divorce rate was 1.85 times higher among persons without college educations and was lower for persons with lumbosacral injuries than for persons with higher injury levels. In general, the impact of spinal cord injury appears to be almost as great on postinjury marriages as it is on preexisting marriages. However, this study yields descriptive rather than causal information. Other factors must be identified before a clinically useful model to predict persons at high risk for divorce can be developed.

Spinal cord injury rehabilitation: state of the science.

Sipski ML, Richards JS: Spinal cord injury rehabilitation: State of the science. Am J Phys Med Rehabil 2006;85:310–342.

Depressive symptoms and pain evaluations among persons with chronic pain: catastrophizing, but not pain acceptance, shows significant effects.

ABSTRACT Cognitive factors such as catastrophic thoughts regarding pain, and conversely, one’s acceptance of that pain, may affect emotional functioning among persons with chronic pain conditions. The aims of the present study were to examine the effects of both catastrophizing and acceptance on affective ratings of experimentally induced ischemic pain and also self‐reports of depressive symptoms. Sixty‐seven individuals with chronic back pain completed self‐report measures of catastrophizing, acceptance, and depressive symptoms. In addition, participants underwent an ischemic pain induction procedure and were asked to rate the induced pain. Catastrophizing showed significant effects on sensory and intensity but not affective ratings of the induced pain. Acceptance did not show any significant associations, when catastrophizing was also in the model, with any form of ratings of the induced pain. Catastrophizing, but not acceptance, was also significantly associated with self‐reported depressive symptoms when these two variables were both included in a regression model. Overall, results indicate negative thought patterns such as catastrophizing appear to be more closely related to outcomes of perceived pain severity and affect in persons with chronic pain exposed to an experimental laboratory pain stimulus than does more positive patterns as reflected in measures of acceptance.