James E. Crisson

Pain coping skills training in the management of osteoarthritic knee pain: A comparative study

The purpose of this study was to determine whether a cognitive-behavioral intervention designed to improve pain coping skills could reduce pain, physical disability, psychological disability, and pain behavior in osteoarthritic knee pain patients. Patients in this study were older adults (mean age=64 years) having persistent pain (mean duration=12 years), who were diagnosed as having osteoarthritis of the knee on the basis of medical evaluation and x-rays. Patients were randomly assigned to one of three conditions: pain coping skills training, arthritis education, or a standard care control condition. Patients in the pain coping skills training condition (n=32) attended 10 weekly group sessions training them to recognize and reduce irrational cognitions and to use attention diversion and changes in activity patterns to control and decrease pain. Arthritis education subjects (n=36) attended 10 weekly group sessions providing them with detailed information on osteoarthritis. Standard care control subjects (n=31) continued with their routine care. Measures of coping strategies, pain, psychological disability, physical disability, medication use, and pain behavior were collected from all subjects before and after treatment. Results indicated that patients receiving pain coping skills training had significantly lower levels of pain and psychological disability post-treatment than patients receiving arthritis education or standard care. Correlational analyses revealed that patients in the pain coping skills training group who reported increases in the perceived effectiveness of their coping strategies were more likely to have lower levels of physical disability post-treatment. Taken together, these findings indicate that pain coping skills training can reduce pain and psychological disability in osteoarthritis patients. Future studies should examine whether behavioral rehearsal or spouse training can strengthen the effects of pain coping skills training in order to reduce physical disability and pain behavior as well as pain and psychological disability.

The relationship of locus of control to pain coping strategies and psychological distress in chronic pain patients

Although behavioral scientists have long been interested in how an individuals locus of control relates to coping and adjustment, basic information remains to be gathered on the relevance of locus of control to adaptation to persistent pain. This study examined the relationship of locus of control orientation to pain coping strategies and psychological distress in chronic pain patients. Subjects were 62 chronic pain patients. All patients were administered: (1) the Multidimensional Health Locus of Control Scales to assess locus of control, (2) the Coping Strategies Questionnaire to evaluate pain coping strategies, and (3) the Symptom Checklist-90 Revised to assess psychological distress. Correlational analyses revealed that patients who viewed outcomes as controlled by chance factors such as fate or luck tended to rely on maladaptive pain coping strategies and rated their abilities to control and decrease pain as poor. They also exhibited greater psychological distress. Regression analyses indicated that patients having a chance orientation toward locus of control were more likely to report depression, anxiety, and obsessive-compulsive symptoms and to have higher overall levels of psychological distress. Chance locus of control also predicted greater reliance on diverting attention and praying/hoping in dealing with their pain. In addition, patients high on chance locus of control reported feeling helpless to deal effectively with their pain problem. Clinicians evaluating chronic pain patients need to be aware that patients who view outcomes as controlled by external factors such as chance may have deficits in pain coping strategies and may report greater psychological distress than patients who do not have this locus of control orientation.

Analyzing chronic low back pain: the relative contribution of pain coping strategies.

&NA; Sixty‐two chronic low back pain patients were administered the Coping Strategies Questionnaire (CSQ) to assess the frequency of use and perceived effectiveness of a variety of cognitive and behavioral pain coping strategies. Analysis of individual variables revealed that CSQ factors, gender, physical examination findings, and chronicity of pain had significant effects on one or more of a series of pain, psychological distress or behavioral measures. To assess the relative contribution of each of these variables hierarchical stepwise regression analyses were carried out. These analyses revealed that the Helplessness factor of the CSQ explained 50% of the variance in psychological distress (Global Severity Index of the SCL‐90R), and 46% of the variance in depression (Beck Depression Inventory). Patients scoring high on this CSQ factor had significantly higher levels of psychological distress. None of the demographic or medical status variables explained a significant proportion of variance in the psychological distress measures. The Diverting Attention and Praying factor of the CSQ explained a moderate (9%), but significant amount of variance in pain report. Patients scoring high on this factor had higher scores on the McGill Pain Questionnaire. Coping strategies were not strongly related to pain behavior measures such as guarding or uptime. A consideration of pain coping strategies may allow one to design pain coping skills training interventions so as to fit the needs of the individual low back pain patient.

Osteoarthritic knee pain: a behavioral analysis.

&NA; This study used behavioral assessment techniques to analyze pain in osteoarthritis (OA) patients. Elghty‐seven OA patients having chronic knee pain served as subjects. Pain behavior was evaluated using a standard observation method and functional impairment was assessed using the Arthritis Impact Measurement Scales. Data analysis revealed that pain and limitations in physical activities were the most common functional impairments and that the most frequently observed pain behavior was guarded movement. Predictive analyses indicated that disability support status and scores on a Pain Control and Rational Thinking factor of the Coping Strategies Questionnaire (CSQ) were predictive of functional impairment. Patients receiving disability support payments were much more functionally limited than those not receiving this financial support. Patients scoring high on the Pain Control and Rational Thinking factor of the CSQ were much less functionally impaired, walked a 5 m course more rapidly and moved from a standing to a sitting or reclining position more quickly than patients scoring low on this factor. The implications of these results for behavioral treatment of OA knee pain are discussed.

Social support and pain behavior

&NA; Research has shown that social support is generally associated with better adaptation to chronic disease. However, the role that social support plays in adjustment to chronic pain syndromes has received less research attention. The present study was designed to examine the relation of high versus low levels of social support to pain behavior in chronic pain patients. Fifty‐one patients with chronic pain completed the Social Support Questionnaire (SSQ) and the McGill Pain Questionnaire. Patients were also observed using a standard observation system to assess pain behaviors. In order to compare pain behaviors displayed by subjects with high versus low levels of social support, a median split was performed on the 2 dimensions of the SSQ: (1) satisfaction with support and (2) availability of people for support. The results indicated that pain behavior varied as a function of level of satisfaction with social support. Individuals reporting high satisfaction with social support exhibited significantly higher levels of total pain behavior and higher levels of individual pain behaviors such as guarding, rubbing and bracing. There was no significant difference in total pain behaviors between those high versus low in terms of level of availability of support. There also were no differences between high versus low social support groups in total pain ratings as measured by the McGill Pain Questionnaire. The results are discussed in terms of an operant conditioning perspective on social support. Individuals who are satisfied with the quality of their social support may be satisfied because they receive positive reinforcement from the social environment when they engage in pain behavior.

The relation of stress and family environment to atopic dermatitis symptoms in children.

The relation of stress and family environment to symptom severity in children with atopic dermatitis (AD) was examined. Forty-four children with severe AD and their families completed questionnaires measuring life events, chronic everyday problems and family environment. Measures of symptom severity were collected during medical evaluation and included an estimate of body surface affected by AD, course of AD symptoms over time, medication usage, and scratching intensity during the day and night. Regression analyses indicated that the measures of stress and family environment were important predictors of symptom severity even after controlling for demographic and medical status variables such as age and serum IgE level. These results have important implications for health care professionals working with children who have AD. Future research directions in the area of stress and AD are discussed.

Behavioral assessment of low back pain: identification of pain behavior subgroups

&NA; A hierarchical cluster analysis procedure was used to identify homogeneous subgroups of low back pain patients who show similar pain behavior patterns during a videotaped behavior sample. Subjects, 106 chronic low back pain patients, were divided into 2 samples. The cluster analysis procedure identified 4 very similar subgroups in sample 1 and sample 2. The first subgroup showed a low or moderate level of guarding and a low level of other pain behaviors. The second subgroup showed a high level of guarding and a moderate level of rubbing of the painful area. The third subgroup showed high levels of guarding and moderate levels of bracing and rubbing. The fourth subgroup exhibited a very high level of rubbing and moderate levels of bracing. The subgroups identified may require somewhat different approaches to pain assessment and treatment. The results of this study suggest that the variability in pain behavior evident in low back pain populations may be due to the fact that within these populations there are homogeneous subgroups of patients who differ in the motor pain behaviors they display.

Illness behavior as a predictor of pain and overt behavior patterns in chronic low back pain patients.

This study examined the relationship of self-reports of illness behavior to pain ratings and overt pain behaviors in a group of chronic low back pain patients referred for pain management. Illness behavior was measured using the Pilowsky and Spence Illness Behavior Questionnaire (IBQ) and pain behavior was recorded using a standard behavioral observation method. Multivariate regression analyses revealed that scores on the IBQ were highly predictive of a variety of indices of pain and pain behavior. These results were obtained even after controlling for significant demographic and medical status variables. The findings of this study support the utility of the IBQ in the behavioral assessment of chronic pain patients.

Self-report of depressive symptoms in low back pain patients

Two studies designed to examine the self-report of depressive symptoms in low back pain patients are presented. Symptoms of depression were assessed with the Beck Depression Inventory. In the first study, a sample (N = 134) of patients who presented for neurosurgical evaluation were evaluated. In the second study, a subgroup of patients found to have lumbar disc protrusion were compared to a subgroup with few or no positive physical findings at the time of physical examination. If the cut-off scores recommended by Beck were used, patients in both studies would be classified as mildly depressed. Both studies found that patients were significantly more likely to report somatic than cognitive symptoms of depression. Patients with multiple physical findings or a disc abnormality at the time of operation were not found to be more likely to report somatic symptoms than patients with few physical findings.

Direct observation of scratching behavior in children with atopic dermatitis

This study examines scratching behavior in children with atopic dermatitis (AD). Thirty children with severe AD and one parent of each child were observed for a 10-minute observation period during a five-minute structured and five-minute unstructured task. Observers coded child and parent behaviors. Data analyses revealed that children engaged in more scratching behavior during the unstructured than structured task. Furthermore, regression analyses indicated that parent responses to scratching behavior in children were important predictors of scratching behavior even after controlling for demographic and medical status variables, such as serum IgE level and percentage of body area affected by AD. These results have important implications for health care professionals working with children who have AD. Suggestions for future behavioral treatment studies are discussed.