James W. Atchison

PATIENT SATISFACTION WITH TREATMENT FOR CHRONIC PAIN: PREDICTORS AND RELATIONSHIP TO COMPLIANCE

Objectives:Patient satisfaction with treatment has been extensively researched in a variety of medical patients. However, satisfaction with treatment of chronic pain has received considerably less attention. The present study sought to identify the predictors of patient satisfaction with treatment of chronic pain. In addition, the relationship between patient satisfaction and compliance with treatment recommendations was explored. Methods:One hundred eighty patients (84 men and 96 women) seeking treatment of chronic pain at University of Florida pain clinics were recruited for this telephone follow-up study. Results:Satisfaction ratings were generally high, with ratings of satisfaction with care significantly higher (t(179) = 9.58, P < 0.001) than ratings of satisfaction with improvement. Aspects of the patient-provider interaction, pain relief, and anxiety at treatment onset predicted satisfaction with care. These same variables, with the exception of anxiety, also predicted satisfaction with improvement. Those patients who were more satisfied with their improvement were also more compliant with treatment recommendations, and this relationship was stronger for health care provider-rated compliance. Discussion:Results suggest the importance of distinguishing between satisfaction with care and satisfaction with improvement in assessments. Satisfaction with treatment of chronic pain is not merely a matter of pain relief. To increase the probability of treatment success and satisfaction, attention to the interpersonal aspects of the health care provider-patient relationship appear critical. Explanations for satisfactions stronger relationship to health care provider-rated compliance were discussed.

Sex Differences in Clinical Pain: A Multisample Study

A recent meta-analysis of the experimental pain literature revealed effect sizes of .55 for pain threshold and .57 for pain tolerance, indicating a moderate difference in pain perception between men and women, with women reporting an increased sensitivity to pain. The current study investigated the relationship between sex and clinical pain ratings, in patients seeking care at a tertiary care facility. Five samples of chronic pain patients were recruited from several diverse clinics associated with the University of Florida. Analyses of clinical pain ratings revealed similar effect sizes for all samples, ranging from −.07 to −.25, indicating small differences, with women reporting higher levels of clinical pain. This is the first paper to report effect sizes for differences in report of pain in samples of chronic pain patients presenting for treatment at a tertiary care facility.

Intraindividual variability in daily sleep and pain ratings among chronic pain patients: Bidirectional association and the role of negative mood

ObjectivesSleep disturbance is a common problem among chronic pain patients. Cross-sectional data from clinical populations and experimental studies have shown an association between sleep disturbance and pain. However, there has been little prospective research into the relationship between daily variability between sleep and pain among chronic pain patients. MethodsTwenty-two women with chronic pain (back pain, facial pain, fibromyalgia) completed a sleep diary and wore an actigraph for a 2-week period. Self-report measures of pain, mood, and sleep were also completed at baseline. Hierarchical linear modeling (HLM) was used to examine intraindividual variability in sleep and pain ratings among these women. The impact of mood and baseline pain ratings was also examined as potential moderators. ResultsHierarchical linear modeling analyses supported a bidirectional relationship between sleep and pain, such that a night of poor sleep was followed by increased pain ratings the following day and a day of increased pain was followed by a night of poor sleep. Depression scores further influenced these relationships. DiscussionProspective examination supported a bidirectional relationship between sleep and pain among a group of women with chronic pain. Depressive symptoms had a moderating impact on these relationships. These findings suggest that addressing sleep is important in the treatment of individuals with chronic pain.

Defining Patient‐Centered, Multidimensional Success Criteria for Treatment of Chronic Spine Pain

OBJECTIVE This study aimed to define patient-determined success criteria for treatment of chronic spine pain across four domains: pain, fatigue, emotional distress, and interference with daily activities. PATIENTS Seventy chronic spine pain patients were recruited from university-affiliated pain clinics. DESIGN The study design was longitudinal, with pretreatment and post-treatment assessments. Post-treatment assessment occurred approximately 2 months after treatment initiation. OUTCOME MEASURES Participants completed the Patient-Centered Outcomes Questionnaire and Follow-Up Patient-Centered Outcomes Questionnaire. RESULTS At pretreatment, patient requirements for success were a 58% reduction in pain, 61% reduction in fatigue, 64% reduction in distress, and 66% reduction in interference. These criteria, derived using a direct-scaling approach, are more stringent than criteria developed using other methods. However, patients adjusted their success criteria over time by becoming less stringent, and they used these less stringent criteria to make global judgments of treatment success. Using a scale comparison approach, success criteria for pain were a raw change of 17.5 points (0-100 numerical rating scale) and percent change of 25%. Other criteria were 7.5 (11%) for fatigue, 5.0 (13%) for distress, and 9.5 (12%) for interference. CONCLUSIONS Future research should validate these success criteria, particularly for the less studied domains of fatigue, distress, and interference, and investigate how these criteria evolve over the course of different treatments.

Somatic focus/awareness: Relationship to negative affect and pain in chronic pain patients

Somatic focus refers to the tendency to notice and report physical symptoms, and has been investigated in relation to chronically painful conditions. This study investigated the relationship between somatic focus, as measured by the Pennebaker Inventory of Limbic Languidness (PILL), negative affect and pain. A secondary purpose of the present study was to examine sex differences in these relationships. Participants included 280 chronic pain patients (69.6% females, 88.9% Caucasian), who completed a battery of self‐report measures on somatic focus, pain, negative affect, coping, and dysfunction. Results for the overall sample revealed that the PILL shares considerable variance with measures of negative affect, particularly with the physiological components of anxiety and depression. When the results were analyzed separately for male and female patients, it was found that several components of negative affect and cognitive factors play a stronger role in predicting somatic focus among men compared to women. Additional analyses then examined whether somatic focus was predictive of male and female patients’ pain reports. Results indicated that somatic focus explained a small, but unique amount of variance in female patients’ pain reports, which differed from the relationship observed among male patients.

Preliminary results of patient-defined success criteria for individuals with musculoskeletal pain in outpatient physical therapy settings

OBJECTIVES (1) To investigate patient-defined parameters of treatment success in an outpatient physical therapy setting with musculoskeletal pain, (2) to determine whether patient-defined treatment success was influenced by selected demographic and clinical factors, and (3) to examine whether patient subgroups existed for ratings of importance for each treatment outcome domain. DESIGN Cross-sectional study. SETTING Outpatient physical therapy clinic. PARTICIPANTS Consecutive patients (N=110) with complaints of musculoskeletal pain. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE We reported patient-defined treatment success targets for pain, fatigue, emotional distress, and interference with daily activities using the Patient-Centered Outcomes Questionnaire (PCOQ). We also investigated whether patient subgroups existed based on perceived importance of improvement for these same outcome domains. RESULTS Patient-defined criteria for treatment success included mean reductions (from baseline scores) in pain of 3.0 points, in fatigue of 2.3 points, in emotional distress of 1.4 points, and in interference with daily activities of 3.4 points. There were no differences in patient-defined criteria for treatment success based on sex, age, postoperative rehabilitation, prior physical therapy, other prior health care interventions, duration of symptoms, and anatomical location of symptoms (P>.01). Cluster analysis of the PCOQ importance ratings indicated a 2-cluster solution. The multifocused subgroup demonstrated higher importance for improvement ratings in each treatment outcome domain when compared with the pain-focused subgroup (P>.05). CONCLUSIONS These data indicate that patient-defined criteria for treatment success required greater reductions in the studied outcome domains to be considered successful. These data suggest the potential existence of patient subgroups that either rate improvement in all outcome domains as important or rate pain relief as the most important outcome.

Effects of obesity on rehabilitation outcomes after orthopedic trauma.

Objective This study examined whether differences existed in inpatient rehabilitation outcomes and therapy participation in nonobese and obese patients with orthopedic trauma. Design This was a retrospective study of 294 consecutive patients admitted to an inpatient rehabilitation hospital. Main outcomes included participation in therapy sessions, Functional Independence Measure (FIM) ratings, walking distance and stair climb, length of stay, FIM efficiency (FIM score gain/length of stay), and discharge to home. Data were stratified by patient body mass index values (nonobese, <30 kg/m2; or obese, ≥30 kg/m2). Results There were no differences in therapy participation or length of stay between groups. Both total and motor FIM ratings at discharge were lower in obese patients compared with nonobese patients (P < 0.05). FIM efficiency was significantly lower in the obese than in the nonobese group (2.6 ± 1.5 vs. 3.1 ± 1.5 points gained per day; P = 0.05). Walking distance and stair climb ability were similar between groups by discharge. Even morbidly obese patients attained some improvement with independence in walking. Conclusions Obese patients make significant functional improvement during rehabilitation, but at a lesser magnitude and rate as their nonobese counterparts. Even with morbid obesity, small but important functional gains can occur during rehabilitation for orthopedic trauma.

Investigating patient expectations and treatment outcome in a chronic low back pain population

Objective This study aimed to measure the outcomes that patients consider clinically meaningful across four treatment domains – (1) pain, (2) fatigue, (3) emotional distress, and (4) level of interference – and determine if patients met their own success criteria. Additionally, the role of expectations in treatment outcome was examined. This study also aimed to determine how change in levels of pain, fatigue, disability, and level of interference varied according to the type of treatment delivered to participants. Patients Forty-seven chronic low back pain patients were recruited from university-affiliated pain clinics. Design The study design was longitudinal, consisting of two randomly assigned treatment conditions. The first treatment condition used opioid medication only and the second used both opioid medication and brief cognitive behavioral therapy. Pre- and post-treatment assessments were conducted, which occurred approximately 3 months after the initiation of treatment. Outcome measures A patient-centered outcomes questionnaire was completed by participants at both pre- and post-treatment assessment. Results Results suggest that patients did not meet their own success criteria in treatment across any of the four domains. There was a significant main effect of time for level of pain indicating that both treatment groups had a decrease in their level of pain at post-treatment, F(1, 45) = 11.98, P < 0.001. There was a significant main effect of time for level of interference domain indicating that both groups experienced a reduction in the level of pain-related interference with daily activities, F(1, 45) = 5.46, P < 0.05. There were no significant effects of time for emotional distress or fatigue or any significant group by time interactions. Contrary to our hypothesis, no significant correlations were found between pretreatment expectations and usual level ratings at post-treatment across the four domains. Conclusion Patients sought larger reductions in pain, fatigue, level of distress, and level of interference than they attained at post-treatment. Enhancing opioid treatment with brief cognitive behavioral therapy did not yield additional improvements for the four domains assessed in patients with chronic low back pain.

The challenge of teaching rehabilitative care in medical school

Rehabilitative care has gained importance because the population is aging, and improved acute and chronic medical care saves and prolongs lives but leaves some patients with temporary or permanent physical impairments. However, despite its importance, the teaching and learning of rehabilitative care in medical school lag behind medical education relating to acute and chronic care. The authors analyze the broad scope of rehabilitative care and the need to include it in the medical school curriculum. They also discuss advantages for students and their patients of learning rehabilitative care in the undergraduate curriculum and suggest methods to improve teaching it.

Manipulation efficacy: Upper body

Manipulation, or manual medicine, is a highly utilized form of treatment for many types of musculoskeletal disorders, but there are many questions about the efficacy and safety of this form of treatment. This review of published trials for treatment of the upper body (cervical, thoracic, and upper limb) describes the patient groups that have been studied and may benefit from manual treatment, their outcomes, and their limitations. Cervical manipulation in particular has historically received criticism regarding safety, and the incidence of side effects, severe complications, and contraindications are discussed. The number of studies published for the upper body is small compared to the lumbar spine, and the lack of uniformity of the information still leaves the individual practitioner to decide if and when manipulation fits into his or her treatment algorithms for this region of the body.