Karl S. Bagraith

It's very hard to change yourself: an exploration of overactivity in people with chronic pain using interpretative phenomenological analysis

Abstract Overactivity (activity engagement that significantly exacerbates pain) is a common term in the chronic pain literature. Overactivity is accepted clinically as a behaviour that adversely affects an individuals daily functioning and is the target of one of the most widely endorsed pain management strategies among health professionals (ie, activity pacing). Little research, however, has investigated links between overactivity behaviour and indicators of patient functioning, and activity pacing has not been evaluated as a stand-alone treatment specifically for individuals with chronic pain who are habitually overactive. Two studies, using qualitative research designs and interpretative phenomenological analyses, were conducted to provide insight into (1) why certain individuals develop habitual overactivity patterns in response to pain, (2) the impact of overactivity on daily functioning, and (3) the value of activity pacing as a treatment strategy for this population. Findings suggest that overactivity behaviour is complex, influenced by multiple factors, and negatively impacts on multiple quality-of-life domains. Some participants who were followed up 3 to 6 months after a pain management program were able to learn pacing strategies and enact behaviour change with health professional support; however, the majority reported difficulties changing their behaviour after treatment. It is suggested that provision of pacing education, alone, to chronic pain patients who engage in overactivity behaviour may not be effective in eliciting behavioural change. Key factors that participants believed to contribute to the development and maintenance of their overactive behaviour in this study should be considered in future clinical approaches and empirical investigations.

Use of Condition-Specific Patient-Reported Outcome Measures in Clinical Trials among Patients with Wrist Osteoarthritis: A Systematic Review

Background. This paper aimed to identify condition-specific patient-reported outcome measures used in clinical trials among people with wrist osteoarthritis and summarise empirical peer-reviewed evidence supporting their reliability, validity, and responsiveness to change. Methods. A systematic review of randomised controlled trials among people with wrist osteoarthritis was undertaken. Studies reporting reliability, validity, or responsiveness were identified using a systematic reverse citation trail audit procedure. Psychometric properties of the instruments were examined against predefined criteria and summarised. Results. Thirteen clinical trials met inclusion criteria. The most common patient-reported outcome was the disabilities of the arm, shoulder, and hand questionnaire (DASH). The DASH, the Michigan Hand Outcomes Questionnaire (MHQ), the Patient Evaluation Measure (PEM), and the Patient-Reported Wrist Evaluation (PRWE) had evidence supporting their reliability, validity, and responsiveness. A post-hoc review of excluded studies revealed the AUSCAN Osteoarthritis Hand Index as another suitable instrument that had favourable reliability, validity, and responsiveness. Conclusions. The DASH, MHQ, and AUSCAN Osteoarthritis Hand Index instruments were supported by the most favourable empirical evidence for validity, reliability, and responsiveness. The PEM and PRWE also had favourable empirical evidence reported for these elements. Further psychometric testing of these instruments among people with wrist osteoarthritis is warranted.

Counseling activity in single-session online counseling with adolescents: An adherence study

Abstract While online counseling is increasingly utilized, little is known about what counseling work takes place in the online environment. The aim of this study was to quantify online counseling activity by determining counselors’ adherence to the widely used model in which they had been trained. Transcripts (n=85) of online counseling with adolescents were evaluated, using a standardized and psychometrically sound instrument. We found that, while counseling in 53% of transcripts progressed through each of the key stages of counseling, the focus of most sessions was information gathering; and goal exploration and action planning were typically superficial and often absent. Possible reasons for low counseling depth are discussed and recommendations made for the further development of online counseling.

Rating counselor-client behavior in online counseling: development and preliminary psychometric properties of the Counseling Progress and Depth Rating Instrument.

Abstract Although there are widely accepted and utilized models and frameworks for nondirective counseling (NDC), there is little in the way of tools or instruments designed to assist in determining whether or not a specific episode of counseling is consistent with the stated model or framework. The Counseling Progress and Depth Rating Instrument (CPDRI) was developed to evaluate counselor integrity in the use of Egans skilled helper model in online counseling. The instrument was found to have sound internal consistency, good interrater reliability, and good face and convergent validity. The CPDRI is, therefore, proposed as a useful tool to facilitate investigation of the degree to which counselors adhere to and apply a widely used approach to NDC.

Establishment of cutpoints to categorize the severity of chronic pain using composite ratings with Rasch analysis

Establishment of cutpoints for classifying mild, moderate and severe pain is commonly based on single rating of worst or average pain. However, single pain measure may serve as a brief and partial surrogate for composite pain ratings. This study aimed to base composite pain ratings to establish optimal cutpoint that maximized the difference of pain interference on daily function and compare its utility with those based on single worst and average pain.

Disentangling disability in the fear avoidance model: more than pain interference alone.

To the Editor: We read with great interest the article by Pincus et al. We look forward to the practice and research developments that will likely ensue from their thorough consideration of the conceptualization and measurement of the fear and avoidance components of the Fear Avoidance model (FAM). We would like to add to this discussion by attempting to similarly “disentangle” the disability component of this model, and to highlight opportunities to improve its operationalization. Disability is often a poorly defined, understood, and measured concept. The current conceptualization of disability, as endorsed by the World Health Assembly in 2001, is provided by the International Classification of Functioning, Disability and Health (ICF). The ICF defines disability as body function and structure impairments, activity limitations, and participation restrictions associated with the interaction between a health condition and contextual factors (ie, the environment and personal factors). This moves the experience of disability beyond being simply a direct consequence of pain, to being the result of a complex interaction between an individual and their context. The ICF has made a significant impact on the wider rehabilitation literature, has been endorsed by professional bodies such as the Institutes of Medicine, is being integrated into the OMERACT process and, is central to the first World Report on Disability, scheduled for release in June 2011. Accordingly, Waddell et al have recommended using the ICF as a basis for pain practice. The majority of research examining the FAM has focused on people with low back pain (LBP), with the Roland Morris Disability Questionnaire (RMDQ), the Oswestry Disability Index (ODI), and to a lesser extent the Pain Disability Index (PDI), typically being used to measure disability. Upon close examination of these instruments, the stems and majority of items developed before the introduction of the ICF, tend to focus on the direct impact, or the interference, of pain when executing tasks or engaging in social roles. For example, the RMDQ focuses on whether activity performance is altered “because of the pain in my back.” In the ODI, the focus is on the degree to which “pain prevents” activity performance. And, in the PDI, the key issue is to what extent pain has “disrupted or prevented” activity performance. We would contend that, in terms of the ICF, these instruments are more reflective of pain interference rather than disability. In contrast, contemporary disability measures would instead strive to broadly capture problems with, frequency of, or ability to, execute tasks or engage in life situations. This is consistent with recent developments such as the Patient Reported Outcomes Measurement Information System (PROMIS), which has recognized the importance, but distinctiveness, of pain interference from physical functioning and social participation. These established instruments seem most suited to capturing activity performance that is altered as a direct consequence of pain. They therefore may not be adequate to evaluate disability associated with fears about pain, reinjury, movement, exercise, or activity, as differentiated by Pincus et al. For example, a person with a profound fear of reinjury from household tasks (eg, vacuuming) and subsequent avoidance, might not necessarily endorse items on these instruments, as pain intensity per se is not impacting on performance (“it’s not the pain that’s stopping me, I just don’t want to do anything more to my spine”). Similarly, environmental (physical, social, or attitudinal) influences are unlikely to be adequately captured with these instruments, given their specific focus on the degree to which pain alone impacts performance. For example, disengagement from work may not be a direct consequence of living with LBP, but rather a product of an individual having pain, and of negative attitudes held by an employer toward workers with pain. Such a person may not have beliefs or fears triggering avoidance, however, they would present with greater disability clinically than these measures would indicate (“I’m ready to go back to work, my boss just won’t let me go back until I’m pain free”). These examples highlight the need for more comprehensive measures that are grounded in a modern conceptualization of disability. The ICF provides such a conceptualization, and one that is more comparable with the disability that clinicians and people in pain face each day (ie, disability associated with pain is rarely a simple and direct consequence of it). Furthermore, the universally agreed-upon language and classification system at the heart of the ICF serves as a Rosetta Stone to standardize the description of disability across disciplines and geographic regions. As such, the ICF framework is becoming the new currency for planning, executing, and communicating multidisciplinary assessment and treatment plans. Accordingly, while it has been possible to describe the content of these instruments using this universal language (ie, ICF categories), their inherent focus remains incongruent with the conceptualization of disability provided by this new framework. Tools, such as the ICF LBP Core Sets have been developed to guide the assessment of disability in clinical and research contexts (ie, what to measure). Using these tools to develop new disability measures that operationalize the ICF will enhance the clinical utility of research findings and ensure that pain researchers are not left behind as the world embraces this new standard. The RMDQ, ODI, and PDI have provided a firm platform from which to quantify disability during the development of the FAM. Their psychometric quality has been well demonstrated using classical test theory, and they remain the gold standard. However, the measurement of disability within the FAM, and therefore the operationalized conceptualization of disability, requires further consideration. Developing and using new measures that are grounded in a contemporary conceptualization of disability will assist researchers to refine the theory underpinning the FAM, and to elucidate the most salient and therapeutically modifiable components. Using modern test theory and computerized adaptive testing to do so will move them into a realm far beyond what was practical and possible when current “disability” instruments were produced. It seems high time to take another step along the (never-ending) path toward the Holy Grail. LETTER TO THE EDITOR

PARAMETRIC ANALYSES OF SUMMATIVE SCORES MAY LEAD TO CONFLICTING INFERENCES WHEN COMPARING GROUPS: A SIMULATION STUDY

OBJECTIVE To investigate whether using a parametric statistic in comparing groups leads to different conclusions when using summative scores from rating scales compared with using their corresponding Rasch-based measures. METHODS A Monte Carlo simulation study was designed to examine between-group differences in the change scores derived from summative scores from rating scales, and those derived from their corresponding Rasch-based measures, using 1-way analysis of variance. The degree of inconsistency between the 2 scoring approaches (i.e. summative and Rasch-based) was examined, using varying sample sizes, scale difficulties and person ability conditions. RESULTS This simulation study revealed scaling artefacts that could arise from using summative scores rather than Rasch-based measures for determining the changes between groups. The group differences in the change scores were statistically significant for summative scores under all test conditions and sample size scenarios. However, none of the group differences in the change scores were significant when using the corresponding Rasch-based measures. CONCLUSION This study raises questions about the validity of the inference on group differences of summative score changes in parametric analyses. Moreover, it provides a rationale for the use of Rasch-based measures, which can allow valid parametric analyses of rating scale data.

What do clinicians consider when assessing chronic low back pain? A content analysis of multidisciplinary pain centre team assessments of functioning, disability, and health

Abstract Beyond expert suggestions as to the appropriate subject matter for chronic pain assessments, little is known about the actual content of multidisciplinary pain centre (MPC) clinical assessments. The International Classification of Functioning, Disability and Health Low Back Pain Core Set (ICF LBP-CS) provides a universal language to support the consistent description of LBP-related assessments across disciplines within multidisciplinary teams (MDTs). This study sought to map the content of MPC clinical assessments to the ICF to: (1) identify and compare the content of clinical MDT assessments using a cross-disciplinary framework and (2) examine the content validity of the LBP-CS. A qualitative examination of MPC team clinical assessments of chronic low back pain was undertaken. Multidisciplinary team (pain medicine, psychiatry, nursing, physiotherapy, occupational therapy, and psychology) assessments were audio-recorded and transcribed. Concepts were extracted from transcripts using a meaning condensation procedure and then linked to the ICF. Across 7 MDT assessments, comprised 42 discipline-specific assessments and 241,209 transcribed words, 8596 concepts were extracted. Contextual factors (ie, the person and environment), except for physiotherapy, accounted for almost half of each disciplines assessments (range: 49%-58%). Concepts spanned 113 second-level ICF categories, including 73/78 LBP-CS categories. Overall, the findings revealed novel insights into the content of MPC clinical assessments that can be used to improve health care delivery. International Classification of Functioning, Disability and Health–based assessment profiles demonstrated unique contributions from each discipline to chronic low back pain assessment. Finally, users of the LBP-CS can be confident that the tool exhibits sound content validity from the perceptive of MDT assessments of functioning, disability, and health.