Marisol A. Hanley

Psychosocial predictors of long-term adjustment to lower-limb amputation and phantom limb pain

Purpose: To evaluate the utility of a biopsychosocial model to predict long-term adjustment to lower-limb amputation and phantom limb pain (PLP). Method: One month after lower-limb amputation, 70 participants completed measures of PLP intensity, cognitions (catastrophizing, perceived control over pain), coping (pain-contingent rest), social environment (social support, solicitous responding), and functioning (pain interference, depressive symptoms). The measures of functioning were administered again at 1- and 2-years post-amputation. Multiple regression analyses were used to examine the ability of the psychosocial variables at 1-month post-amputation to predict changes in the functioning measures over time. Results: The psychosocial variables at 1-month post-amputation, controlling for initial PLP intensity, accounted for 21% of the variance in change in depressive symptoms at 1-year (p < 0.05), and 27% and 22% (ps < 0.01 and 0.05, respectively) of the variance in change in pain interference and depressive symptoms, respectively, at 2-years post-amputation. Catastrophizing and social support were associated with decreases (improvement) in both criterion measures, while solicitous responding was associated with increases (worsening) in both measures. Discussion: The findings support a biopsychosocial model of long-term adjustment to amputation and PLP. In addition, results suggest that some psychosocial variables are more important than others for predicting adjustment, providing important implications for early interventions after amputation.

The scope and nature of pain in persons with multiple sclerosis

Much remains unknown about the scope, nature, and impact of pain on the lives of persons with multiple sclerosis (MS). In the present study, 180 community dwelling adults with MS completed a postal survey that included demographic measures, MS disease measures, and several standardized measures of pain, including pain intensity, variability, location, and pain-related interference. Some 66% of the sample reported pain, 25% of whom reported severe pain. Persons with pain reported an average of 6.6 distinct pain sites. Using the Brief Pain Inventory Interference Scale, the average level of overall pain interference was 3.33 (0- 10 scale) in the group reporting pain. The highest levels of pain interference were reported for sleep, recreational activities, and work in and outside the home. Persons with pain were more likely to report greater MS disease severity, poorer psychological functioning, and poorer health than persons with MS but not pain. Persons with pain were also less likely to be employed. These findings are consistent with previous research that shows that pain is common in MS, that it is severe in a substantial subset of these individuals and has the potential to negatively impact physical and psychosocial functioning over and above the effects of MS itself.

Psychosocial factors associated with pain intensity, pain-related interference, and psychological functioning in persons with multiple sclerosis and pain

Abstract Biopsychosocial models of chronic pain that recognize psychological and environmental factors as important aspects of adjustment to pain have been proposed for understanding chronic pain and related suffering in persons with multiple sclerosis (MS), but such models have not been empirically tested. The objective of this study was to test such a model by evaluating the associations of several psychosocial variables (i.e., pain‐related catastrophizing, perceived social support, pain beliefs, and pain coping) with pain intensity, pain interference with functioning, and psychological functioning in persons with chronic pain and MS, after controlling for demographic and disease‐related factors. Participants were 125 community‐dwelling persons with MS and pain who completed a mailed questionnaire that included measures of pain intensity and interference, psychological functioning, catastrophizing, social support, and pain beliefs and coping. The psychosocial variables accounted for an additional 25% of the variance in average pain intensity after controlling for demographic and disease‐related variables (p < .001). These variables explained an additional 22% of the variance in pain‐related interference (p < .001) and 43% of the variance in psychological functioning (p < .001), after adjusting for demographic and MS‐related variables and average pain intensity. Catastrophizing was consistently and independently associated with all criterion measures, whereas social support, pain beliefs, and pain coping were associated with some criterion measures but not others. The results provide empirical support for a biopsychosocial understanding of chronic pain in MS and suggest that specific psychosocial factors (e.g., catastrophizing) may be important regarding adjustment to pain in persons with MS.

Prosthesis use in persons with lower- and upper-limb amputation

This study identified clinical (e.g., etiology) and demographic factors related to prosthesis use in persons with upper- and lower-limb amputation (ULA and LLA, respectively) and the effect of phantom limb pain (PLP) and residual limb pain (RLP) on prosthesis use. A total of 752 respondents with LLA and 107 respondents with ULA completed surveys. Factors related to greater use (hours per day) for persons with LLA included younger age, full- or part-time employment, marriage, a distal amputation, an amputation of traumatic etiology, and an absence of PLP. Less use was associated with reports that prosthesis use worsened RLP, and greater prosthesis use was associated with reports that prosthesis use did not affect PLP. Having a proximal amputation and reporting lower average PLP were related to greater use in hours per day for persons with an ULA, while having a distal amputation and being married were associated with greater use in days per month. Finally, participants with LLA were significantly more likely to wear a prosthesis than those with ULA. These results underscore the importance of examining factors related to prosthesis use and the differential effect that these variables may have when the etiology and location of amputation are considered.

Efficacy of gabapentin in treating chronic phantom limb and residual limb pain.

Twenty-four adults with phantom limb pain (PLP) and/or residual limb pain (RLP) participated in a double-blind crossover trial. Participants were randomly assigned to receive gabapentin or placebo and later crossed over to the other treatment, with a 5-week washout interval in which they did not receive medication. Gabapentin was titrated from 300 mg to the maximum dose of 3,600 mg. Measures of pain intensity, pain interference, depression, life satisfaction, and functioning were collected throughout the study. Analyses revealed no significant group differences in pre- to posttreatment change scores on any of the outcome measures. More than half of the participants reported a meaningful decrease in pain during the gabapentin phase compared with about one-fifth who reported a meaningful decrease in pain during the placebo phase. In this trial, gabapentin did not substantially affect pain. More research on the efficacy of gabapentin to treat chronic PLP and RLP is needed.

Effects of Self-Hypnosis Training and EMG Biofeedback Relaxation Training on Chronic Pain in Persons with Spinal-Cord Injury

Abstract Thirty-seven adults with spinal-cord injury and chronic pain were randomly assigned to receive 10 sessions of self-hypnosis (HYP) or EMG biofeedback relaxation (BIO) training for pain management. Participants in both treatment conditions reported substantial, but similar, decreases in pain intensity from before to after the treatment sessions. However, participants in the HYP condition, but not the BIO condition, reported statistically significant decreases in daily average pain pre- to posttreatment. These pre- to posttreatment decreases in pain reported by the HYP participants were maintained at 3-month follow-up. Participants in the HYP condition, but not the BIO condition, also reported significant pre- to posttreatment increases in perceived control over pain, but this change was not maintained at the 3-month follow-up.

Clinically significant change in pain intensity ratings in persons with spinal cord injury or amputation.

Objective:To examine the clinical significance of changes in chronic pain in 2 disability groups: spinal cord injury and lower limb amputation. Methods:A reanalysis of 2 controlled clinical trials for pain in persons with disabilities. Eighty-two persons with spinal cord injuries and 34 persons with amputations provided pretreatment and posttreatment ratings of pain intensity on 0 to 10 numerical rating scales. After treatment, participants also rated the meaningfulness of any changes in pain they experienced. Results:An average decrease of 1.80 points on the 0 to 10 numerical rating scales and percent decreases of about 36% corresponded to reports of a meaningful change in pain. There was no significant difference between samples, and also no differences due to gender or treatment condition. Age and pretreatment pain, however, were associated with the amount of pain decrease rated as meaningful. The change in pain intensity rated as meaningful was greater for older participants and participants with higher levels of pretreatment pain. Consistent with previous research, percent change scores were less biased by pretreatment pain than were absolute change scores. Discussion:These findings are generally consistent with similar findings in other pain populations, and, in light of previous research, support an approximate 33% decrease in pain as a reasonable standard for meaningful change across chronic pain conditions. Percent change scores may be more useful for comparing the effects of pain treatments across samples or conditions because they are less biased by pretreatment pain level.

Chronic Pain Associated with Upper-Limb Loss

Hanley MA, Ehde DM, Jensen M, Czerniecki J, Smith DG, Robinson LR: Chronic pain associated with upper-limb loss. Objective: To describe the prevalence, intensity, and functional impact of the following types of pain associated with upper-limb loss: phantom limb, residual limb, back, neck, and nonamputated-limb pain. Design: Cross-sectional survey; 104 respondents with upper-limb loss at least 6 months postamputation completed measures of pain intensity, interference, disability, and health-related quality-of-life. Results: Nearly all (90%) of the respondents reported pain, with 76% reporting more than one pain type. Phantom-limb pain and residual-limb pain were the most prevalent (79% and 71%, respectively), followed by back (52%), neck (43%), and nonamputated-limb pain (33%). Although nonamputated-limb pain was least prevalent, it was reported to cause the highest levels of interference and pain-related disability days. Self-reported quality-of-life was significantly lower for individuals with each type of pain compared with those without any pain. Age, time since amputation, and cause of amputation were not associated with pain. Conclusions: In addition to pain in the phantom and residual limb, back, neck, and nonamputated-limb pain are also common after upper-limb loss. All of these pain types are associated with significant disability and activity interference for some individuals, suggesting that assessment of multiple pain types in persons with upper-limb amputation may be important.

Pain catastrophizing and beliefs predict changes in pain interference and psychological functioning in persons with spinal cord injury.

UNLABELLED The current study sought to examine how changes in pain-related beliefs and coping responses are related to changes in pain interference and psychological functioning in individuals with spinal cord injuries (SCI) and pain. To measure longitudinal changes in these variables, respondents completed a survey that included measures of pain intensity, pain interference, and psychological functioning, as well as specific psychosocial variables (pain-related beliefs, coping, and social support) and then completed the same survey 6 months later; analyses included only the individuals who reported pain at both times (n = 40). Demographic and injury-related variables were also assessed, but none were found to be significantly associated with changes in functioning. Changes in catastrophizing and belief in ones ability to control pain were each significantly associated with changes in the outcome variables: Greater pain interference and poorer psychological functioning. Changes in specific coping strategies and social support were not predictors of changes in pain, interference, or psychological functioning. These findings support a biopsychosocial model of pain in persons with SCI. Intervention studies targeting maladaptive pain-related beliefs and catastrophizing may help to identify the causal nature of these relationships and may improve multidisciplinary treatment of pain in SCI. PERSPECTIVE Intervention studies targeting catastrophizing and maladaptive pain-related beliefs may be the next step in determining which variables play a causal role in the pain interference and psychological functioning of individuals with pain and SCI.

Reliability and validity of a self-report FIM™ (FIM-SR) in persons with amputation or spinal cord injury and chronic pain

Masedo AI, Hanley M, Jensen MP, Ehde D, Cardenas DD: Reliability and validity of a self-report FIM™ (FIM-SR) in persons with amputation or spinal cord injury and chronic pain. Am J Phys Med Rehabil 2005;84:167–176. Objective: To evaluate the reliability and validity of a self-report FIM™ (FIM-SR) in two samples of adults with disabilities. Design: Participants in a clinical trial of amitriptyline for pain (n = 84 with spinal cord injury [SCI], n = 38 with amputation) provided responses to the study measures via telephone interview. Reliability was estimated using Cronbachs alpha and test–retest correlation coefficients, and validity was examined by comparing FIM-SR scores with the Craig Handicap Assessment and Reporting Technique (CHART) by comparing the CHART scores between the participants with SCI and amputation, and by comparing CHART scores between subjects with different levels of SCI. Results: In the SCI sample, the FIM-SR demonstrated adequate reliability, and correlational analyses supported the validity of the FIM-SR motor scales. In addition, the FIM-SR motor scales discriminated subjects with different diagnoses (SCI vs. amputation) and injury levels (paraplegia vs. tetraplegia). The psychometric properties of the entire FIM-SR in the amputation sample and of the FIM-SR cognitive scales in the SCI sample were difficult to determine due to a ceiling effect in which these scale scores were skewed toward the top end of the range. Conclusions: The FIM-SR motor scales and total FIM-SR score are reliable and valid measures of perceived functional independence in individuals with SCI. However, all of the FIM-SR scales in the amputation sample, and the FIM-SR cognitive scales in the SCI sample, seem to be less useful measures of functioning due to subjects reporting high levels of independence. The FIM-SR should be retested in amputation samples with more variable levels of functioning.