Robin Weir

Epidemiology of chronic pain with psychological comorbidity: prevalence, risk, course, and prognosis.

Objective: To review the relation between chronic pain and psychological comorbidities, and the influence on course and prognosis, based on epidemiologic and population studies. Method: We present a narrative overview of studies dealing with the epidemiology of chronic pain associated with mental health and psychiatric factors. Studies were selected that were of good quality, preferably large studies, and those that dealt with prevalences, course and prognosis of chronic pain, risk factors predicting new pain and comorbid disorders, and factors that affect health outcomes. Results: Chronic pain is a prevalent condition, and psychological comorbidity is a frequent complication that significantly changes the prognosis and course of chronic pain. In follow-up studies, chronic pain significantly predicts onset of new depressions, and depression significantly predicts onset of new chronic pain and other medical complaints. Age, sex, severity of pain, psychosocial problems, unemployment, and compensation are mediating factors in course and prognosis. Conclusion: In assessment of chronic pain, the evidence from epidemiologic studies makes it clear that chronic pain can best be understood in the context of psychosocial factors.

An epidemiological follow-up survey of persistent pain sufferers in a group family practice and specialty pain clinic☆

&NA; The course and prognosis of persistent pain are largely unknown. In addition, follow‐up studies of chronic pain sufferers have come from specialized pain clinics and have ignored the question of how representative this special group is to the general population who suffer persistent pain. Because health care planners are assumed to require these data for projection of health care needs, it is important to determine the course of persistent pain in those persistent pain sufferers in the general population as well as those referred to a specialty clinic. An epidemiological study compared 2 groups of self‐reported persistent pain sufferers from a Family Practice Clinic and a Specialty Pain Clinic over a 2 year period. All subjects reporting a persistent problem with pain at the time of the initial survey were contacted 2 years later to determine whether the initial differences between the 2 groups remained constant over time and whether there were any changes within each group over time. Despite the similarities between the study groups on multiple socioeconomic and demographic variables, the Specialty Pain Clinic group remained distinctly different from the Family Practice pain sufferers on many pain behavior and emotional variables. Thirteen percent of the persistent pain sufferers from the Pain Clinic group and 36% of the persistent pain sufferers from the Family Practice group no longer reported pain as a problem at follow‐up. Of those pain sufferers from either group who continued to experience pain at 2 years follow‐up, their pain became more intermittent, psychological distress factors improved, and the use of health services decreased. The implications are that persistent pain does not necessarily continue forever and that persistent pain sufferers in the general population have a better prognosis than those who are referred to a Specialty Pain Clinic. All follow‐up studies need to be interpreted in light of these findings.

The Effectiveness and Efficiency of Home-Based Nursing Health Promotion for Older People: A Review of the Literature:

Despite the large potential role that community nurses have in providing individualized health promotion to older people, there is a lack of consensus in the literature regarding this roles effectiveness and efficiency. This article presents a literature review and synthesis of 12 randomized controlled trials selected from 344 published studies on preventive home visitation programs for older people. The findings suggest that a diversity of home visiting interventions carried out by nurses can favorably affect health and functional status, mortality rates, use of hospitalization and nursing homes, and costs. Further research is needed that focuses on the outcomes of quality of life, mental health, social support, caregiver burden, the acceptability of intervention, and specific subgroups of clients who benefit most. Findings also indicate the need for a theoretical foundation, increased emphasis on health-promotion strategies, and more research using a more complete economic evaluation to establish efficiency.

Biopsychosocial approaches to the treatment of chronic pain.

Background: Biopsychosocial treatments address the range of physical, psychological, and social components of chronic pain. Objective: This review sought to determine how effective unimodal and multimodal biopsychosocial approaches are in the treatment of chronic pain. Methodology: The literature search identified three systematic reviews of the literature and 21 randomized controlled trials to provide the evidence for this review. Results: The systematic reviews and 12 randomized controlled trials reported on chronic low back pain. Other randomized controlled trials studied fibromyalgia (three trials) and back or other musculoskeletal disorders (five trials). Biopsychosocial components reviewed were electromyogram feedback and hypnosis as unimodal approaches, and behavioral and cognitive-behavioral treatments and back school, or group education, as multimodal approaches for chronic low back pain. For other chronic pain disorders, cognitive-behavioral treatments were reviewed. Comparisons were hindered by studies with heterogeneous subjects, varied comparison groups, different cointerventions and follow-up times, variable outcomes, and a range of analytic methods. Conclusions: Multimodal biopsychosocial treatments that include cognitive-behavioral and/or behavioral components are effective for chronic low back pain and other musculoskeletal pain for up to 12 months (level 2). There is limited evidence (level 3) that electromyogram feedback is effective for chronic low back pain for up to 3 months. The remaining evidence of longer-term effectiveness and of effectiveness of other interventions was inadequate (level 4a) or contradictory (level 4b). Future studies of cognitive-behavioral treatments should be condition specific, rather than include patients with different pain conditions.

Developing a model of collaborative research: the complexities and challenges of implementation

While the benefits of collaborative research have been well documented, fewer publications exist regarding the complex, problematic issues involved in these undertakings. This paper offers an integrated collaborative research model to depict the complexities and challenges of initiation and implementation of a 2 1/2 year joint research project between a community hospital and a university school of nursing in Southern Ontario, Canada. A sampling of the experiences of the researchers are analyzed to clarify the dynamic and often competing issues and interactions involved in encouraging hospital-wide research involvement during periods of organizational growth and change. The model reflects the simultaneous interaction of organizational, change and collaborative processes while maintaining the rigor of the research (RCT), and ensuring minimal disruption to the service agency. Quantitative outcomes of this collaboration are presented through an analysis of participant involvement on multiple organizational levels. Recommendations for future collaborative research, including design and methodological issues and collaborative and change strategies are offered. The complexity of balancing the necessary trade-offs required of successful collaborative research are highlighted and will be useful to those considering and planning future collaborations.

Interventions for Disability Management

Background: With an increasing prevalence of low back pain, management can include modified work, work-conditioning, or work-hardening programs. Modified work programs, or employers worksite interventions or clinic-based programs under medical supervision, provide a gradual increase of workload. Work-conditioning programs, or unimodal physical conditioning and function activities, promote return to work. Work-hardening programs, or graded work simulations and psychological interventions, are used as part of an interdisciplinary program addressing physical and functional needs. Objective: The objective of the review was to determine how effective modified work programs, work hardening, and work conditioning are in the management of chronic pain disability. Methodology: The literature search identified two systematic literature reviews to provide the evidence about these interventions for disability management. Results: Studies of work conditioning showed methodological variability, heterogeneous subjects, variable definitions of modified work, and limited outcome measures. Using return-to-work outcomes, 8 of the 11 studies of adequate methodological quality reported positive effects of modified work programs, mostly light duty. For work conditioning and work hardening, studies showed methodological variability combined with heterogeneous subjects, including varying times out of work and varying work ethics from different countries. Most study results were uncertain, though results of three of the four medium-quality studies were positive. Conclusions: Modified work programs may improve return-to-work rates of workers with work-related injuries for 6 months or longer (level 2). There is inadequate evidence (level 4a) to determine what particular aspects of modified work programs are helpful. Work conditioning and work hardening may or may not improve the return to work of more chronically disabled workers (level 4b).

Interprofessional stroke rehabilitation for stroke survivors using home care.

OBJECTIVE To compare a specialized interprofessional team approach to community-based stroke rehabilitation with usual home care for stroke survivors using home care services. METHODS Randomized controlled trial of 101 community-living stroke survivors (<18 months post-stroke) using home care services. Subjects were randomized to intervention (n=52) or control (n=49) groups. The intervention was a 12-month specialized, evidence-based rehabilitation strategy involving an interprofessional team. The primary outcome was change in health-related quality of life and functioning (SF-36) from baseline to 12 months. Secondary outcomes were number of strokes during the 12-month follow-up, and changes in community reintegration (RNLI), perceived social support (PRQ85-Part 2), anxiety and depressive symptoms (Kessler-10), cognitive function (SPMSQ), and costs of use of health services from baseline to 12 months. RESULTS A total of 82 subjects completed the 12-month follow-up. Compared with the usual care group, stroke survivors in the intervention group showed clinically important (although not statistically significant) greater improvements from baseline in mean SF-36 physical functioning score (5.87, 95% CI -3.98 to 15.7; p=0.24) and social functioning score (9.03, CI-7.50 to 25.6; p=0.28). The groups did not differ for any of the secondary effectiveness outcomes. There was a higher total per-person costs of use of health services in the intervention group compared to usual home care although the difference was not statistically significant (p=0.76). CONCLUSIONS A 12-month specialized, interprofessional team is a feasible and acceptable approach to community-based stroke rehabilitation that produced greater improvements in quality of life compared to usual home care. Clinicaltrials.gov identifier: NCT00463229.

The meaning of illness questionnaire : further evidence for its reliability and validity

&NA; Cognitive appraisal processes or the meaning a person gives a stressful event are believed to mediate an individuals reaction to an event and, as such, have been demonstrated to explain adjustment to illness. The purpose of this paper is to test this cognitive as well as other social and illness variables to explain the variance in a persons adjustment to chronic pain. Two hundred and twenty‐two patients, who were randomly selected from an original sample of referrals to a chronic pain specialty clinic, completed a questionnaire by telephone interview or mail. The questionnaire consisted of psychosocial scales (PAIS‐SR; Social Support) and cognitions including the Meaning of Illness Questionnaire (MIQ). Fifty‐six percent of the sample had poor psychosocial adjustment to their pain problem. Seventy percent of the variance in adjustment was explained by social and cognitive variables which corroborates their importance. The MIQ 5‐factor structure was supported and provides credible evidence of the role of cognitions in differentiating between the poor and well adjusted.

Epidemiologic Perspective on Chronic Pain Treatment

Objective: To review the epidemiologic literature concerning psychosocial mediators of outcome in chronic pain. These factors deserve attention in the assessment and treatment of chronic pain by mental health professionals. Method: We reviewed literature dealing with epidemiologic perspectives on abuse, depression, addiction, employment, coping skills, and psychosocial problems. Treatments considered include analgesics, psychological rehabilitation, and prevention of disability. Results: Psychosocial factors such as abuse, mood disorder, employment handicap, poor coping skills, and other psychosocial problems are commonly found in chronic pain patients referred to clinics. Conclusion: Many psychosocial factors that can be identified in chronic pain sufferers are relevant to the professional skills of mental health professionals. These factors are determinants of prognosis, course, and outcome of chronic pain.

Use of home telehealth in palliative cancer care: a case study.

We conducted a mixed-methods case study to explore the perceptions of family caregivers and palliative cancer patients of home telehealth, and their experience with it. The intervention in the randomized controlled trial from which study participants were selected consisted of specialist nurses available 24 hours per day who communicated with patients and families using videophones, with optional remote monitoring. Qualitative data were collected from interviews with five patient/caregiver dyads and seven bereaved family caregivers, direct observation and nursing documentation. Quantitative data were collected from computerized nursing documentation and analyzed for patterns of use. During the study there were 255 contacts, including videophone, telephone or face-to-face visits, between tele-nurses and families. Overall the patients, family caregivers and tele-nurses felt that home telehealth enabled family caregiving, citing increased access to care, and patient and family caregiver reassurance. Pain management was the most common reason for initiating contact with the nurse, followed by emotional support. Concerns included lack of integration of services, inappropriate timing of the intervention and technical problems. The case study confirmed the importance of timely and accessible care for a group of clinically vulnerable, dying cancer patients and their family caregivers.