Sheri D. Pruitt

Effects of noradrenergic and serotonergic antidepressants on chronic low back pain intensity.

To understand the relative efficacy of noradrenergic and serotonergic antidepressants as analgesics in chronic back pain without depression, we conducted a randomized, double-blind, placebo-control head-to-head comparison of maprotiline (a norepinephrine reuptake blocker) and paroxetine (a serotonin reuptake blocker) in 103 patients with chronic low back pain. Of these 74 completed the trial; of the 29 who did not complete, 19 were withdrawn because of adverse effects. The intervention consisted of an 8-week course of maprotiline (up to 150 mg daily) or paroxetine (up to 30 mg daily) or an active placebo, diphenhydramine hydrochloride (up to 37.5 mg daily). Patients were excluded for current major depression. Reduction in pain intensity (Descriptor Differential Scale scores) was significantly greater for study completers randomized to maprotiline compared to placebo (P=0.023), and to paroxetine (P=0.013), with a reduction of pain by 45% compared to 27% on placebo and 26% on paroxetine. These results suggest that at standard dosages noradrenergic agents may provide more effective analgesia in back pain than do selective serotonergic reuptake inhibitors.

The contribution of job satisfaction to the transition from acute to chronic low back pain

OBJECTIVE To determine the extent to which job satisfaction predicts pain, psychological distress, and disability 6 months after an initial episode of low back pain (LBP). DESIGN A longitudinal design was used to follow an inception cohort experiencing first-episode low back pain with assessment at 2 and 6 months after pain onset. SETTING Urban medical center outpatient orthopedic clinic. PATIENTS The consecutive sample was comprised of 82 men with initial-onset acute LBP (T6 or below, daily pain for 6 to 10 weeks). INTERVENTION Usual orthopedic care. MAIN OUTCOME MEASURES The primary study outcomes were pain (Descriptor Differential Scale, Visual Analog Scales); disability (Sickness Impact Profile, Quality of Well-Being); and psychological distress (Beck Depression Inventory, Hamilton Rating Scale for Depression, Automatic Thoughts Questionnaire); predictor variables were orthopedic impairment (Waddell Physical Impairment Index) and job satisfaction (Job Descriptive Index, Work APGAR). RESULTS Measures of job satisfaction, pain, disability, and psychological distress at baseline and 6 months after pain onset were separately reduced into factors using principle components factor analysis. In hierarchical multiple regression analyses, baseline job satisfaction significantly predicted variance in outcome scores at 6 months after pain onset, beyond the variance explained by control factors (demographics; baseline pain, mood, and disability; orthopedic impairment). Zero-order correlations between job satisfaction and orthopedic impairment were small and nonsignificant, suggesting that these two variables act independently in predicting outcome. Although type of work performed (desk work or work requiring light, moderate, or heavy lifting) and social position were correlated with job satisfaction at baseline, neither contributed to the prediction of outcome at 6 months. CONCLUSIONS Satisfaction with ones job may protect against development of chronic pain and disability after acute onset back pain and, alternatively, dissatisfaction may heighten risk of chronicity. Vocational factors should be considered in the rehabilitation of acute back injury.

One-year follow-up of first onset low back pain

&NA; Efforts to examine the process and risk of developing chronic back pain have relied generally upon retrospective study of individuals with already established pain. In an alternative approach to understanding the clinical course and evolution of low back disorders, a cohort of 76 men experiencing their first episode of back pain was assessed prospectively at 2, 6 and 12 months following pain onset. Standard measures of pain (Descriptor Differential Scale: DDS), disability (Sickness Impact Profile: SIP), and distress (Beck Depression Inventory: BDI) were employed to classify the sample into five groups: Resolved, Pain Only, Disability/Distress Only, Pain and Mild Disability/Distress, and Clinical Range. At both 6 and 12 months post pain onset, most (78%, 72% respectively) of the sample continued to experience pain. Many also experienced marked disability at 6 months (26%) and 12 months (14%). At 12 months, no participants had worsened relative to the 2‐month baseline. Doubly multivariate analyses of variance (MANOVAs) were employed to compare baseline groups (Pain Only, Pain and Mild Disability/Distress, Clinical Range) on the DDS, SIP, and BDI across time. The group by time interaction from 2 through 12 months was reliable, with greatest change occurring in the Clinical Range group in disability and distress; interestingly, the decrease in pain was comparable among all groups. Follow‐up tests across measures demonstrated greater change in the early (2–6‐month) interval and relative stability in the later (6–12‐month) interval. Comparison of those classified as ‘improvers’ with those who did not improve from 2 to 12 months showed similar findings. The clinical course of first onset back pain may be prolonged for many patients, and involves a continuum of related disability and distress. Individuals at risk for marked symptoms 1 year after an initial episode of back pain can be identified early, and prompt treatment might reduce the risk of pain chronicity.

Functional Status in Children With Limb Deficiency: Development and Initial Validation of an Outcome Measure

OBJECTIVE To develop a new outcome measure in response to the increasing demands for cost effectiveness analyses and empirically derived outcome instruments in the treatment of pediatric limb deficiency. This article describes the development, refinement, and initial psychometric properties of the Child Amputee Prosthetics Project-Functional Status Inventory (CAPP-FSI). DESIGN Parents of children with limb deficiency were surveyed during routine clinic visits. SETTING Two outpatient pediatric clinics. PARTICIPANTS Seventy-five parents and their children with limb deficiency (ages 8 to 17 years) participated in the study as part of annual physical evaluations or routine follow-up care. MAIN OUTCOME MEASURE The newly developed CAPP-FSI. RESULTS Internal consistency reliability (Cronbachs alpha) = .96 for the CAPP-FSI. Content validity is described and initial construct validity is empirically confirmed. CONCLUSION The CAPP-FSI is a promising assessment instrument for measuring important health outcomes in children with upper or lower limb deficiency.

Prosthesis satisfaction outcome measurement in pediatric limb deficiency

OBJECTIVE To describe the development and initial psychometric properties of a new outcome measure to assess satisfaction with prosthesis in children with limb deficiencies. DESIGN Parents of children with limb deficiency were surveyed during routine outpatient clinic visits. SETTING Two outpatient pediatric clinics. PARTICIPANTS Ninety-seven parents of children with limb deficiency aged 1 to 17 years. MAIN OUTCOME MEASURE The newly developed Child Amputee Prosthetics Project-Prosthesis Satisfaction Inventory (CAPP-PSI). RESULTS Internal consistency reliability is high. Zero-order correlations with prosthesis wear/use patterns and with parent ratings of prosthesis appearance provide support for the construct validity of the CAPP-PSI. CONCLUSION The CAPP-PSI is a promising, brief, parent-administered inventory for the assessment of prosthesis satisfaction in children with limb deficiency. It may be useful in future research for predicting prosthesis wear and use patterns in this population.

Functional Status in Limb Deficiency: Development of an Outcome Measure for Preschool Children

OBJECTIVE To develop an outcome measure of functional status in preschool children with limb deficiency. DESIGN Parents of preschool children with limb deficiency completed self-report measures during a routine medical clinic visit. SETTING Outpatient pediatric clinic. PARTICIPANTS Fifty-two parents of children (ages 4 to 7) with acquired or congenital limb deficiency. MAIN OUTCOME MEASURE The newly developed Child Amputee Prosthetics Project-Functional Status Inventory for Preschool children (CAPP-FSIP). RESULTS Initial psychometric studies indicate high internal consistency reliability of the new instrument. Content validity was established through expert clinician review. Initial construct validity analyses confirm that the CAPP-FSIP discriminates between children with upper and lower deficiency and their prosthesis use for functional activities. CONCLUSION The CAPP-FSIP is a promising new measure for evaluating preschool age children with limb deficiency.

The clinical significance of behavioral treatment for chronic low back pain: an evaluation of effectiveness.

Abstract The clinical effectiveness of behavioral treatment for chronic low back pain (CLBP) was evaluated using an empirical strategy to quantify individual patient change. Patients with CLBP (n=17) presenting to an outpatient pain clinic were evaluated at baseline and six months posttreatment on variables of pain, disability and distress. Similar patients receiving usual medical care (n=17) were evaluated on the same outcome measures and time line for purposes of descriptive comparison. Validated and widely‐used measures of pain (McGill Pain Questionnaire), disability (Sickness Impact Profile), and depression (Beck Depression Inventory) served as outcome measures. Forty‐seven percent of patients receiving behavioral treatment evidenced clinically significant improvement in at least one of the dimensions of pain, disability and depression associated with CLBP. However, clinically significant improvement across all three measures was rare. These findings are discussed in terms of the viability of behavioral treatment for CLBP, the need to enhance the degree of clinically significant outcome associated with behavioral treatments, and the value of empirical evaluation of clinically significant improvement following treatment interventions.

Toddlers with limb deficiency: conceptual basis and initial application of a functional status outcome measure.

OBJECTIVE To describe the conceptual foundation, development, and initial psychometric analyses of a new outcome measure of functional status in toddlers with limb deficiency. DESIGN Parents of children with limb deficiency completed self-report measures during a routine medical clinic visit. SETTING Outpatient orthopedic pediatric clinic. PARTICIPANTS Twenty parents (mothers) of children (ages 1 to 4 years) with acquired or congenital limb deficiency. MAIN OUTCOME MEASURE The newly developed Child Amputee Prosthetics Project-Functional Status Inventory for Toddlers (CAPP-FSIT). RESULTS Estimates of internal consistency reliability of the measure are high, suggesting conceptual congruence among the items. Initial validity studies confirm the CAPP-FSIT differentiates between toddlers with upper limb deficiency and lower limb deficiency in terms of functional activity and prosthesis use. The new measure does not appear to be contaminated by gender or socioeconomic status. CONCLUSION The CAPP-FSIT is a promising measure for assessing functional abilities in toddlers with limb deficiency.

Prediction of physician visits and prescription medicine use for back pain

The primary purpose of this study was to examine the extent to which specific patient attitudes and beliefs about medical care and self-care for back pain predict future healthcare use. An automated database allowed examination of the predictive relationships in two primary care patient samples. In general, beliefs that physicians should find a definitive cause and permanent cure for back pain predicted neither physician visits nor prescription medication fills. Patient attitudes endorsing the benefits of medical treatment for back pain (as opposed to a permanent cure) predicted the use of these specific healthcare services. In a third sample of primary care back pain patients, we assessed whether a four-session self-care intervention modified those attitudes and beliefs shown to predict future healthcare use. The group intervention was associated with changes in attitudes about use of physician services but not medication use. A secondary purpose was to examine initial psychometric properties of a proposed back pain Self-Care Orientation Scale made up of the original 11 items. Factor analyses of the item set yielded three factors, but inconclusive results; the internal consistency of the identified sub-scales was only moderate. However, findings that a subset of items predicted physician visits and prescriptions medication fills, and was sensitive to change following a self-care intervention, suggest avenues for improving measurement of self-care orientation. These findings help clarify specific patient attitudes and beliefs that are related to healthcare utilization and suggest that a subset of these beliefs can be modified through a brief educational intervention.