Stephen T. Wegener

Prevalence of chronic pain seven years following limb threatening lower extremity trauma.

Abstract Although the etiology of chronic pain following trauma is not well understood, numerous retrospective studies have shown that a significant proportion of chronic pain patients have a history of traumatic injury. The present analysis examines the prevalence and early predictors of chronic pain in a cohort of prospectively followed severe lower extremity trauma patients. Chronic pain was measured using the Graded Chronic Pain Scale, which measures both pain severity and pain interference with activities. Severe lower extremity trauma patients report significantly higher levels of chronic pain than the general population (p < 0.001). Their levels are comparable to primary care migraine headache and back pain populations. A number of early predictors of chronic pain were identified, including: having less than a high school education (p < 0.01), having less than a college education (p < 0.001), low self‐efficacy for return to usual major activities (p < 0.01), and high levels of average alcohol consumption at baseline (p < 0.05). In addition, high reported pain intensity, high levels of sleep and rest dysfunction, and elevated levels of depression and anxiety at 3 months post‐discharge were also strong predictors of chronic pain at seven years (p < 0.001 for all three predictors). After adjusting for early pain intensity, patients treated with narcotic medication during the first 3 months post‐discharge had lower levels of chronic pain at 84 months. It is possible that for patients within these high risk categories, early referral to pain management and/or psychologic intervention may reduce the likelihood or severity of chronic pain.

The Effects of Guided Care on the Perceived Quality of Health Care for Multi-morbid Older Persons: 18-Month Outcomes from a Cluster-Randomized Controlled Trial

BACKGROUNDThe quality of health care for older Americans with chronic conditions is suboptimal.OBJECTIVETo evaluate the effects of “Guided Care” on patient-reported quality of chronic illness care.DESIGNCluster-randomized controlled trial of Guided Care in 14 primary care teams.PARTICIPANTSOlder patients of these teams were eligible to participate if, based on analysis of their recent insurance claims, they were at risk for incurring high health-care costs during the coming year. Small teams of physicians and their at-risk older patients were randomized to receive either Guided Care (GC) or usual care (UC).INTERVENTION“Guided Care” is designed to enhance the quality of health care by integrating a registered nurse, trained in chronic care, into a primary care practice to work with 2–5 physicians in providing comprehensive chronic care to 50–60 multi-morbid older patients.MEASUREMENTSEighteen months after baseline, interviewers blinded to group assignment administered the Patient Assessment of Chronic Illness Care (PACIC) survey by telephone. Logistic and linear regression was used to evaluate the effect of the intervention on patient-reported quality of chronic illness care.RESULTSOf the 13,534 older patients screened, 2,391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 18 months, 95.3% and 92.2% of the GC and UC recipients who remained alive and eligible completed interviews. Compared to UC recipients, GC recipients had twice greater odds of rating their chronic care highly (aOR = 2.13, 95% CI = 1.30–3.50, p = 0.003).CONCLUSIONGuided Care improves self-reported quality of chronic health care for multi-morbid older persons.

Psychometric Properties of the Patient Activation Measure among Multimorbid Older Adults

OBJECTIVES The Patient Activation Measure (PAM) quantifies the extent to which people are informed about and involved in their health care. Objectives were to determine the psychometric properties of PAM among multimorbid older adults and evaluate a theoretical, four-stage model of patient activation. Methods. A cross-sectional analysis was used to assess the psychometric properties of PAM. Internal consistency was assessed using Cronbach α. Construct validity was evaluated using general linear modeling to compute associations between PAM scores and health-related behaviors, functional status, and health care quality. Latent class analysis was used to evaluate the theoretical four-stage structure of patient activation. STUDY SETTING Participants in a randomized trial of Guided Care (N = 855), a model of comprehensive health care for older adults with chronic conditions that put them at risk of using health services heavily during the coming year. PRINCIPAL FINDINGS Higher PAM activation scores and stage were positively associated with higher functional status, health care quality, and adherence to some health behaviors. Latent class analysis supported the multistage theory of patient activation. CONCLUSIONS The PAM is a reliable, valid, and potentially clinically useful measure of patient activation for multimorbid older adults.

Patient activation and adherence to physical therapy in persons undergoing spine surgery.

Study Design. Prospective longitudinal study. Objective. To determine the association between baseline patient activation and participation in postoperative physical therapy in a cohort of individuals after lumbar spine surgery. Summary of Background Data. The Patient Activation Measure is a recently developed tool to assess patient activation. Patient activation is defined as an individual’s propensity to engage in adaptive health behavior that may, in turn, lead to improved patient outcomes. It has not previously been used in spine research. Methods. We assessed baseline patient activation levels in individuals presenting for surgery of the lumbar spine via the Patient Activation Measure. Differences in patient characteristics across patient-activation quartiles were assessed using analysis of variance. After surgery, we assessed attendance (self-reported weekly) and engagement in physical therapy (at the last visit, using the Hopkins Rehabilitation Engagement Rating Scale) and determined the ratio of sessions attended to sessions prescribed. The influence of baseline patient activation, in the setting of other patient characteristics, to predict attendance and engagement with physical therapy was examined using linear regression methods. Results. Scores on the Patient Activation Measure were positively correlated with participation (r = 0.53) and engagement (r = 0.75) in physical therapy. Individuals with low activation were more likely to report low self-efficacy for physical therapy, low hope, and external locus of control compared with those with high activation. Conclusion. Increased patient activation is associated with improved adherence with physical therapy as reflected in attendance and engagement.

Positive psychological variables in the prediction of life satisfaction after spinal cord injury.

OBJECTIVE To examine relationships between select positive psychological variables and life satisfaction in persons with spinal cord injury during acute rehabilitation and 3 months after discharge. DESIGN Prospective observational design; correlational and regression analyses. Eighty-seven adults who were participating in in-patient, acute rehabilitation for spinal cord injury in two metropolitan hospitals completed the following measures: Benefit finding Scale, Hope Scale, Brief Symptom Inventory, COPE, Positive and Negative Affect Schedule, and Satisfaction with Life Scale. RESULTS Hypothesized relationships of hope and positive affect (facilitator variables) with greater life satisfaction during the initial acute rehabilitation period were supported. Facilitators, as measured at baseline, accounted for a significant amount of variance in life satisfaction above and beyond barrier variables (depression, negative affect, and avoidant coping) both during the acute rehabilitation phase (R(2) change = .20, p < .0001) and at 3 months after discharge (R(2) change = .09, p < .029). CONCLUSIONS Findings suggest that positive psychological variables play a significant role in postrehabilitation subjective well-being for persons with spinal cord injury and may provide potential avenues for interventions to facilitate positive outcomes.

Psychological distress mediates the effect of pain on function.

&NA; As part of a larger longitudinal study, the current analyses characterize the relationship among pain, psychological distress, and physical function after major lower extremity trauma. Structural equation modeling techniques were utilized to analyze data from a prospective 2‐year observational study of 327 patients treated at 8 level I trauma centers. Data were gathered at 3, 6, 12, and 24 months after injury. In the models tested, higher levels of depressive and anxious distress at the preceding time point was related to lower levels of functioning at 6, 12, and 24 months, and higher levels of pain at the preceding time point were related to lower levels of functioning at 6 and 12 months, but not at 24 months. A reverse model in which lower levels of functioning led to higher levels of psychological distress or pain was tested and did not fit the data. The combination of depressive and anxious distress plays an increasingly important role in mediating the impact of pain on physical function as the recovery from lower extremity trauma progresses from early to later stages. Both pain and psychological distress contribute to reduced function during the first year after a serious injury; however, as recovery proceeds, the role of psychological distress in determining function increases. Longitudinal data on patients with severe leg trauma demonstrates that as recovery proceeds, psychological distress plays an increasingly important role in mediating the impact of pain on function.

Longitudinal relationships between anxiety, depression, and pain: Results from a two-year cohort study of lower extremity trauma patients

Summary Structural models indicate that after trauma, pain predicts anxiety and depression, but in the chronic phase, only the ability of anxiety to predict pain is observed. Abstract Previous studies have shown that pain, depression, and anxiety are common after trauma. A longitudinal relationship between depression, anxiety, and chronic pain has been hypothesized. Severe lower extremity trauma patients (n = 545) were followed at 3, 6, 12, and 24 months after injury using a visual analog “present pain intensity” scale and the depression and anxiety scales of the Brief Symptom Inventory. Structural model results are presented as Standardized Regression Weights (SRW). Multiple imputation was used to account for missing data. A single structural model including all longitudinal pain intensity, anxiety symptoms, and depression symptoms time‐points yielded excellent fit measures. Pain weakly predicted depression (3–6 months SRW = 0.07, P = .05; 6–12 months SRW = 0.06, P = .10) and anxiety (3–6 months SRW = 0.05, P = .21; 6–12 months SRW = 0.08, P = .03) during the first year after injury, and did not predict either construct beyond 1 year. Depression did not predict pain over any time period. In contrast, anxiety predicted pain over all time periods (3–6 months SRW = 0.11, P = .012; 6–12 months SRW = 0.14, P = .0065; 12–24 months SRW = 0.18, P < .0001). The results suggest that in the early phase after trauma, pain predicts anxiety and depression, but the magnitude of these relationships are smaller than the longitudinal relationship from anxiety to pain over this period. In the late (or chronic) phase after injury, the longitudinal relationship from anxiety on pain nearly doubles and is the only significant relationship. Despite missing data and a single item measure of pain intensity, these results provide evidence that negative mood, specifically anxiety, has an important role in the persistence of acute pain.

Self-management improves outcomes in persons with limb loss.

OBJECTIVE To test the acceptance and effectiveness of a community-based self-management (SM) intervention designed to improve outcomes after limb loss. A priori hypothesis was that an SM intervention will be more effective than standard support group activities in improving outcomes. DESIGN Randomized controlled trial. SETTING General community. PARTICIPANTS Intervention (N=287) and control participants (N=235) with major limb loss. INTERVENTION(S) Nine, 90-minute SM group sessions delivered by trained volunteer leaders. Retention rates at immediate postintervention and 6-month follow-up were 97% and 91% for the SM group. MAIN OUTCOME MEASURE(S) Primary outcomes were depression, positive mood, and self-efficacy. Secondary outcomes were improved functional status and quality of life. RESULTS By using intent-to-treat analyses, the odds for being depressed are significantly lower for those in SM group, 50% less likely at treatment completion (95% confidence interval [CI]=0.3-0.9) and 40% less likely at the 6-month follow-up (95% CI=.03-1.1). Treatment completers have a 70% reduction in likelihood of being depressed at posttreatment (P<.01) and this persists at six months (P<.05). For those in the SM group, functional limitations were significantly lower at 6 months (P<.05), and general self-efficacy was significantly higher at immediate posttreatment (P<.05) and at 6 months (P<.05). Treatment completers have generally significantly larger effect sizes at all follow-up points. Pain intensity, self-efficacy for pain control, and quality of life were not significantly different between the groups. Subgroup analyses indicated the impact of the intervention was greater for participants who were less than 3 years postamputation, participants who were less than 65 years of age, or participants who showed at least 1 secondary condition at baseline. CONCLUSIONS The study provides evidence that SM interventions can improve the outcomes of persons with limb loss beyond benefits offered by support groups.

Examining the role of positive and negative affect in recovery from spine surgery

Summary Multivariable mixed‐model linear regression analyses illustrated the unique relation between postoperative positive affect and functional status and postoperative negative affect and pain interference and disability after spine surgery. Abstract Consistent evidence supports a significant association between lower positive affect and higher negative affect and increased pain and disability in adults with chronic pain. However, examining this relation in surgical populations has received little empirical consideration. The primary purpose of this study was to determine whether preoperative and postoperative positive and negative affect predict pain, disability, and functional status after spine surgery. A secondary objective was to assess the relation of depression to postoperative outcomes compared with positive and negative affect. Participants were 141 patients treated by spine surgery for lumbar or cervical degeneration. Data collection occurred at baseline and 6 weeks and 3 months postoperatively. Affect was measured with the Positive and Negative Affect Schedule. Multivariable mixed‐model linear regression analyses found that preoperative variables were not predictive of postoperative pain, disability and functional status. However, multivariable postoperative analysis found that 6‐week positive affect predicted functional status, and 6‐week negative affect predicted pain interference and pain‐related disability at 3 months following surgery. Postoperative depression demonstrated statistically significant and stronger associations with pain intensity, pain interference, and pain‐related disability at 3‐month follow‐up, as compared with negative affect. Results suggest that positive affect and depression are important variables to target when seeking to improve postoperative outcomes in a spine surgery population. Recommendations include postoperative screening for positive affect and depression, and treating depression as well as focusing on rehabilitation strategies to bolster positive affect so as to improve functional outcomes after spine surgery.

Hope predicts positive functional role outcomes in acute rehabilitation populations

PURPOSE/OBJECTIVE The purpose of this study was to examine the association between facilitating psychological variables and functional rehabilitation outcomes following acute medical rehabilitation. RESEARCH METHOD/DESIGN Using a longitudinal design and correlational and regression analyses, we studied 174 adults who were participating in inpatient rehabilitation for acute spinal cord dysfunction, stroke, amputation, or orthopedic surgery recovery. All participants completed the Hope Scale, Positive and Negative Affect Schedule, and Functional Independence Measure (FIM) during the first days of their inpatient stay, and then were contacted 3 months after discharge to complete the Craig Hospital Assessment and Reporting Technique (CHART) and FIM. RESULTS Hope accounted for a statistically significant amount of the variance in the prediction of functional role participation at 3 months postdischarge (as measured by the CHART) above and beyond the variance accounted for by demographic and severity variables. In contrast, positive affect was not found to contribute to the prediction of functional role participation, and neither hope nor positive affect contributed to the prediction of functional skill level (FIM). CONCLUSIONS/IMPLICATIONS The results indicate that positive psychological variables present during the rehabilitation stay, such as hopefulness, may contribute to the prediction of functional outcomes after discharge in rehabilitation populations. These findings suggest that incorporating interventions that enhance hope and build on the individuals psychological strengths may be useful to improve participation outcomes following acute medical rehabilitation.