Depression and the long-term risk of pain, fatigue, and disability in patients with rheumatoid arthritis

OBJECTIVE: To determine whether a previous episode of major depression leaves a "scar" that places previously depressed patients with rheumatoid arthritis (RA) at risk for experiencing high levels of pain, fatigue, and disability. METHODS: A cohort of 203 patients with RA was randomly selected from a national panel and interviewed by phone about pain, fatigue, depressive symptoms, disability, and history of major depression. RESULTS: Excluding patients who met the criteria for current major depression, patients with both a history of depression and many depressive symptoms at the time of the interview (dysphoria) reported more pain than those without current dysphoria, irrespective of whether they had a history of depression. Dysphoria alone was not reliably related to pain reports. CONCLUSION: An episode of major depression, even if it occurs prior to the onset of RA, leaves patients at risk for higher levels of pain when depressive symptoms persist, even years after the depressive episode.     

The effect of compensation involvement on the reporting of pain and disability by patients referred for rehabilitation of chronic low back pain

STUDY DESIGN: In this prospective, observational, cohort study of 192 individuals with chronic low back pain, the group of individuals was divided based on compensation involvement, and their presentation pain and disability, treatment recommendations, and compliance were compared. For 85 of these individuals who completed a spine rehabilitation program, their pain and disability at 3 and 12 months were compared. OBJECTIVES: To test the theory that individuals with compensation involvement presented with greater pain and disability and would report less change of pain and disability after rehabilitation efforts. BACKGROUND: Previous studies have produced conflicting results concerning this issue. METHODS: Individuals were recruited as consecutive patients referred for consultation at a spine rehabilitation center. Pain, depression, and disability were assessed using self-report questionnaires at evaluation and at 3 and 12 months. Rehabilitation services consisted of aggressive, quota-based exercises aimed at correcting impairments in flexibility, strength, endurance, and lifting capacity, identified through quantification of back function. Multifactoral analysis of variance models were used to control for baseline differences between compensation and noncompensation patients during analysis of target variables. RESULTS: The compensation group included 96 patients; these patients reported more pain, depression, and disability than the 96 patients without compensation involvement. These differences persisted when baseline differences were controlled for with multifactoral analysis of variance models. Treatment recommendations and compliance were not affected by compensation. For patients completing the spine rehabilitation program, length of treatment, flexibility, strength, lifting ability, and lower extremity work performance before and after treatment and patient satisfaction ratings were similar for the compensation and noncompensation groups. At 3 and 12 months, improvements in depression and disability were noted for both groups, but were statistically and clinically less substantial for the compensation group. At the 12 month follow-up visit, pain scores improved for the noncompensation group, but not for the compensation group. CONCLUSIONS: In chronic low back pain, compensation involvement may have an adverse effect on self-reported pain, depression, and disability before and after rehabilitation interventions.     

Epicondylopathia humeri. The indication for, technic and clinical results of radiotherapy

BACKGROUND: The efficacy of radiotherapy for degenerative-inflammatory disorders is well known, but so far long-term observations and reliable assessment of symptoms according to objective criteria and scores for validation are still missing. PATIENTS AND METHOD: From 1986 to 1991, 104 patients with refractory epicondylopathia humeri were irradiated. 85 patients or 93 elbows (due to double-sided symptoms) were documented in long-term follow-up according to objective criteria. All patients had received intensive therapy. Pain symptoms were quantified in "categories" and "grades" prior to and 6 weeks after radiotherapy and at last follow-up. In addition, the elbow score of Morrey et al. [36] was used for long-term evaluation. The onset of pain symptoms was acute in 41 and chronic in 52 cases. The mean symptom duration prior to radiotherapy was 16 months. Pain was mostly triggered off during professional (46) or sportive activities (23) or spontaneously (11). Fifty-one patients were severely disabled in professional or sportive activities. The involved elbow(s) received 2 radiotherapy series of 6 x 1 Gy (total 12 Gy) with 3 fractions per week; the second radiotherapy series was started 6 weeks after the first series. Mean follow-up was 4 +/- 2 (1 to 8) years. RESULTS: Forty-three patients (50 elbows) achieved "complete pain relief (CR)" in all pain categories: 59% elbows with pain at strain had "complete pain relief", 79% with pain at night, 84% with permanent pain, 80% with pain at rest and 81% with pain at initiation or morning stiffness. Nineteen elbows gained "major pain relief (PR)", i.e. had minor symptoms (maximum grade 1) in all categories. Thus, a total of 69 (74%) elbows responded to radiotherapy. Seventeen patients (19 elbows) were operated because of persistent symptoms or dissatisfaction in long-term follow-up; 7 of those became completely free of symptoms. The Morrey-Score improved by a mean of 18 points from 78 prior to radiotherapy to 96 points at last follow-up. According to the Morrey-Score only 2 patients became worse in long-term follow-up. Two parameters indicated a negative prognosis in multivariate analysis: long symptom duration prior to radiotherapy and immobilisation with plaster (p < 0.05). CONCLUSIONS: Radiotherapy for refractory epicondylopathia humeri is highly effective. Long symptom duration and long-term immobilisation by plaster are negative prognostic factors for treatment outcome. Due to the low side effects and treatment costs, radiotherapy is a good therapeutic option in comparison to conventional treatment methods and surgery in the chronic stage of epicondylopathia humeri.     

Comparison of operant behavioral and cognitive-behavioral group treatment for chronic low back pain.

To evaluate and compare the efficacy of two widely used behavioral approaches for the treatment of chronic pain, 81 mildly dysfunctional chronic low back pain patients were randomly assigned to operant behavioral (OB) treatment, cognitive-behavioral (CB) treatment, or a waiting-list (WL) control condition. Both treatments, which were conducted in eight-session outpatient groups, resulted in decreased physical and psychosocial disability. The OB patients showed greater pre- to posttreatment improvement as rated by patients and their spouses than did the CB patients. Generally, the OB patients showed a leveling off in improvement at 6- and 12-month follow-ups, whereas the CB patients generally continued to improve over the 12 months following treatment. At 12-month follow-up, patients in both treatments remained significantly improved, with no significant differences between conditions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Changes in beliefs, catastrophizing, and coping are associated with improvement in multidisciplinary pain treatment.

To examine the associations between changes in cognitions and coping and multidisciplinary pain treatment outcomes, the authors had 141 patients with chronic pain complete measures of adjustment, beliefs, catastrophizing, and coping; in addition, their significant others rated patient physical functioning at pretreatment, posttreatment, and 6- and 12-month follow-ups. Decreases in guarding and resting and in the belief that pain signals damage were associated with decreases in patient disability. Increases in perceived control over pain and decreases in catastrophizing and in the belief that one is disabled were associated with decreases in self-reported patient disability, pain intensity, and depression. The results are consistent with the hypothesis, derived from cognitive-behavioral models of chronic pain, that the outcomes of multidisciplinary pain treatment are associated with changes in patient cognitions and coping responses. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Development and validation of the pain response inventory for children.

The Pain Response Inventory (PRI) was developed as a multidimensional instrument to assess children's coping responses to recurrent pain. The PRI assesses 3 broad coping factors—Active, Passive, and Accommodative—each with subscales representing specific strategies for coping with pain. Confirmatory factor analysis was used to derive and cross-validate the factor structure of the PRI in 3 different samples of children and adolescents: 688 9–16 yr olds in general population, 120 8–18 yr old abdominal pain patients who also completed followup interviews 2-wks and 6 mo after initial interview, and 224 11–23 yr old former abdominal pain and well patients. The subscales were found to be internally consistent and reasonably stable. Validity of the subscales was assessed by examining the relations of particular coping strategies to various outcome indicators, including functional disability, somatization symptoms, and depressive symptoms. Results indicated that different types of health outcome were predicted by different patterns of PRI coping strategies, thus supporting the utility of a multidimensional approach to the assessment of coping responses to pain. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An examination of the co-morbidity between chronic pain and posttraumatic stress disorder on U.S. Veterans.

The purpose of this study was to assess the comorbidity between chronic pain and posttraumatic stress disorder (PTSD) and examine the extent to which PTSD is associated with changes in the multidimensional experience of pain in a sample of Veterans with chronic pain. It was hypothesized that Veterans with comorbid chronic pain and PTSD would report significantly higher scores on measures of pain intensity, pain behaviors, pain-related disability, and affective distress than Veterans with pain alone. Data were obtained from 149 Veterans who completed self-report questionnaires as part of their participation in a Psychology Pain Management program at a northeastern Department of Veterans Affairs health care facility. Analyses indicated that 49% of the sample met criteria for PTSD. A multivariate analysis of covariance was conducted with age, sex, pain duration, and depressive symptom severity as covariates. In partial support of our hypothesis, the presence of PTSD was found to contribute significantly to measures of affective distress, even after controlling for the effects of depressive symptom severity. The implications of these data are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The web of coping resources and pathways to reemployment following a job loss.

Structural equation modeling analyses of data from 2 longitudinal community studies of recently laid-off workers examined the interrelationships and pathways from personal coping resources to job-search intensity and the extent and quality of reemployment at 2 follow-ups (at 6 months and at 12 or 24 months). In both studies, the proposed models for predicting reemployment and reemployment quality provided a good fit to the data with the same pattern of results, which demonstrated that job-search motivation increased reemployment at all follow-ups but did not affect reemployment quality. At both the 6- and 12-month follow-ups, level of depressive symptoms decreased the extent and quality of reemployment. The results also highlighted the dual role of financial strain, which on the one hand facilitates reemployment by increasing job-search motivation and job-search intensity and on the other hand inhibits it by increasing depressive symptoms. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults

STUDY DESIGN: Population-based, cross-sectional, mailed survey. OBJECTIVES: To determine the lifetime, 6-month period, and point prevalence of low back pain and its related disability among Saskatchewan adults and to investigate the presence and strength of selective response bias. SUMMARY OF BACKGROUND DATA: There have been many reports of the prevalence of low back pain in different populations, and the estimates vary widely depending on case definition. However, most studies fail to differentiate between trivial and disabling back pain, which raises the issue of the usefulness of these estimates. No studies have yet documented the prevalence of graded low back pain severity and its related disability in a North American, general, population-based survey. METHODS: The Saskatchewan Health and Back Pain Survey was mailed to a probability sample of 2184 Saskatchewan adults between 20 and 69 years of age. Fifty-five percent of the eligible population responded to the survey. Respondents were compared with nonrespondents, and the presence of selective response bias by back pain status was investigated by wave analysis. The point and lifetime prevalence of low back pain was determined by simple questions, and the 6-month period prevalence of low back pain was determined by the Chronic Pain Questionnaire. All estimates were age standardized to the Saskatchewan population. RESULTS: The authors estimate that at the time of the survey 28.4% (95% confidence interval, 25.6-31.1) of the Saskatchewan adult population were experiencing low back pain, and 84.1% (95% confidence interval, 81.9-86.3) had experienced it during their lifetime. Overall, 48.9% (95% confidence interval, 45.9-52.0) of the population had experienced low intensity/low-disability low back pain in the previous 6 months, 12.3% (95% confidence interval, 10.3-14.4) had experienced high-intensity/low-disability low back pain, and an additional 10.7% (95% confidence interval, 8.8-12.5) had experienced high-disability low back pain in the previous 6 months. There was little variation in the estimates over age groups, but women experienced more high-disability back pain than men. There was no evidence of selective response bias by low back pain status in the survey. CONCLUSION: Low-intensity/low-disability low back pain is a common problem in the general population. Approximately 11% of the adult population studied had been disabled by low back pain in the previous 6 months.     

Predicting outcome of chronic back pain using clinical predictors of psychopathology: A prospective analysis.

This study evaluated whether a comprehensive assessment of psychosocial measures is useful in characterizing those acute low back pain patients who subsequently develop chronic pain disability problems. A cohort of 324 patients was evaluated, with all patients being administered a standard battery of psychological assessment tests. A structured telephone interview was conducted 6 months after the psychological assessment to evaluate return-to-work status. Analyses, conducted to differentiate between those patients who were back at work at 6 months versus those who were not because of the original back injury, revealed the importance of 3 measures: self-reported pain and disability, the presence of a personality disorder, and scores on Scale 3 of the Minnesota Multiphasic Personality Inventory. These results demonstrate the presence of a psychosocial disability variable that is associated with those injured workers who are likely to develop chronic disability problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prospective outcome evaluation of spinal cord stimulation in patients with intractable leg pain

STUDY DESIGN: The results of spinal cord stimulation were prospectively evaluated using both subjective patient self-report measures and objective physical functional testing. OBJECTIVES: The purpose of this study was to evaluate prospectively the effects of spinal cord stimulation implantation, performed with the patient awake and providing feedback, in patients with primary reports of intractable leg pain. SUMMARY OF BACKGROUND DATA: Spinal cord stimulation has been used for treating chronic pain of many types. However, even among those with intractable lower extremity pain, the outcome results have shown great variability. METHODS: The surgical procedure was performed with the patient awake and providing feedback to ensure optimal pain relief from the lead placement. The study group comprised 40 patients, ranging in age from 28 to 86 years. The average symptom duration was 65.4 months, and the average number of prior lumbar spine surgeries was 2.3 (range, 1 to 8). The primary data collection periods were preoperative, 6 weeks after, and 12 and 24 months after surgery. RESULTS: Statistically significant improvement in isometric lower extremity function was demonstrated 6 weeks after the spinal cord stimulation implantation. In the more painful leg, the performance increased from 457.5 ft-lb-sec to 629.8 ft-lb-sec (P < 0.01). The performance remained significantly improved at the 12- and 24-month follow-ups. Significant improvement was demonstrated on the physical scale of the Sickness Impact Profile at 6 weeks. At 24 months, all three scales (physical, psychological, and other) as well as the total score were significantly improved. Statistically significant decreases in pain, assessed by changes in visual analog scale scores, were noted in the legs, when walking, and in overall lifestyle. The use of narcotic medication decreased at all follow-up periods. At least 66% of the patients who were taking narcotics before spinal cord stimulation were taking reduced amounts or no narcotics 2 years later. At the time of the 24-month follow-up, at least 70% of patients reported that the procedure helped them, and would recommend it to someone with similar symptoms. CONCLUSIONS: Spinal cord stimulation implantation can result in improved physical function and decreased pain in patients who are carefully screened and in whom the implantation is performed with the patient awake to help ensure optimal pain-relieving lead placement.     

Suprachiasmatic nucleus organization

OBJECTIVE: To assess the effect of a combined exercise and motivation program on the compliance and level of disability of patients with chronic and recurrent low back pain. DESIGN: A double-blind prospective randomized controlled trial. SETTING: Physical therapy outpatient department, tertiary care. PATIENTS: Ninety-three low back pain patients were randomly assigned to either a standard exercise program (n = 49) or a combined exercise and motivation program (n = 44). INTERVENTIONS: Patients were prescribed 10 physical therapy sessions and were advised to continue exercising after treatment termination. The motivation program consisted of five compliance-enhancing interventions. Follow-up assessments were performed at 3 1/2 weeks, 4 months, and 12 months. MAIN OUTCOME MEASURES: Disability (low back outcome score), pain intensity, physical impairment (modified Waddell score, fingertip-to-floor distance, abdominal muscle strength), working ability, motivation, and compliance. RESULTS: The patients in the motivation group were significantly more likely to attend their exercise therapy appointments (p = .0005). Four and 12 months after study entry there was a significant difference in favor of the motivation group with regard to the disability score (p = .004) and pain intensity (p < or = .026). At 4 months, there was a significant advantage for the motivation group in the fingertip-to-floor distance (p = .01) and in abdominal muscle strength (p = .018). No significant differences were found in motivation scores, self-reported compliance with long-term exercise, and modified Waddell score. In terms of working ability, there was a trend favoring the combined exercise and motivation program. CONCLUSION: The combined exercise and motivation program increased the rate of attendance at scheduled physical therapy sessions, ie, short-term compliance, and reduced disability and pain levels by the 12-month follow-up. However, there was no difference between the motivation and control groups with regard to long-term exercise compliance.     

A high-risk method for studying psychosocial antecedents of chronic pain: The prospective investigation of herpes zoster.

Although patients with chronic pain (CP) are often psychologically distressed, it has been difficult to determine whether this distress is an antecedent of CP or whether it is caused by the experience of living with CP. This investigation aimed to develop a method that would allow individuals who are at risk for the development of CP to be studied before the pain has become chronic. Patients with acute herpes zoster (HZ) were assessed with demographic, medical, pain, and psychosocial measures. Pain was assessed in follow-up interviews at 6 wks and 3, 5, 8, and 12 mo after these initial assessments. There were no significant differences between Ss who developed short-term HZ pain and Ss who did not develop short-term pain for any of the measures at the initial assessment, except for 1 measure of pain intensity. Ss who developed HZ CP, however, had significantly greater pain intensity, higher state and trait anxiety, greater depression, lower life satisfaction, and greater disease conviction at the initial assessment than Ss who did not develop CP. In discriminant analyses, disease conviction, pain intensity, and state anxiety each made a unique contribution to discriminating Ss who did and did not develop CP. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A replicated prospective investigation of life stress, coping, and depressive symptoms in multiple sclerosis

Life stress and coping responses jointly contribute to psychological adjustment in many chronic illness populations, but their significance in multiple sclerosis (MS) has not been extensively investigated. Physical disability, cognitive status, negative life stress, coping strategies, and depressive symptoms were prospectively assessed in 27 adults with definite or probable MS. Of the original subjects, 22 provided two additional assessments at 6-month intervals. After accounting for cognitive status and physical disability, life stress was positively correlated with current as well as future depressive symptoms; the prospective relationship was replicated within the second pair of prospective data waves. Escape avoidance was the only coping strategy that added to the prediction of future mood symptoms, but this was not replicated. Results suggest that MS-related depressive symptoms are a function of prior disease-related impairment, life stress, and possibly escape avoidance coping.     

Efficiency and costs of medical exercise therapy, conventional physiotherapy, and self-exercise in patients with chronic low back pain. A pragmatic, randomized, single-blinded, controlled trial with 1-year follow-up

STUDY DESIGN: A multicenter, randomized, single-blinded controlled trial with 1-year follow-up. OBJECTIVES: To evaluate the efficiency of progressively graded medical exercise therapy, conventional physiotherapy, and self-exercise by walking in patients with chronic low back pain. SUMMARY AND BACKGROUND DATA: Varieties of medical exercise therapy and conventional physiotherapy are considered to reduce symptoms, improve function, and decrease sickness absence, but this opinion is controversial. METHODS: Patients with chronic low back pain or radicular pain sick-listed for more than 8 weeks and less than 52 weeks (Sickness Certificate II) were included. The treatment lasted 3 months (36 treatments). Pain intensity, functional ability, patient satisfaction, return to work, number of days on sick leave, and costs were recorded. RESULTS: Of the 208 patients included in this study, 71 were randomly assigned to medical exercise therapy, 67 to conventional physiotherapy, and 70 to self-exercise. Thirty-three (15.8%) patients dropped out during the treatment period. No difference was observed between the medical exercise therapy and conventional physiotherapy groups, but both were significantly better than self-exercise group. Patient satisfaction was highest for medical exercise therapy. Return to work rates were equal for all 3 intervention groups at assessment 15 months after therapy was started, with 123 patients were back to work. In terms of costs for days on sick leave, the medical exercise therapy group saved 906,732 Norwegian Kroner (NOK) ($122,531.00), and the conventional physiotherapy group saved NOK 1,882,560 ($254,200.00), compared with the self-exercise group. CONCLUSIONS: The efficiency of medical exercise therapy and conventional physiotherapy is shown. Leaving patients with chronic low back pain untampered poses a risk of worsening the disability, resulting in longer periods of sick leave.     

Persistent disability associated with ankle sprains: a prospective examination of an athletic population

The purpose of this study was to examine a young athletic population to update the data regarding epidemiology and disability associated with ankle injuries. At the United States Military Academy, all cadets presenting with ankle injuries during a 2-month period were included in this prospective observational study. The initial evaluation included an extensive questionnaire, physical examination, and radiographs. Ankle sprain treatment included a supervised rehabilitation program. Subjects were reevaluated at 6 weeks and 6 months with subjective assessment, physical examination, and functional testing. The mean age for all subjects was 20 years (range, 17-24 years). There were 104 ankle injuries accounting for 23% of all injuries seen. There were 96 sprains, 7 fractures, and 1 contusion. Of the 96 sprains, 4 were predominately medial injuries, 76 were lateral, and 16 were syndesmosis sprains. Ninety-five percent had returned to sports activities by 6 weeks; however, 55% of these subjects reported loss of function or presence of intermittent pain, and 23% had a decrement of >20% in the lateral hop test when compared with the uninjured side. At 6 months, all subjects had returned to full activity; however, 40% reported residual symptoms and 2.5% had a decrement of >20% on the lateral hop test. Neither previous injury nor ligament laxity was predictive of chronic symptomatology. Furthermore, chronic dysfunction could not be predicted by the grade of sprain (grade I vs. II). The factor most predictive of residual symptoms was a syndesmosis sprain, regardless of grade. Syndesmosis sprains were most prevalent in collision sports. This study demonstrates that even though our knowledge and understanding of ankle sprains and rehabilitation of these injuries have progressed in the last 20 years, chronic ankle dysfunction continues to be a prevalent problem. The early return to sports occurs after almost every ankle sprain; however, dysfunction persists in 40% of patients for as long as 6 months after injury. Syndesmosis sprains are more common than previously thought, and this confirms that syndesmosis sprains are associated with prolonged disability.     

Global impressions versus validated measures of treatment effectiveness in patients with chronic nonmalignant pain.

This study compared global impressions of improvement with validated indices of treatment outcome in patients with chronic nonmalignant pain and explored 2 factors that might mediate reports of improvement: patient status at follow-up and secondary financial gain. Information concerning pain intensity, disability behavior, and secondary financial gain was obtained from 148 patients at intake and from 42 patients at follow-up (a minimum of 6 months postintake). It was found that patients evidenced significantly diminished pain and disability at follow-up. However, patients failed to acknowledge that improvement had occurred on a global impressions measure. Of the validated outcome measures, only reduction in pain intensity was associated with patient status at follow-up, and only number of disability days was associated with the presence of secondary financial gain. These findings suggest that health care professionals and researchers who rely on global measures of improvement may fail to detect important changes in patient functioning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A causal analysis of chronic pain and depression.

There is considerable controversy in the literature regarding the extent to which chronic pain and depression are associated and the possible causal relationship of such an association. The present study examines these issues with a sample of 243 patients diagnosed with rheumatoid arthritis (RA) who were mailed questionnaires for six waves of data collection. The results indicated that RA patients experience higher levels of depressive symptomatology than community samples. Using a two-latent-variable, cross-lagged design, covariance structural modeling was conducted on self-report measures of pain and depression over 6-month intervals. Results most strongly supported a causal model in which pain predicts depression during the last 12 months of the study. (PsycINFO Database Record (c) 2010 APA, all rights reserved)