Perception of traumatic onset, compensation status, and physical findings: impact on pain severity, emotional distress, and disability in chronic pain patients

The primary purposes of the present study were to investigate the roles of physical findings, financial compensation, and types of pain onset (i.e., trauma vs. insidious onset) on adaptation by chronic pain patients. Comparisons between patients who were receiving or seeking compensation and those who were not revealed that, despite comparable degrees of physical findings, the compensation status was associated with reports of (a) more severe pain, (b) greater disability, (c) higher levels of emotional distress, and (d) greater life interference. The compensation status of 74% of the patients was correctly classified by combination of pain severity, perceived disability, and life interference. Objective indices of physical findings did not significantly improve classification accuracy. In order to eliminate the possible confound of compensation, analyses of the relationship between the types of onset and chronic pain were conducted only for a subset of patients who were not receiving or actively seeking compensation. The results indicated that the patients who attributed their pain to a specific trauma reported significantly higher levels of emotional distress, life interference, and higher levels of pain severity than did the patients who indicated that their pain had an insidious or spontaneous onset, regardless of the extent of objective physical findings.     

Severity and impact of pain after day-surgery

PURPOSE: To assess the intensity, duration and impact of pain after day-surgery interventions. Predictors of pain severity were also evaluated along with the quality of analgesic practices and patient satisfaction. METHODS: Eighty-nine consecutive day-surgery patients completed self-administered questionnaires before leaving the hospital and at 24, 48 hr and seven days after discharge. The survey instrument was composed of 0-10 pain intensity scales, selected items of the Brief Pain Inventory, of the Patient Outcome Questionnaire and of the Barriers Questionnaire. Analgesic intake in hospital and at home was recorded along with the use of other pain control methods. RESULTS: Forty percent of the patients reported moderate to severe pain during the first 24 hr after hospital discharge. The pain decreased with time but it was severe enough to interfere with daily activities in a substantial number of patients. The best predictor of severe pain at home was inadequate pain control during the first few hours following the surgery. More than 80% of the participants were satisfied with their pain treatment. However, one patient in four (25%) needed contact with a health care provider because of pain at home. Many patients (33% to 51%) reported that instructions about pain control were either unclear or non-existent on several aspects. Medication use was low overall. Thirty-two percent of the patients did not take any pain medication during the first 24 hr after discharge although almost half of them (46%) rated their pain > or = 4. The most common concerns patients had about using pain medication were fear of drug addiction and side effects. CONCLUSION: The severity and duration of pain after day-surgery should not be underestimated. Aggressive analgesic treatment during the hospital stay should be provided along with take-home analgesia protocols and comprehensive patient education programs.     

Prediction and assessment of the severity of post-operative pain and of satisfaction with management

A prospective observational study of cohorts of patients undergoing hip replacement (30), knee replacement (31), and spinal nerve root decompressive surgery (30) were interviewed pre-operatively to identify factors which might correlate with and potentially predict severe post-operative pain and dissatisfaction with analgesic management. The hip patients comprised 33% females and averaged 64 years, while the knee patients were 45% female and older (mean 71 years) and the spinal patients were 43% female and averaged 50 years. The three groups were similar with respect to all other pre-operative variables. Pain intensity was assessed mainly by self-report using the Present Pain Intensity (PPI) and Visual Analogue Scales (VAS) of the McGill Pain Questionnaire. The PPI was preferred by patients and nurses and, as there were no analytical advantages for the VAS, the PPI data are presented. The average post-operative pain during routine management mainly with patient controlled intravenous opiate, was mild to moderate and declined over days 1-5, declined further at discharge but rose slightly 1 month after discharge. The hip replacement patients experienced significantly (P < 0.01) less pain overall than the patients in the other two groups. Nurses' assessments of pain severity from observed behaviour were low and agreed poorly with the patients' self reports. Assessed on Likert Scales (0-6), the patients generally indicated good or excellent pain control, better than expected pain experience, and high levels of satisfaction with analgesic management. Significant (P < or = 0.01) multivariate correlates of severe post-operative pain assessed by logistic regression analysis of 11 variables were female gender, high pre-operative pain severity, and younger age. Significant (P < or = 0.01) multivariate correlates of both worse than expected pain experience and low satisfaction were female gender, high pre-operative pain severity, high anxiety about risks and problems, low expected pain severity, age (younger) and high willingness to report pain. These variables may reasonably be tested in further studies as potential predictors of adverse post-operative pain experience.     

Parents with human immunodeficiency virus infection: perceptions of their children's emotional needs

OBJECTIVE: To investigate the likelihood of patients who have human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) being parents and to identify concerns of these parents about their children. DESIGN: A survey was conducted of parental status, demographics, perceptions of social/emotional needs of self and one's children. Responses were analyzed for demographic differences. PARTICIPANTS: A total of 242 patients from the university HIV/AIDS clinics completed the survey. MAIN OUTCOME MEASURES: Parental status, number, and ages of children, parental concerns about their children related to their own HIV/AIDS: RESULTS: Nearly one third (31.8%) of the sample of HIV/AIDS patients were parents, and three fourths (76%) of the female patients were mothers. Slightly more than one third of these were married, and these were not predominantly families who also had infected children. The percentage of women in the parent subsample (40.8%) was higher than the percentage of women in the overall patient sample (16.7%). Only half of the parents reported that their children > 4 years of age knew of their diagnosis. Two thirds of the parents reported they believed their children did not need to talk to someone about their parent's health, and nearly half of the parents reported that they did not need help dealing with their children concerning issues related to AIDS. CONCLUSION: The percentage of HIV/AIDS patients who are parents is high, and parental status and emotional needs of parents and their children will likely become an increasingly important issue. Many questions are raised by our findings. Should we be concerned that many parents have been unable to talk to their children about their own health? Should we help parents acknowledge that their children may need some outside help to cope?     

Determination of pentachlorophenol in commercially prepared lyophilized human urine control samples

OBJECTIVE: The decision to perform total hip arthroplasty (THA) in patients with osteoarthritis (OA) of the hip is based largely on patients' reports of pain and disability and not on radiographic findings of OA. We determine the severity of radiographic OA and its association with disability in patients undergoing THA. METHODS: Individual radiographic features (osteophytes, joint space narrowing, sclerosis, cysts, deformity) and global severity of hip OA were assessed in 95 consecutive elderly patients with hip OA undergoing THA who were enrolled in a Patient Outcome Research Team (PORT) project. RESULTS: Eighty-seven patients (91.5%) had either severe or moderate OA in the hip to be replaced; 17% of these had a previous contralateral THA. Only 8 patients (8.4%) had mild or no signs of OA in the hip to be replaced and 4 (50%) of these patients had their opposite hip replaced previously. CONCLUSION: These data indicate that radiographic features of moderate to severe hip OA are associated with clinical findings and the necessity to perform THA in the majority of patients. Patients who have had a prior hip replacement, however, may be more likely to have a contralateral replacement done earlier (p = 0.03), before radiographic signs are evident.     

Relationship of asthma severity and psychological problems in children

OBJECTIVE: To determine whether physiological severity of asthma is associated with increased psychological symptoms in children. METHOD: Participants were 337 children, aged 7 to 19 years (mean 11.9, SE 0.13), and a parent of each child. Children's asthma severity was rated by experienced pediatric asthma specialists using current guidelines from the National Heart, Lung, and Blood Institute. Children filled out the Children's Manifest Anxiety Scale and the Weinberger Adjustment Inventory. Parents reported on their child's medical history, completed the Child Behavior Checklist (CBCL) about their child, and completed the Pennebaker Inventory of Linguid Languidness as a measure of their own physical symptoms. RESULTS: Child-rated anxiety symptoms were unrelated to asthma severity or to markers of asthma functional morbidity. Parental ratings of internalizing symptoms in their children were related to severity. Parent physical symptoms explained 10.2% of the variance in CBCL Internalizing symptoms, and asthma severity added an additional 6.7% to the variance. CONCLUSIONS: Asthma severity may be a more salient stressor to parents, who in turn report higher levels of child internalizing symptoms for children with severe asthma, than to children themselves. Contrary to prior hypotheses, children with severe asthma did not rate themselves as having higher levels of anxiety than those with mild or moderate asthma or than standardized norms.     

Determinants of decisions to seek medical treatment by patients with acute myocardial infarction symptoms.

Among 43 myocardial infarction patients (mean age 53.4 yrs), Ss who delayed between noting initial symptoms and deciding they were ill were those who reported that they characteristically exhibited some Type A behaviors, experienced little initial pain at a time when work was quite demanding, responded to their symptoms with depression and fatigue, and were currently quite pessimistic about their health. Those who delayed between deciding they were ill and seeking treatment were those who were assessed as Type B on the structured interview and who talked to others to assess the meaning of their symptoms. (38 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pain and discomfort during orthodontic treatment: causative factors and effects on compliance

Orthodontic patients experience pain and discomfort to a varying degree during the course of treatment. The aims of the present investigation were to follow the progress of adaptation after insertion of new appliances and to study the relationships between the type of appliance worn and pain or discomfort experienced, between pain sensations and attitude toward the treatment and their effects on patients' compliance. Pain and discomfort experienced by 84 patients undergoing orthodontic treatment, their attitude toward the treatment, and compliance were assessed 7 days, 14 days, 6 weeks, 3 months, and 6 months after appliance insertion, using specially designed protocols, questionnaires, and rating scales. Evaluation of the results showed that an adaptation to pain and discomfort occurred during the first 3 to 5 days after placement of the appliance. The severity of pain and discomfort experienced by the patients wearing functional or fixed appliances was significantly higher than by those treated with upper and/or lower removable plates. Patients who had higher personal perception of the severity of their malocclusion and displayed attitudes characteristic for internal control orientation according to the so-called locus of control theory, seemed to adapt faster and have less pain. The results of this study also indicate that acceptance of orthodontic appliances and treatment in general may be predicted by the amount of initial pain and discomfort experienced.     

A fourth empirically derived cluster of chronic pain patients based on the Multidimensional Pain Inventory: Evidence for repression within the dysfunctional group.

The authors proposed that chronic pain patients with repressive defenses are not represented in current 3-cluster solutions of the Multidimensional Pain Inventory and that such a group can be distinguished by using a measure of defensiveness together with subscales of the MPI. For 178 pain patients, hierarchical cluster analyses were performed on the MPI and Balanced Inventory of Desirable Responding. Profile analysis of validation measures showed that repressors scored comparably with dysfunctional patients on somatic symptoms of depression, pain severity, and perceived disability but significantly higher on these factors than the adaptive copers. Repressors scored comparably with adaptive copers on cognitive-affective symptoms of depression, anxiety, and anger but significantly lower on these variables than dysfunctional patients. Repressors also reported greater pain severity and perceived disability relative to their reports of negative affect, whereas dysfunctional and adaptive coper groups exhibited no such disparities. Without a measure of defensiveness, the MPI may misclassify a distinct group of patients as dysfunctional, but who readily endorse physical symptoms yet report low levels of emotional distress. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitions, emotions, and behavior of patients with migraine when taking medication during an attack

Fifty-three patients with migraine, recruited from the Dutch Society of Migraine Patients and a general practice, were investigated regarding pain, moods, thoughts, and functioning during their most recent migraine attack, using a semistructured interview. Salient findings were: the high pain intensity the patients endured before they took analgesic medication, concerns about medication damaging their health, overoptimism regarding the effect of analgesic medication, and the relatively large proportion of patients (43%) who took medication primarily to be able to continue their activities. We recommend that future clinical trials on the effects of medication on migraine should not only include the measurement of pain during the attack, but also emotions, concerns about potential side effects and the ability to continue or resume work. Furthermore, it is important to provide patients with information about the side effects of medication and to apply cognitive-behavioral techniques for improvement of their mood during the attack.     

The relationship between health status and blood pressure in urban African Americans

African Americans have higher rates of hypertension and poorer health status than their white counterparts. This study assessed the relationship between health status, cardiovascular risk factors, and measured blood pressure. Free blood pressure screenings were performed at businesses and organizations located in west Baltimore. All individuals with cardiovascular risk factors were offered health education. Also, participants with a measured blood pressure of > or = 140/90 mm Hg were referred for free medical treatment. Participants completed a questionnaire that included demographics, cardiovascular risk factors, the Medical Outcomes Study SF 36, and two tests on cholesterol and heart disease knowledge. A total of 1389 African-American men and women were screened; 20% were found to have high normal blood pressure and 31% had stage 1 hypertension or higher. Those with hypertension reported lower physical functioning and poorer general health than those without high blood pressure. When compared with US normative data, participants reported higher levels in vitality and physical and emotional role functioning, more bodily pain, and poorer general health, but they were similar in physical functioning, social functioning, and mental health. Preliminary data suggest that hypertension does have an effect on health function.     

The supportive care needs of newly diagnosed cancer patients attending a regional cancer center

BACKGROUND: The objective of this study was to examine the physical and emotional health status, self-perceived problems, and needs of newly diagnosed cancer patients to determine and plan supportive care strategies. METHODS: A cross-sectional survey of newly diagnosed cancer patients attending a regional cancer center during a 6-month period was performed. Patients with breast, colorectal, head and neck, lung, and prostate carcinoma as well as nonmelanoma of the skin were selected randomly. Patients were interviewed prior to their first appointment at the clinic. Physical health status was assessed using the Symptom Distress Scale, psychologic health status was assessed with the General Health Questionnaire (GHQ), day-to-day functioning with the Rapid Disability Scale, and social support with the modified Sarason's Social Support Scale. Perceived needs were assessed in a number of ways, including identification of patients' specific social concerns and informational needs, and by asking them to list their current problems or concerns. RESULTS: Of 156 eligible patients, 134 completed the interview. One hundred and twenty-nine patients (96%) reported current symptoms that included fatigue (66%), worried outlook (61%), difficulty sleeping (48%), and pain (42%). Forty-four patients (33%) were identified as psychologically distressed with a GHQ score of > or = 6. One hundred and fourteen patients (85%) had informational needs, 89 (66%) indicated > or = 1 social concerns, and 55 (41%) reported a need for assistance with day-to-day living. CONCLUSIONS: Patients with newly diagnosed cancer commonly report symptoms related to fatigue, pain, and psychologic distress. Other frequently reported issues relate to the need for information and social concerns regarding the patients' ability to take care of their home and maintain family and other relationships. Awareness of these issues is important for planning supportive care interventions for newly diagnosed cancer patients.     

Remote recollection of preoperative pain in patients undergoing excision of endometriosis

To determine the accuracy of postoperative recall of preoperative pain, this prospective, longitudinal study was conducted by a general gynecologist in private practice at a referral center. Before excision of endometriosis at laparoscopy or laparotomy and again at 6 to 18 months after surgery, 168 patients completed a 5-point scale assessing 11 symptoms that may be related to endometriosis. For 6 of the 11 symptoms, over 50% of patients had exact recall of pain level. For 10 symptoms, over 80% recalled their preoperative pain level within +/-1 point. Patients requiring reoperation were most likely to recall preoperative pain levels accurately. Those not requiring reoperation tended to inflate slightly their remote assessment of preoperative pain, indicating that successfully treated patients tend to forget how much they formerly hurt.     

Role of health locus of control beliefs and expectations of treatment efficacy in adjustment to cancer.

Examined the effects of health locus of control beliefs (self-, doctor, and chance control) and expectations of treatment efficacy on short-term psychological adjustment in 137 18–86 yr old newly diagnosed cancer patients. The role of these beliefs and expectations in moderating the relation between perceived and actual disease severity and depression was also examined. Ss completed an intake questionnaire assessing the perceived severity of illness, the amount of pain or discomfort they were experiencing, how sad or depressed they were, and expectations about complying with medication instructions; Ss also completed items from Rotter's Internal–External Locus of Control Scale, the Multi-Dimensional Health Locus of Control Scale, and the Self-Rating Depression Scale. The relation between perceptions of disease severity and depression was weaker for Ss who believed that they could personally control their health and for those who held positive expectations about the effects of complying with medical treatment. Similar patterns were found when disease severity was defined in terms of prognosis for survival. Strong negative correlations between self-control/treatment expectations and depression were found for Ss who perceived that their illness was severe. The results for chance and doctor control were less consistent. The stability of health control beliefs and treatment expectations over the course of a serious long-term illness is discussed. (34 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Concerns about breast cancer and relations to psychosocial well-being in a multiethnic sample of early-stage patients.

Much work on psychosocial sequelae of breast cancer has been guided by the assumption that body image and partner reaction issues are focal. In a tri-ethnic sample of 223 women treated for early-stage breast cancer within the prior year, the authors assessed a wider range of concerns and relations to well-being. Strongest concerns were recurrence, pain, death, harm from adjuvant treatment, and bills. Body-image concerns were moderate; concern about rejection was minimal. Younger women had stronger sexual and partner-related concerns than older women. Hispanic women had many stronger concerns and more disruption than other women. Life and pain concerns and sexuality concerns contributed uniquely to predicting emotional and psychosexual disruption; life and pain concerns and rejection concerns contributed to predicting social disruption. In sum, adaptation to breast cancer is a process bearing on several aspects of the patient's life space. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The medical context of hypochondriacal traits

OBJECTIVE: This study examines the effects of two medical contexts on the relationship of hypochondriacal traits and their potential correlates. METHOD: Correlates of hypochondriacal traits were compared from a matched sample of fifty-five general medical inpatients with a sample of fifty-five medical inpatients referred for psychiatric evaluation. Patients completed questionnaires assessing emotional distress and health attitudes, beliefs, and behaviors, and their attending physician completed ratings of the patient's illness and illness behavior. RESULTS: Patients referred for psychiatric consultation exhibited significantly higher levels of hypochondriacal illness presentation than the matched nonreferred sample. Moderated regression analyses revealed three trends regarding the interactive effects of group status on the relationship of hypochondriacal traits to their potential correlates: 1) presence of angry feelings and interpersonal friction was positively associated with hypochondriacal concerns for the psychiatric referred patients only, 2) the tendency to deny life stresses and attribute all problems to the effects of illness was positively associated with a misinterpretation of the severity of their illness and hypochondriacal illness presentation for the psychiatric referred patients, whereas this association was negative for the nonreferred medical patients, and 3) the association of reports of emotional distress symptoms with hypochondriacal illness preparation was negative for the psychiatric referred patients and positive for the nonreferred medical patients. CONCLUSIONS: Study results suggest that hypochondriasis may not represent a uniform nosological disorder and that the context of its study can significantly influence etiologic findings.     

Stress buffering effects of daily spousal support on women's daily emotional and physical experiences in the context of breast cancer concerns.

Objective: This study examined whether the relationship between daily spousal support and daily psychological and physical outcomes varied as a function of level of breast cancer related concern (stress buffering model). Design: Ninety-five women with early stage breast cancer completed daily reports of emotional and physical experiences and satisfaction with spousal support for 30 days. Women also rated problems dealing with three types of cancer specific concerns: emotional, physical, and social. Main outcome measures: Women's positive and negative affect and cancer related pain and fatigue. Results: Multilevel analyses supported a stress buffering effect for social concerns and a reverse stress buffering effect for emotional and physical concerns. Conclusion: Daily spousal support appears to be an important contributor to the daily emotional and physical wellbeing of women with breast cancer. Contrary to the tenets of the stress buffering model, these data suggest that the buffering effect of spousal support is attenuated when breast cancer related emotional and physical concerns reach high levels. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The long-term clinical outcome of patients undergoing anterior cervical discectomy with and without intervertebral bone graft placement

OBJECTIVE: This retrospective study provides data on the long-term clinical outcomes of patients with either anterior cervical discectomy alone (ACD) or anterior cervical discectomy with intervertebral bone graft placement (ACDF). METHODS: A questionnaire was mailed to 525 patients who had undergone ACD (290 patients) or ACDF (235 patients) at least 2 years previously. All procedures were performed by University of Nebraska Medical Center faculty in the Section of Neurosurgery. The follow-up period averaged 8.1 years, with a range of 2 to 14 years. RESULTS: Two hundred sixty-two (49.9%) patients responded to the questionnaire. There was no demographic difference between respondents and nonrespondents (P > 0.05). Respondents who underwent ACDF reported fewer problems with pain than did those who underwent ACD (P < 0.05). A higher percentage of respondents with ACDF reported that they had normal function than did those who underwent ACD (P < 0.05). When limited to respondents who underwent first-time, single-level operations (191 patients), similar results were obtained for the pain parameter (P < 0.05) but not for the level of function (P = 0.25). Patients with longer follow-up periods had fewer problems with pain and better levels of function (P < 0.05). CONCLUSION: Patients who underwent ACD or ACDF did well and benefited from their operations. Those who underwent ACDF did better than those who underwent ACD. Length of follow-up was also an important predictor of current levels of function and pain.     

A randomized double blind trial of verbal NSAID education compared to verbal and written education

OBJECTIVE: We performed a double blind randomized controlled trial to investigate whether patients taking nonsteroidal antiinflammatory drugs (NSAID) knew more about these drugs at followup depending on whether they were randomized to receiving or not receiving an NSAID information sheet. The patients were unaware they were in a study. METHODS: All patients received verbal education on the side effects of NSAID that was standardized and always given by the same rheumatologist. Thirty patients randomly received an NSAID information sheet and 26 patients did not. At next clinic followup, after reading a letter of explanation about the study and signing a consent form, patients completed a questionnaire asking about their knowledge of NSAID. RESULTS: Outcome variables assessed within the questionnaire included whether NSAID : (1) can decrease inflammation; (2) help with pain; (3) cause stomach upset and bleeding in the bowels. None of these variables were statistically significant. The only variable that was statistically significantly different between the groups was their report of whether they had received an information sheet about NSAID (p<0.00004). A greater proportion of patients who received the NSAID information sheet correctly reported they had received one compared to those who had not received one and who said they had not received one (85% in the former group, 70% in the latter group). The group who received the NSAID information sheet were more apt to say that NSAID can help with their pain (odds ratio 6.1, p<0.05). Education level was positively correlated with knowledge (p<0.04). However, level of education explained only 11% of the variance in overall knowledge scores (r=0.34) among all patients. CONCLUSION: An information sheet may not add educational value over verbal information by a physician in a clinic setting.     

Patient empowerment and feedback did not decrease pain in seriously ill hospitalized adults

We tested a nurse clinician-mediated intervention to relieve pain in a group of seriously ill hospitalized adults using a randomized controlled trial at five tertiary care academic centers in the US. The study included 4804 patients admitted between January 1992 and January 1994 with one or more of nine high mortality diagnoses; 2652 were allocated to the intervention and 2152 to usual care. Specially-trained nurse clinicians assessed patients' pain, educated them and their families about pain control, empowered patients to expect pain relief, informed patients' nurses and physicians about level of pain and suggested or used other pain management resources. Patients' pain was determined from hospital interviews with patients and surrogates. Pain 2 and 6 months later or after death and satisfaction with its control at all time periods were also assessed. All analyses were adjusted for baseline risk of being in pain and propensity to be in the intervention group. Overall, 50.9% of patients reported some pain. After adjustment for other variables associated with pain, comparing the intervention to the control group, there was not a statistically significant difference in level of pain (OR for higher levels of pain 1.15; CI 1.00-1.32) or satisfaction with control of pain during the hospitalization (OR for higher levels of pain 1.12; CI 0.91-1.39), 2 or 6 months after discharge, or during the last 3 days of life. A multifaceted intervention using information, empowerment, advocacy, counseling and feedback was ineffective in ameliorating pain in seriously ill patients. Control of pain in these patients remains an important problem. More intensive pain treatment strategies addressing the needs of seriously ill hospitalized adults must be evaluated.