Here we go again: outcomes, outcomes, outcomes.
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Back Pain↗
Biomedical subjects
D C Turk
Publications and source records attributed to D C Turk.
Improving the rate of classification of patients with the multidimensional pain inventory (MPI): clarifying the meaning of "significant other".
OBJECTIVE: The Multidimensional Pain Inventory (MPI) has been used widely to assess the psychosocial adaptation in chronic pain patients. The MPI can also be used to classify patients into one of three primary subgroups. However, studies have reported that anywhere from 3% to 30% of patients are unclassifiable, mostly attributable to an excessive number of missing responses to questions. The purpose of this study was to examine the reasons for the large number of missing responses and subsequently to reduce the number of patients who cannot be classified within one of the three primary MPI subgroups. DESIGN: Two versions of the MPI were evaluated on two samples of patients (N = 147; and N = 143) with persistent pain being evaluated by the Workers Compensation Board of British Columbia, Canada. One version used the published MPI instructions and the second modified the instructions to clarify the meaning of the term "significant other." In addition, patients were required to designate a significant other who would serve as the anchor for all responses related to a significant other. RESULTS: Approximately 18% of patients could not be classified within one of the three primary profiles and were determined to be unanalyzable using the MPI standard classification procedure. Most patients who could not be classified had excessive missing data to those questions asking about support received from "significant other." Almost all of these patients with missing data were unmarried and living alone. Modifying the instructions of the MPI to specify the meaning of the term "significant other" resulted in an almost threefold (6.3% vs. 18%) reduction in the percentage of patients whose responses could not be analyzed and consequently classified into one of the three primary MPI subgroups. The revised instructions did not lead to any difference in the actual distribution of patients assigned to one of the three profiles. Thus, using the modified instruction did not alter the proportion of patients assigned to one of the three primary groups. CONCLUSION: Modification of the MPI instructions clarifying the definition of a significant other can greatly reduce the number of patients who are classifiable within one of the three primary MPI profiles. Thus, the modified instructions of the MPI (hence the MPI-M) have a significant advantage over the original version. The mean scores on the individual scales of the MPI and the MPI-M are comparable. Moreover, the results demonstrate that the proportion of the previously unanalyzable patients classified within one of the three primary subgroups is comparable to the original proportion of patients assigned to each of the primary subgroups. Thus, it may not be necessary to reestablish the norm scores based on the modified instructions. Future studies and clinicians who wish to use the MPI for the purpose of classifying patients on the basis of psychosocial and behavioral factors should make use of the MPI-M that incorporates the clarification of the meaning of "significant other."
Adaptation, Psychological↗
Interdisciplinary treatment for fibromyalgia syndrome: clinical and statistical significance.
OBJECTIVES: The primary purposes of the study were to: evaluate the treatment efficacy of an outpatient, interdisciplinary treatment program for fibromyalgia syndrome (FMS); examine whether treatment gains would be sustained for 6 months following the treatment; assess whether improvements were clinically significant; and delineate the factors associated with clinically significant improvement in pain severity. METHODS: Sixty-seven FMS patients completed a 4-week outpatient program consisting of medical, physical, psychologic, and occupational therapies. Six-month followup data were available for 66% of treated patients. RESULTS: Comparisons between pretreatment and posttreatment measures revealed significant improvements in pain severity, life interference, sense of control, affective distress, depression, perceived physical impairment, fatigue, and anxiety; however, there was no improvement in interpersonal relationships or general activities. Clinically significant improvement in pain severity, using the Reliable Change Index, was obtained by 42% of the sample and was predicted by the pretreatment levels of depression, activity, perceived disability, solicitous responses of significant others, and idiopathic onset. Pretreatment level of pain severity was not a significant predictor of the degree of pain improvement. Comparisons among pretreatment, posttreatment, and 6-month followup data revealed that the patients maintained treatment gains in pain, life interference, sense of control, affective distress, and depression. However, the quadratic polynomial analysis revealed that relapse occurred in the subjective rating of fatigue. CONCLUSIONS: The results suggest that, overall, an outpatient interdisciplinary treatment program was effective in reducing many FMS symptoms. Treatment gains tended to be maintained for at least 6 months. However, there were large individual differences in response to treatment. These results suggest that identification of subgroups of FMS patients and their specific clinical characteristics may be useful for maximizing treatment efficacy.
Activities of Daily Living↗
Differential responses by psychosocial subgroups of fibromyalgia syndrome patients to an interdisciplinary treatment.
OBJECTIVES: To evaluate differential treatment responses among 3 empirically derived, psychosocial subgroups of patients with fibromyalgia syndrome to a standard interdisciplinary treatment program. METHOD: Patients were classified into 1 of 3 psychosocial groups on the basis of their responses to the Multidimensional Pain Inventory. Forty-eight patients completed a 6 one-half-day outpatient treatment program consisting of medical, physical, occupational, and psychological therapies spaced over a period of 4 weeks (3 sessions the first week followed by 1 session per week for the next 3 consecutive weeks). RESULTS: Statistically significant reductions were observed in pain, affective distress, perceived disability, and perceived inteference of pain in the patients characterized by poor coping and high level of pain ("dysfunctional" group). In contrast, individuals who were characterized by interpersonal difficulties ("interpersonally distressed" group) exhibited poor responses to the treatment. "Adaptive copers," the third group, revealed significant improvements in pain but due to low pretreatment levels of affective distress and disability showed little improvement on these outcomes. CONCLUSIONS: The results provided support for the hypothesis that customizing treatment based on patients' psychosocial needs will lead to enhanced treatment efficacy. They also emphasize the importance of using appropriate outcome criteria, as low levels of problems at baseline are not likely to show significant changes following any treatment.
Activities of Daily Living↗
Adaptation to metastatic cancer pain, regional/local cancer pain and non-cancer pain: role of psychological and behavioral factors.
The present study compared the adaptation of cancer pain patients and chronic non-cancer pain patients. Differences between samples of cancer pain patients with and without metastatic disease were also examined. Cancer pain patients reported comparable levels of pain severity to non-cancer chronic pain patients; however, pain due to cancer was associated with higher levels of perceived disability (t(250) = 2.97, P < 0.004) and lower degree of activity (t(286) = 2.45, P < 0.04). The patients with cancer pain, particularly those with metastatic disease, reported significantly higher levels of support and solicitous behaviors from significant others, compared to non-cancer chronic pain patients. The majority of the cancer patients, both with (81%) and without (84%) metastatic disease as well as non-cancer chronic pain patients (85%), could be classified into one of three psychosocial subgroups that had been previously identified with non-cancer chronic pain patients: 'dysfunctional' (high levels of pain, perceived interference, affective distress and low levels of perceived control and activity), 'interpersonally distressed' (high levels of affective distress, negative responses from significant others and low levels of perceived support) and 'adaptive copers' (low levels of interference and affective distress, high levels of perceived control and activity). The distribution of the profiles was significantly different across groups (chi2(4) = 12.79, P < 0.02). However, within each profile. the response patterns were highly comparable across groups. Thus, contrary to the suggestions of some authors, cancer pain and non-cancer chronic pain patients share many features in common. Furthermore, the heterogeneity of psychosocial adaptation to pain within each patient group suggests the importance of psychological assessment in determining the pain management plan.
Adaptation, Psychological↗
Nonpharmacological treatment for migraine: incremental utility of physical therapy with relaxation and thermal biofeedback.
The identification of musculoskeletal abnormalities in headache patients has led to the incorporation of physical therapy (PT) into treatment programs for chronic headache. The current studies: (i) investigated the efficacy of PT as a treatment for migraine, and (ii) investigated the utility of PT as an adjunct treatment in patients who fail to improve with relaxation training/thermal biofeedback (RTB). PT alone is not effective in reducing headache, with only 14% of subjects reporting significant headache reduction (mean reduction of 15.6% in comparison with 41.3% in RTB). However, PT may have been a useful adjunct, with 47% of a group of 11 subjects who had failed to improve with RTB reporting improvement with the addition of PT. It is recommended that RTB remain the nonmedical treatment of choice for migraine, and that PT may be a useful adjunct for patients who fail to improve after such treatment.
Adolescent↗
Psychological approaches in pain management: what works?
Outcome studies evaluating psychological treatments for pain vary in nature and intensity. Overall, however, treatment programs that include psychological interventions have been shown to be effective in treating postoperative pain, noncardiac chest pain, fibromyalgia syndrome, and chronic back pain. Cost analyses of the treatments indicate not only the clinical efficacy but the cost-effectiveness of psychological interventions. Issues related to subject attrition, noncompliance, and individual differences in treatment response should be addressed in future studies.
Journal Article↗
Psychosocial and behavioral assessment of patients with temporomandibular disorders: diagnostic and treatment implications.
The literature on chronic pain reveals that several psychosocial and behavioral factors, in addition to physical pathology, play a role in reports of pain and disability. Therefore it is important to assess patients more broadly rather than focus exclusively on physical pathology. Understanding and treatment of temporomandibular disorders has been impeded by the lack of agreement on a classification system with which to make a differential diagnosis. Research supports the appropriateness of a dual-diagnostic approach for temporomandibular disorders based on physical and psychological axes. Treatment should be directed toward the physical diagnoses supplemented by treatment that targets relevant psychosocial characteristics. This approach encourages diagnosticians to think in terms of the two relevant axes and to customize treatment to physical and psychosocial characteristics and thus should foster better outcomes.
Behavior Therapy↗
Headache during pregnancy and in the postpartum: a prospective study.
The association between sex hormones and chronic headache has been the subject of a good deal of speculation. Headache is predicted to improve during pregnancy, when estrogen levels rise steadily until delivery. Retrospective studies have suggested that women with a history of migraines do tend to report decreases in headache activity with pregnancy. The purpose of this naturalistic study was to examine changes in headache that may occur during pregnancy and postpartum in women complaining of migraine, tension-type, or combined migraine and tension-type headaches in a prospective design. Thirty women recorded their headaches daily throughout pregnancy and up to 12 weeks postpartum. Results based on these ratings demonstrated a nonsignificant trend for headache to decrease throughout pregnancy and to increase during the birth week. Headache patterns varied slightly depending on headache diagnosis and parity. Contrary to previous retrospective study reports, migraine sufferers demonstrated an increase in headache in the third trimester. In addition, there was a tendency in multiparous women for headaches to increase in the third trimester, whereas primiparous women reported less headache activity throughout pregnancy and the postpartum.
Adult↗
What factors affect physicians' decisions to prescribe opioids for chronic noncancer pain patients?
OBJECTIVE: To evaluate the contribution of pain severity, physical pathology, demographic factors, initiators of symptoms, affective distress, behavioral expressions of pain, and functional activity levels in physicians' decisions to prescribe opioid medication for chronic noncancer pain patients. DESIGN: Patients were examined by a physician and physical therapist, interviewed by a psychologist, and asked to complete a medical history form and a set of self-report questionnaires. Patients who were prescribed opioids were compared with those who were not prescribed opioids on each of these. In addition, logistic regression analysis was performed to determine the best predictors of opioid prescriptions. SUBJECTS: A total of 191 (96 female and 95 male) consecutive patients referred to a multidisciplinary pain treatment facility diagnosed with a variety of chronic pain syndromes. RESULTS: Neither pain severity nor objective physical pathology influenced physicians' prescribing of opioids medication. Similarly, duration of pain and demographic factors had minimal impact on prescribing of opioids. Patients' behavioral manifestations of pain, distress, and suffering--pain behaviors--and reports of functional disability and distress did distinguish between patients prescribed opioid medications from those who did not. However, when all variables were entered into a logistic regression model, only observed pain behaviors showed a significant association with opioid prescriptions. CONCLUSIONS: Physicians' practice in prescribing of opioids appears to be influenced most by patients' nonverbal communications of pain, distress, and suffering. Some of the factors not directly evaluated in this study that may also contribute to the decision to prescribe opioids for chronic noncancer pain patients are discussed.
Adult↗
Traumatic onset of temporomandibular disorders: positive effects of a standardized conservative treatment program.
OBJECTIVE: To compare presenting problems and response to treatment of chronic temporomandibular (TMD) patients who perceive the onset of their symptoms to be related to trauma with those who report symptoms of unknown origin. DESIGN: Prospective treatment outcome study. SETTING: Outpatient multidisciplinary pain treatment center at a university medical center. PATIENTS: A total of 361 were evaluated initially, including 103 who perceived traumatic onset of symptoms and 258 who did not perceive onset to be related to trauma. Two hundred thirty-three (59 trauma and 174 nontrauma) returned for follow-up evaluation 6 months after the conclusion of treatment. INTERVENTIONS: Standardized six-session treatment program consisting of intraoral appliance, biofeedback, and stress management training. OUTCOME MEASURES: Clinical changes in muscle pain, temporomandibular joint pain, and mandibular opening. Self-report of change in perceived pain severity (MPQ--short form), depressive symptoms (BDI), catastrophizing about pain (CSQ--catastrophizing scale), MPI--interference scale, oral parafunctional habits, global evaluation of improvement, and use of pain medications at follow-up. RESULTS AND CONCLUSIONS: Regression of onset type on pretreatment variables indicated that a small but statistically significant proportion of pretreatment variability (8.7%) could be accounted for by onset. Both traumatic and nontraumatic onset groups showed positive outcomes following treatment. No significant differences between groups were found for any of the clinical or self-reported outcome measures with the exception that a significantly higher percentage of the trauma group reported using pain medication at follow-up. These findings are in contrast with previous suggestions that post-traumatic TMD patients show poorer response to treatment than nontrauma TMD patients.
Adolescent↗
Evaluating the role of physical, operant, cognitive, and affective factors in the pain behaviors of chronic pain patients.
Behavioral manifestations of pain, distress, and suffering have been characterized as pain behaviors. Although acquisition and maintenance of pain behaviors have been considered to occur through reinforcement contingencies, empirical evidence suggests that pain behavior is better understood as a multidimensional entity. The present study was designed to evaluate the contributions of physical, operant, cognitive, and affective factors to individual differences in pain behaviors. A total of 63 chronic pain patients diagnosed with the disorder fibromyalgia underwent medical, physical, and psychological evaluations. Hierarchical regression analyses revealed that the physical, cognitive, and affective factors, but not operant factors, were significantly related to observed pain behaviors. The set of all factors accounted for 53% of the variance in observed pain behavior. The results in this study suggest that pain behaviors should be conceptualized as behavioral manifestation of pain based on a complex interaction of various psychological and physical factors.
Adult↗
A standardized manual tender point survey. I. Development and determination of a threshold point for the identification of positive tender points in fibromyalgia syndrome.
OBJECTIVE: To (a) develop a standardized tender point examination protocol [Manual Tender Point Survey (MTPS)] as a diagnostic procedure to evaluate the tender point (TP) criterion for fibromyalgia syndrome (FM) and (b) determine a threshold point for positive TP. METHODS: A standardized MTPS consisted of standardized components including (a) location of the survey sites, (b) patient and examiner positioning, (c) order of examination, (d) pressure application technique, and (e) pain severity rating scores [0 (no pain) - 10 (worst pain)]. Seventy patients with FM and 70 with chronic headache were examined using the MTPS protocol. RESULTS: A pain severity score of 2 (i.e., 0-1 = negative) was found to be an optimal threshold point for identifying positive TP, with sensitivity of 88.57% and specificity of 71.43%. These results are comparable to the sensitivity and specificity of the 1990 multicenter study. CONCLUSION: The MTPS provides a step-by-step, standardized TP examination protocol, which is sensitive and specific in discriminating patients with FM from patients with chronic headache.
Adult↗
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.
Adaptation, Psychological↗
Clinicians' attitudes about prolonged use of opioids and the issue of patient heterogeneity.
Despite advances in medical knowledge, sophisticated imaging procedures, and treatment approaches, a significant number of chronic pain patients continue to suffer from unremitting pain. Recently, it has been suggested that opioid analgesics should be used more extensively with this population. This suggestion has resulted in considerable controversy. The preliminary research upon which opioid use for chronic pain patients is based is reviewed and demonstrated to be equivocal. The results of two recent surveys that have addressed physicians' attitudes and prescribing practices for chronic pain patients are discussed. Proposed guidelines for prescribing opioids for chronic pain patients are examined.
Attitude of Health Personnel↗
Effects of type of symptom onset on psychological distress and disability in fibromyalgia syndrome patients.
The purpose of the study was to investigate the differences between two types of onset (post-traumatic versus idiopathic) in pain, disability, and psychological distress in patients with fibromyalgia syndrome (FS). Forty-six FS patients with post-traumatic onset and 46 FM patients with idiopathic onset, who were matched in age and pain duration, were included in the study. All participants completed self-report inventories assessing their adaptation to the pain conditions, and during the medical examination, an examining physician completed an inventory (Medical Examination and Diagnostic Information Coding System; MEDICS) to indicate the degree of physical abnormality. The analysis revealed that the degrees of physical abnormality of the patients were comparable in the two groups. However, controlling for the involvement with financial compensation issues (e.g. disability, litigation), the post-traumatic FS patients reported significantly higher degrees of pain, disability, life interference, and affective distress as well as lower level of activity than did the idiopathic FS patients. Furthermore, evaluation of the treatment history in these patients revealed that a significantly larger number of the posttraumatic FS patients were receiving opioid medications and had been treated with nerve block, physical therapy, and TENS. The results suggest that (1) post-traumatic onset is associated with high level of difficulties in adaptation to chronic FS symptoms and (2) FS patients are a heterogeneous group of patients.
Accidents↗
Dysfunctional patients with temporomandibular disorders: evaluating the efficacy of a tailored treatment protocol.
Forty-eight dysfunctional patients (i.e., high levels of pain, interference, and affective distress and low levels of perceived control) with temporomandibular disorders (TMDs) were randomly assigned either to a treatment consisting of an intraoral appliance (IA) and stress management with biofeedback (SM) plus nondirective, supportive counseling (SC) -- IA + SM + SC -- or to a customized treatment that included cognitive therapy (CT) with the IA and SM--IA + SM + CT. Both treatment groups reported statistically significant reductions on a set of physical, psychosocial, and behavioral measures posttreatment and at a 6-month follow-up. However, the intervention that included CT demonstrated significantly greater reductions in pain, depression, and medication use. Only the groups receiving the treatment that included the CT demonstrated continued improvements to the follow-up on pain associated with muscle palpation, self-reported pain severity, depression, and use of medications. These results support the efficacy of the tailored treatment for dysfunctional TMD.
Adult↗
Maintenance of effects in the nonmedical treatment of headaches during pregnancy.
In a previous study, 30 pregnant women suffering from headaches were treated with physical therapy, relaxation training, and biofeedback. Eighty percent of these women experienced significant relief of headaches following treatment. Although this study demonstrated the effectiveness of nonmedical treatment during pregnancy, little is known about the influence of changing hormones during pregnancy on fluctuations in headache. One purpose of this study was to present a follow-up of the women who were included in the previous study to determine whether the results from the nonmedical treatment were maintained up to a year after giving birth. In addition, this study examined the influence of headache diagnosis and breastfeeding on changes in headache activity and maintenance of treatment effects. The results indicate that the reductions in headache activity were maintained at follow-up in the majority of the women treated, with 67.5% of the sample maintaining a significant decrease in headache up to 1 year after giving birth. Neither IHS diagnosis nor breastfeeding was related to maintenance of headache improvement. We conclude that the beneficial effects of nonpharmacological treatment of headaches during pregnancy demonstrated in a previous study are maintained up to 1 year following delivery. Headache diagnosis and breastfeeding were not related to treatment outcome, a finding that contradicts the reports of many retrospective studies.
Adult↗