Qualitative Analysis of Illness Representations and Coping Perceptions Among Older Adults With Chronic Spinal Disability: "A Thought in the Back of My Mind".

OBJECTIVE: The purpose of this study was to explore older adults' illness representations, their beliefs about health, and their coping perceptions of chronic spinal disability. METHODS: This qualitative descriptive study used structured interviews that were completed during a randomized trial of non-pharmacological management of spine-related disability with chiropractic spinal manipulative therapy and exercise. Dual coders conducted a descriptive thematic analysis of 50 randomly selected transcripts supported by qualitative data management software. The Common-Sense Model provided an organizing framework for coding and interpretation. RESULTS: Fifty participants (34 women, median age: 68 years) described 4 illness representations, 4 coping styles, and 6 coping strategies for their management of spinal disability. Illness representations formed a continuum of little-to-no health impact to bothersome symptoms to heightened symptom intensity to unmanaged pain and/or disability. Most participants adopted either self-care or self-management coping styles, but some used healthcare-seeking or fear avoidance with worsening symptoms or interference with employment or preferred activities. Participants mentioned 6 coping strategies for spinal disability. Distraction included position changes, hobbies, and supportive relationships. Limitation focused on rest and/or relaxation, restricted movements, and activity modifications. Prevention enhanced self-care knowledge, posture and/or ergonomics, nutrition, and stress management. Movement emphasized stretching, home exercise and/or walking, and exercise therapy. Palliation augmented patient comfort through the use of heat and/or ice, over-the-counter medicine, and spinal manipulation. Avoidance strategies included missing employment, stopping house and/or yard work, and prescription medication. CONCLUSION: The community-dwelling older adults in this study offered varied illness representations of their chronic spinal disability. Most participants combined and personalized coping strategies to minimize pain and symptom impact; thus, representations may influence the coping styles adopted by older persons to manage their spinal conditions. A quote from a participant that pain was "a thought in the back of my mind" suggests the presence of cognitive and emotional processes that may influence individual perceptions and feelings about their spinal symptoms or conditions. These findings suggest that there may be a broader role for spine care clinicians to include teaching older people about self-management strategies to better cope with spinal disabilities.

The Relationship Between Spinal Pain and Comorbidity: A Cross-sectional Analysis of 579 Community-Dwelling, Older Australian Women.

OBJECTIVES: The aims of this study were to (1) report the prevalence and explore the influence of spinal pain on quality of life and (2) assess the relationship between spinal pain and the type and number of comorbidities. METHODS: This cross-sectional study comprised 579 community-dwelling, older Australian women. Women had "spinal pain" if they marked "yes" to neck pain, upper back pain, mid-back pain, and/or lower back pain. Descriptive statistics and binary logistic regression were performed to report the prevalence and explore the relationship between spinal pain and the type and number of comorbidities. RESULTS: A majority of women (55.8%) who returned surveys had spinal pain. Women with spinal pain had significantly lower physical and mental quality of life scores than women without spinal pain (Medical Outcomes Study: 36 Item Short Form Survey [SF-36] physical component summary: 40.1 ± 11.1 vs 49.0 ± 9.0, and SF-36 mental component summary: 50.0 ± 10.5 vs 53.9 ± 8.2, respectively). Having spinal pain was significantly associated with overweight and obesity (odds ratio 1.98 [95% confidence interval 1.3-2.96] and 2.12 [1.37-3.28]), diabetes (1.93 [1.01-3.67]), pulmonary comorbidity (1.66 [1.04-2.65]), and cardiovascular comorbidity (1.57 [1.07-2.28]). More than half of the women with spinal pain reported 2 or more comorbidities, with comorbidities significantly more common among women with spinal pain than among women without spinal pain. The odds of having spinal pain increased with an increasing number of comorbidities (2 comorbidities: 2.44 [1.47-4.04], 3 comorbidities: 3.07 [1.66-5.67], 4 comorbidities: 5.05 [1.64-15.54]). CONCLUSIONS: Spinal pain is common in community-dwelling, older Australian women and is associated with greater disability and poorer quality of life. Diabetes, cardiovascular disease, pulmonary disease, and obesity appear to have a relationship with spinal pain. There was an incremental increase in the risk of spinal pain associated with increasing comorbidity count.

Terapia de la risa. En el dolor crónico músculo-esquelético / Laughter Therapy for chronic skeletal muscular pain

Se explican los efectos de la introducción de talleres de risoterapia y relajación en una unidad de educación terapéutica y rehabilitación funcional, y se comprueba si su aplicación ayuda a disminuir el dolor, mejorar la movilidad y reducir el estado emocional alterado (ansiedad-depresión) del paciente(AU)

The authors explain the effects introducing workshops for laughter therapy and relaxation to a unit dedicated to therapeutic education and functional rehabilitation; the authors test to see if the application of this therapy hepls to decrease pain, to improve mobility and to reduce na altered emotional state, such as anxiety-depression, common among chronic pain patients(AU)

Assessment of biopsychosocial risk factors for medical treatment: a collaborative approach.

There is a growing body of evidence that psychosocial variables have a significant ability to predict the outcome of medical treatment procedures, especially when the procedure is performed to reduce pain. The study described in this paper serves as an illustration of the valuable role psychologists can play in dealing with the challenges of biopsychosocial assessment of patients who are candidates for medical treatments, especially elective, invasive procedures. Based on a convergent model of risk factors that can potentially influence outcomes from spinal surgery and spinal cord stimulation, exclusionary and cautionary risk factors were identified, and the BHI 2 and BBHI 2 tests were used to assess them. An estimate of the prevalence of these risk factors was calculated using data obtained from 1,254 patient and community subjects gathered from 106 sites in 36 US states. Standardized Cautionary Risk and Exclusionary Risk scores demonstrated a test-retest reliability of .85 to .91. Evidence of validity of these scores was also provided based on subjective and objective criteria, using multiple groups of patients and community subjects. Recommendations are made regarding how biopsychosocial assessments could be used in collaborative settings for presurgical candidates to identify risks that could compromise a patient's ability to benefit from other medical treatments as well. Once identified, appropriate interventions could ameliorate these risks, or lead to the consideration of other treatments that are more likely to be effective. Methods of refining this approach for specific clinical applications are also discussed.

[Is early differentiation between psychogenic and somatogenic lumbago-ischialgia syndrome patients possible by anamnesis? Results of a screening study]. / Ist eine frühe Differenzierung psychogener von somatogenen Lumbago-Ischialgie-Syndrom(LIS)-Patienten mittels Anamnese möglich? Ergebnisse einer Screeningstudie.

Low back pain (LBP) is one of the most frequent causes for early retirement, hospital treatment and loss of days of work (Raspe u. Kohlmann 1993). Further differentiation and earlier diagnosis of psychogenic LBP could significantly reduce health costs. We interviewed 101 patients with LBP in the departments of Neurology and Neurosurgery (Gemeinschaftskrankenhaus Herdecke, University Witten/Herdecke) with the "structured biographical interview for patients with pain" (Egle 1992). This questionnaire has been used successfully differentiating between patients with organic and psychogenic chronic pain syndromes. It is a semi-standardised instrument based on observations, mainly made by Engel (1959), showing that many patients suffering from chronic benign pain syndromes had experienced psychic traumatisation during childhood. We compared a group of patients with clear neurological deficits and organic pain origin (n = 47) with a group of patients with psychogenic LBP (n = 25). Parameters were among others their biographical family constellations, their past medical history (also looking for symptoms of dissociation [conversion]), their present life and their coping with pain. In comparison with other studies examining similar aspects in patients who had pain in other parts of the body (Egle et al. 1991), our groups showed less discriminating results concerning biographical aspects. We found that also 40% of patients with organic pain origin hat traumatic constellations in their childhood. The following factors differentiated best between the both groups and characterised the psychogenic group: Intensity of pain was judged to be significantly higher with the "visual analog scale": age of the patient less than 40 years; distraction does not alter the pain; preceding experiences with physicians had often been negative; pain leads to impairment of familiar contacts; conflicts with parents during childhood could not adequately discussed with them at that time. These seven aspects can very well be part of a clinical history taking in a general medical setting, so that patients with LBP can be differentiated more effectively.

Prognostic factors of spinal cord stimulation for chronic back and leg pain.

Spinal cord stimulation (SCS) has been used for more than 20 years in the treatment of diverse pain conditions. Although recent studies have identified more clearly those conditions for which SCSoffers a favorable prognosis, the identification of a patient population in whom reasonably long-term success can be expected has been difficult. In an effort to improve patient selection and increase the overall success rate of treatment, we have examined various physical, demographic, and psychosocial variables as predictors of SCS outcome. The study population consisted of 40 patients with chronic low back and/or leg pain, 85% of whom were diagnosed with failed back surgery syndrome. Medical history and demographic data were collected as part of an initial assessment along with patient responses to the Minnesota Multiphasic Personality Inventory, the visual analogue pain rating scale (VAS), the McGill Pain Questionnaire, the Oswestry Disability Questionnaire, the Beck Depression Inventory, and the Sickness Impact Profile. Treatment outcomes were examined and found to improve significantly after 3 months of stimulation. Subsequent regression analysis revealed that patient age, the Minnesota Multiphasic Personality Inventory depression subscale D, and the evaluative subscale of the McGill Pain Questionnaire (MPQe) were important predictors of posttreatment pain status. Increased patient age and D subscale scores correlated negatively with pain status, as measured by the percentage of changes in pretreatment and posttreatment VAS scores, % delta VAS. In contrast, higher MPQe correlated with improved pain status. By the use of the following equation and the definition commonly associated with SCS success (at least 50% decrease in the VAS pain level), the success or failure of 3 months of SCS was correctly predicted in 88% of the study population. Our results suggest that patient age, Minnesota Multiphasic Personality Inventory depression, and MPQe may be clinically useful in the prediction of pain status after 3 months of SCS in patients with chronic low back and/or leg pain. % delta VAS = 112.57 - 1.98 (D)-1.68 (Age) + 35.54 (MPQe).

[Results of ambulant treatment of vertebral syndromes (author's transl)]. / Ergebnisse bei der ambulanten Behandlung des Wirbelsäulen-Syndroms.

Summary of a Dissertation worked out in a General Medical Practice: 255 patients with vertebral conditions were investigated in a medium-sized general practice on the edge of an industrial town. The treatment and therapeutic results were observed over 2 years. The complaints included pains in the head and neck, shoulder-arm syndrome, back and low back pains including sciatica and sensitivity disorders. The therapeutic results revealed that the general medical practice is in a position to treat vertebral conditions satisfactorily with a minimum of expenditure if the treatment is multicentric and individually designed after a previous exact diagnosis and carried out over the long term if necessary.

Psychological aspects of chronic pain.

Except in emergencies, the physician's obligation is not to relieve pain, but to diagnose and treat pathology. Psychological factors complicate organic pain, and make the diagnosis of "psychogenic" pain virtually impossible on the basis of psychological tests alone. In acute (short-term) pain, anti-anxiety agents are useful, but in chronic pain antidepressants are usually more appropriate. Continuing anxiolytic drugs past the acute stage tends to potentiate depressions. In addition to antidepressants, modalities which help in the management of chronic pain are physical therapy, transcutaneous electrical neurostimulation, use of weak analgesics on a "clock" rather than an "as needed" basis, and behavior modification. Explicit agreement on the features of the doctor--patient relationship is almost always essential for successfully managing these difficult and demanding patients.