Differences in presurgical MMPI-3 scores across trajectories of recovery from spine surgery.

Approximately 30% of patients who undergo spinal surgery for chronic back pain continue to experience significant pain and disability up to 2 months following surgery. Prior studies have identified mental health variables including depression and anxiety as predictors of poorer postsurgical outcomes using screening instruments, but no studies have examined long-term outcomes using the Minnesota Multiphasic Personality Inventory-3 (MMPI-3), a commonly used tool used in presurgical psychological evaluations (PPE). Using group-based trajectory modeling and a sample of 404 spine surgery evaluees, the present study examined the trajectories of changes in disability scores from presurgery through 3, 12, and 24 months postsurgery. We then compared scores on MMPI-3 scales between trajectory groups. We identified three trajectory groups of change in disability over time: a rapid-remitting group (8%), characterized by moderate presurgical disability that rapidly and substantially remitted by 12 and 24 months; a steady-recovering group (68%), characterized by moderate presurgical disability, slower change over time, and mild levels of disability at the 2-year time point; and a persisting disability group (24%), characterized by severe presurgical disability that continued into long-term follow-ups. Participants in the persisting pain group produced higher presurgical scores on somatic/cognitive and internalizing MMPI-3 scales than participants in the rapid-remitting and steady-recovering groups. Our results support the clinical utility of the MMPI-3 in PPEs and highlight the importance of evaluating somatic/cognitive concerns and internalizing dysfunction to identify patients who are likely to have poorer postsurgical outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Incremental Contribution of the Minnesota Multiphasic Personality Inventory - 3 to Predicting One-Year Postoperative Spinal Cord Surgery/Spinal Cord Stimulation Outcomes.

Pre-surgical psychological assessments are becoming common in the United States and are recommended or required prior to surgical/spinal cord stimulator intervention for chronic back pain. Psychological testing is often recommended for these evaluations and the various versions of the Minnesota Multiphasic Personality Inventory (MMPI) have demonstrated utility for predicting outcomes in this setting. This investigation sought to extend that literature with the newest version of the MMPI, the MMPI-3. The sample comprised of 909 patients (50.5% men, 49.5% women) who consented to participating in an outcome study and took the MMPI-3 along with other self-report measures of pain, functional disability, and emotional functioning prior to surgery as part of their pre-surgical psychological assessment. Self-report measures of pain, functional disability, and emotional functioning were administered again one-year following the intervention. MMPI-3 scale scores accounted for up to 9% of additional variance in the outcomes after controlling for pre-surgical measures. Measures of emotional/internalizing dysfunction, somatic dysfunction, and, to a lesser extent, behavioral/externalizing dysfunction contributed the most to the prediction of poorer outcomes.

Reliability and validity of Minnesota Multiphasic Personality Inventory-3 (MMPI-3) scale scores among patients seeking spine surgery.

The Minnesota Multiphasic Personality Inventory (MMPI) family of instruments has been commonly used for the evaluation of patients seeking surgical intervention for back pain. A new version of the MMPI, the Minnesota Multiphasic Personality Inventory-3 (MMPI-3), has been released with updated normative data, expanded and revised item content, and updated scales. The purpose of this investigation is to report reliability and validity findings for MMPI-3 scale scores of patients seeking spine surgery. Using a sample of 761 spine surgery candidates (390 men and 371 women), descriptive data, reliability and standard error of measurement, and zero-order correlations using external criteria (self-report and information gathered from a medical record review/clinical interview) were calculated. By and large, men and women produced MMPI-3 scale scores that were similar with a few exceptions. Many reliability estimates and standard errors of measurement were replicable compared to those reported for the MMPI-3 normative sample for scales that yielded adequate range. The scale scores of the MMPI-3 also yielded evidence of good convergent and discriminant validity when correlated with external criteria. Indeed, MMPI-3 scale scores accounted for 2%-15% of incremental variance in data obtained via the clinical interview and medical chart, once other self-report measures were accounted for. Overall, many of the MMPI-3 scale scores used in spine surgery evaluations appear to be reliable and valid. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Validity of a pre-surgical algorithm to predict pain, functional disability, and emotional functioning 1 year after spine surgery.

Psychopathology has been associated with patient reports of poor outcome and an algorithm has been useful in predicting short-term outcomes. The objective of this study is to investigate whether a pre-surgical psychological algorithm could predict 1-year spine surgery outcome reports, including pain, functional disability, and emotional functioning. A total of 1,099 patients consented to participate. All patients underwent spine surgery (e.g., spinal fusion, discectomy, etc.). Pre-operatively, patients completed self-report measures prior to surgery. An algorithm predicting patient prognosis based on data from the pre-surgical psychological evaluation was filled out by the provider for each patient prior to surgery. Post-operatively, patients completed self-report measures at 3- and 12-months after surgery. Longitudinal latent class growth analysis (LCGA) was used to derive patient outcome groups. These outcome groups were then compared to pre-surgical predictions made. LCGA analyses derived three groups of patients from the reported outcome data (entropy = .84): excellent outcomes, good outcomes, and poor outcomes. The excellent and good groups demonstrated improvements over time, but the poor outcome groups, on some measures, reported worsening of pain, functional disability, and emotional functioning over time. The pre-surgical algorithm yielded good concordance with the statistically derived outcome groups (Kendall's W = .81). Using a pre-surgical psychological evaluation algorithm for predicting long-term spine surgery outcomes can identify patients who are unlikely to report good outcomes, and point to areas for psychological intervention that can either improve surgery results or to be utilized as alternatives to elective spine surgery. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Presurgical Psychological Evaluation: Risk Factor Identification and Mitigation.

Presurgical psychological evaluations (PPEs) are becoming an established component of the surgical process, though methods of conducting PPEs are variable. There is a lack of clarity about the goals of PPEs, the types of information that should be included, and the process for integrating information and making recommendations to the referring physicians/surgeons. This review proposes an empirically supported model for PPEs that is systematic, but flexible enough to be utilized across the broad range of surgical evaluations. This five-step method is termed the Risk Identification and Mitigation (RIM) model and is discussed in detail. The RIM model presented in this review can both serve as a structure to be utilized in under-researched PPE areas and as a stimulus for future empirical investigations.

Reliability and Validity of the Minnesota Multiphasic Personality Inventory - 2 - Restructured Form (MMPI-2-RF) in Spine Surgery and Spinal Cord Stimulator Samples.

It is not uncommon for patients to report diminished outcomes as a result of spine surgery or a spinal cord stimulator implant. Presurgical psychological evaluations are increasingly used to identify patients at increased risk for such outcomes and use of personality assessment instruments in these evaluations provides incremental information beyond a clinical interview and medical chart review. This investigation explores the psychometric properties of the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) in a sample of spine surgery patients (n = 810) and in a sample of spinal cord stimulator patients (n = 533). Results indicated that MMPI-2-RF substantive scale scores are reliable, with evidence of good convergent and discriminant validity in both samples. Incorporating the MMPI-2-RF as part of the presurgical evaluation of spine surgery and spinal cord stimulator patients can provide meaningful insight into patients' functioning and help guide pre- and postsurgical treatment in these settings.

Flexible and Conditional Administration of the Minnesota Multiphasic Personality Inventory-2-Restructured Form in Presurgical Psychological Evaluations of Spine Surgery Candidates.

The purpose of this study was to evaluate a flexible and conditional administration (FCA) for the MMPI-2-RF in archival samples of spine surgery and spinal cord simulator candidates presenting for presurgical psychological evaluations. The sample included 1,477 spine surgery candidates (709 male, 276 female) and 476 spinal cord stimulator candidates (178 male, 298 female). Using a simulation design, the results of this study indicated that an FCA of the MMPI-2-RF closely approximates the amount of information gained from a standard MMPI-2-RF administration. In addition, time savings were substantial in both samples, particularly the spine surgery sample, as item savings varied from 40% to 80%, depending on the number of substantive domains flexibly administered. Overall, the results of the study lend support for the feasibility of the FCA approach in presurgical evaluations of spine surgery candidates, in particular for those situations where the length of the test would otherwise preclude its use.

Elucidating somatization in a dimensional model of psychopathology across medical settings.

Research using a categorical-polythetic classification system for mental illness has raised concern regarding the validity of categorical classification systems. Recent efforts suggest psychopathology is better understood from a dimensional framework, though there has been varying evidence of a somatization factor. The current investigation seeks to produce and validate a dimensional model of psychopathology, with a particular emphasis on the placement of somatization, across three nonoverlapping medical samples. Using a bariatric surgery seeking sample (n = 1,268), a spine surgery/spinal cord stimulator seeking sample (n = 1,711), and a chronic pain treatment seeking sample (n = 1,388), a dimensional model of psychopathology was replicated across all three samples using a dimensional measure of psychopathology (the Minnesota Multiphasic Personality Inventory-2-Restructured Form [MMPI-2-RF]). Clear evidence of a separate somatization factor was found in addition to broad internalizing, externalizing, and social detachment factors. Constructs assessable with the model yielded good convergent and discriminant validity coefficients with external criteria, and further supported the presence of a higher-order somatization construct. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Validation of a Psychological Screening Algorithm for Predicting Spine Surgery Outcomes.

It is well established that psychological factors can affect spine surgery results. A widely utilized presurgical psychological screening (PPS) algorithm that combines established psychosocial risk factors to determine patients' likelihood of achieving successful spine surgery results is evaluated in this study. Patients (n = 603) underwent a PPS, including a diagnostic interview, psychometric testing, and review of medical records. The evaluator completed a PPS algorithm for patients, placing them into one of five prognosis categories, ranging from excellent to poor. For analysis purposes, these categories were collapsed into three prognosis groups: Excellent, Good, and Fair to Very Poor. Patients classified as having an Excellent prognosis achieved the best outcomes following surgery, whereas those in the Fair to Very Poor category obtained the worst results. Analyses of specific components of the PPS algorithm demonstrated that algorithm items were modestly associated with reduced spine surgery results. Implications for presurgical assessments of spine surgery candidates are discussed.

Patient Activation Mediates the Association Between Psychosocial Risk Factors and Spine Surgery Results.

Although spine surgery (SS) and spinal cord stimulators (SCSs) can provide significant relief for patients with intractable pain, their effectiveness is variable. Previously, a number of pre-operative psychosocial risk factors have predicted suboptimal outcomes of these procedures. However, recent research has found that "patient activation"-the extent to which patients are engaged and active in their own health care-can predict positive surgical results. The purpose of the current investigation was to determine whether patient activation helps explain associations between established psychosocial risk factors and suboptimal outcomes. Candidates for SS and SCS (n = 1254; 56.3% women, mean age 50.4 years) consented to participate in an outcome study prior to their pre-surgical psychological evaluation. Of those, 46.3% returned self-report measures an average of 180 days (SD = 79.1) post-surgery. Bootstrapped mediation analyses indicated that patient activation mediates numerous associations between psychosocial risk factors and suboptimal outcomes. That is, patients' involvement in obtaining information, decision making, and their resilience can explain why some patients do not experience adverse surgical results when pre-surgical psychosocial risk factors are present. Pre-surgical psychological evaluations should include examination of patient strengths in addition to psychosocial risk factors, so that treatments can be appropriately individualized and the most effective surgical results obtained.

Associations Between Pre-Implant Psychosocial Factors and Spinal Cord Stimulation Outcome: Evaluation Using the MMPI-2-RF.

Spinal cord stimulation (SCS) has variable effectiveness in controlling chronic pain. Previous research has demonstrated that psychosocial factors are associated with diminished results of SCS. The objective of this investigation is to examine associations between pre-implant psychological functioning as measured by the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) and SCS outcomes. SCS candidates at two sites (total N = 319) completed the MMPI-2-RF and measures of pain, emotional distress, and functional ability as part of a pre-implant psychological evaluation. At an average of 5 months post-implant, patients completed the measures of pain and emotional distress a second time. Poorer SCS outcomes and poorer patient satisfaction were associated with higher pre-implant MMPI-2-RF scores on scales used to assess emotional dysfunction, somatic/cognitive complaints, and interpersonal problems. Ways through which pre-implant psychological evaluations of spinal cord stimulator candidates can be informed by MMPI-2-RF findings are discussed.

Demoralization, Patient Activation, and the Outcome of Spine Surgery.

It is now well established that psychosocial factors can adversely impact the outcome of spine surgery. This article discusses in detail one such recently-identified "risk" factor: demoralization. Several studies conducted by the author indicate that demoralization, an emotional construct distinct from depression, is associated with poorer pain reduction, less functional improvement and decreased satisfaction among spine surgery patients. However, there are indications that the adverse impact of risk factors such as demoralization can be mitigated by psychosocial "maximizing" factors-characteristics that propel the patient towards positive surgical results. One of these maximizing factors, patient activation, is discussed in depth. The patient activation measure (PAM), an inventory assessing the extent to which patients are active and engaged in their health care, is associated not only with improved spine surgery results, but with better outcomes across a broad range of medical conditions. Other maximizing factors are discussed in this article. The author concludes that the past research focus on psychosocial risk factors has limited the value of presurgical psychological screening, and that future research, as well as clinical assessment, should recognize that the importance of evaluating patients' strengths as well as their vulnerabilities.

The Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF): incremental validity in predicting early postoperative outcomes in spine surgery candidates.

A substantial proportion of individuals who undergo surgical procedures to relieve spine pain continue to report significant pain and dysfunction after recovery. Psychopathology and patient expectations have been linked to poor results, leading to an increasing reliance on presurgical psychological screening (PPS) as part of the surgical diagnostic process. The original Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1943) and the MMPI-2 (Butcher, Graham, Ben-Porath, Tellegen, & Dahlstrom, 2001) were among the measures most commonly used in PPS evaluations and research. This study focuses on the newest version of the test, the MMPI-2-Restructured Form (MMPI-2-RF; Ben-Porath & Tellegen, 2008/2011; Tellegen & Ben-Porath, 2008/2011) as a predictor of outcomes for spine surgery candidates. Using a sample of 172 men and 210 women who underwent a PPS, we examined the ability of MMPI-2-RF scale scores to predict early surgical outcomes independent of other presurgical risk factors identified by other means, as well as patients' presurgical expectations. MMPI-2-RF results accounted for up to 11% of additional variance in measures of early postoperative functioning. MMPI-2-RF scales that assess for emotional/internalizing problems, specifically Demoralization, measures of somatoform dysfunction, and interpersonal problems contributed most to the prediction of diminished outcome.

Psychological risk factors for poor outcome of spine surgery and spinal cord stimulator implant: a review of the literature and their assessment with the MMPI-2-RF.

Back pain is experienced by up to of 85% of the United States population. Most often it resolves with minimal to no medical treatment. For those whose pain endures, worsens, or becomes protracted, conservative care is typically first attempted. Individuals who continue to experience significant back pain are often considered for surgical procedures, the results of which are not uniformly positive. The consequences of failed surgical intervention can be quite devastating, and psychosocial factors have been found to predict poor outcome. The literature on psychosocial risk factors for failed back surgery is reviewed first, identifying psychological dysfunction in the domains of emotions, cognitions, behavior, and interpersonal processes as increasing the risk for failed back surgery. Empirical findings with the MMPI-2 Restructured Form (MMPI-2-RF) are presented next, including descriptive analyses with a sample of 1341 individuals assessed as part of a pre-surgical psychological screening. Correlations between MMPI-2-RF scale scores and measures of the primary risk factors identified in this review are reported for a smaller sample of 197 pre-surgical candidates. Interpretive implications of the MMPI-2-RF findings are discussed along with suggestions for further research in this area.

Behavioral treatment of chronic low back pain: clinical outcome and individual differences in pain relief.

The response of 111 chronic low back pain patients to a comprehensive behavioral treatment program emphasizing relaxation procedures is examined. Over the course of treatment, significant reductions were obtained on measures of subjective tension, EMG activity, and pain. Many patients also decreased their intake of analgesic/narcotic agents and reported an increase in activity level. In order to examine individual differences in pain relief, the 28 patients who had the greatest decreases in pain were compared to those who had the least decreases in pain. Patients who had the best outcome in terms of pain relief were significantly more likely to show improvements in other outcome measures. In addition, these patients rated their pain initially as more severe, had continuous pain for fewer years, and were less likely to be on disability or to have had multiple surgical procedures. These results are discussed in the light of recent data from other behavioral treatment studies with chronic low back pain patients and implications for behavioral assessment and treatment are discussed.

Behavioral treatment of chronic pain: the spouse as a discriminative cue for pain behavior.

Twenty married chronic pain patients (pain duration > 8 mo.) consecutively admitted to a pain management program were administered a taped structured interview designed to elucidate the responses of their spouses to pain behavior. Additionally, patients were required to report their pain levels in two different observational conditions: when observed by their spouse and when observed by a "neutral observer", the ward clerk. Those patients who reported that their spouses were relatively non-solicitous in responding to pain behavior reported significantly lower pain levels in the spouse-observing condition than in the neutral-observer condition. Patients who reported that their spouses were relatively solicitous in responding to pain behavior reported marginally higher levels of pain in the spouse-observing condition than in the neutral-observer condition.

Behavioral treatment of chronic pain: variables affecting treatment efficacy.

Behavioral approaches to pain management have been shown to be efficacious in many instances but many of the variables indicating or contraindicating such treatment remain unspecified. The data reported here demonstrated that while patients referred by both Disability and Medical Subspecialties showed improvement in pain report, affect, and feelings of control, those patients referred by Disability improved reliable less, remain hospitalized longer and were reliably less compliant. These data can be understood within an operant conditioning conceptualization of illness behavior.