Original Article Biobehavioral Pain Profile in Individuals with Chronic Spine Pain ---
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From the School of Nursing, State University of New York, University at Buffalo, Buffalo, New York. Address correspondence to Yu-Ping Chang, PhD, RN, Assistant Professor, School of Nursing, University at Buffalo, 3435 Main Street, Wende Hall Rm 201E, Buffalo, NY 14214. E-mail: [email protected] Received August 20, 2011; Revised June 25, 2012; Accepted June 26, 2012. 1524-9042/$36.00 Ó 2014 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2012.06.009
Deborah Matteliano, PhD, ANP, FNP, BC, Yvonne Krall Scherer, EdD, CNS, and Yu-Ping Chang, PhD, RN
ABSTRACT:
Pain in the spine is the most frequently described pain problem in primary care, afflicting at least 54 million Americans. When spinal pain becomes chronic, the prognosis for recovery is poor, often leading to disability and reduced quality of life. Clinical treatment is inadequate, often focusing on physical pathology alone. To improve treatment outcomes for chronic pain as recommended by current guidelines, the Biobehavioral Pain Profile (BPP), which includes six pain response subscales, was developed to guide cognitive behavioral therapy (CBT). The purpose of this study was to describe the BPP in 100 individuals with chronic spine pain and examine the associations between the BPP and important clinical outcomes, including chronic pain, disability, and quality of life. Participants reported a high level of pain, a low quality of life, and a high level of disability despite receiving treatment with opioids. Scores on BPP subscales including evaluating loss of control, past and current experience, physiologic responsivity, and thoughts of disease progression were elevated, indicating a need for CBT. Five of the six BPP subscales had a significant association with quality of life, chronic pain, and disability with the thought of disease progression being a strong factor for most of the clinical outcome variables. By identifying BPP, clinicians can provide appropriate treatments to improve individuals’ quality of life and prevent further disability. Further study using the BPP to guide CBT is needed. Ó 2014 by the American Society for Pain Management Nursing Pain in the spine is the most frequently described pain problem in primary care, afflicting at least 54 million Americans (Deyo, Mirza, & Martin, 2006; Long, 2006). It is estimated that 80% of adults experience back pain during their lives. Those who do not improve go on to develop chronic spine pain (CSP). For individuals with CSP who continue to suffer after 1 year, the prognosis for recovery is poor (Wright & Gatchel, 2002). According to Luo, Pietrobon, Sun, Liu, and Hey (2004), the total annual health care cost of this disorder was 91 billion US dollars in 1998. Long-term negative consequesces of the CSP include persistently high levels of pain intensity, increased disability, and reduced physical and mental quality of Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 97-106
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life measures (Martin, Deyo, Mirza, Turner, Comstock, Hollingworth, & Sullivan, 2008; Turk & Monarch, 2002). Many patients with CSP experience difficulty in adapting to their condition (Klapow, Slater, Patterson, Atkinson, Weickgenant, Grant, & Garfin, 1995; Robinson & Vetter, 2010). Family relationships erode when roles change, and individuals may beome socially isolated owing to high levels of pain and lack of capacity to do what they used to in their usual roles. Negative pain responses such as these have more of an impact on the evolution of disability and poor quality of life than any physical pathology for those suffering with CSP (Fanciullo, Hanscom, Weinstein, Chawarski, Jamison, & Baird, 2003; Koleck, Mazaux, Rascle, & Bruchon-Schweitzer, 2006; Linton, 2000). The problem of CSP continues to grow, because clinical treatment addressing physical pathology alone is inadequate (Hush, 2008; Pruit & von Korff, 2002). Currently, clinical assessment involves an acute care approach focusing on structural abnormalities with physical exam findings, imaging studies, and the patient’s perception of levels of pain intensity (Nicholas & George, 2011). These factors are used as clinical indicators leading to treatment strategies such as rest, surgery, and pain medication. However, rest has been found to be an inappropriate treatment modality for CSP, surgery outcomes are poor, and emphasis on prescribing more pain medications has been implicated in worsening the disability and reducing role function (BenDebba, Torgerson, Boyd, Dawson, Hardy, Robertson, . Long, 2002; Martin et al., 2008; Pruit & von Korff, 2002). Koes, Van Tulder, and Ostelo (2001) published an evidence-based summary examining the international guidelines for management of spine pain. Unanimously, the guidelines from 12 different countries promoted measurement of psychosocial factors to determine the risk associated with diminished quality of life and subsequent chronic disability. However, the guidelines lacked any descripton of how these factors should be measured and what should be done when providing treatment using psychosocial factors (Koes et al., 2001). In addition, catastrophizing and preoccupation with fear of disease progression were noted risks for poor outcomes in individuals with CSP (Dennison, Aselof, Sandborgh, & Lindberg, 2007). To address the growing problem of poor outcomes, clinical assessment of the pain responses associated with poor outcomes is necessary so that more effective treatment can be provided to prevent chronic impairment (Feuerstein, Hartzell, Rogers, & Marcus, 2006; Nicholas, & George, 2011). These pain responses are described using a biobehavioral approach that considers the interactive role of various biological,
environmental, cultural, and psychosocial aspects (Moore, 2010). A profile of biobehavioral pain responses for clinical appreciation was developed previously as a potential avenue for assessing persons with chronic pain (Fuerstein & Beattie, 1995). Biobehavioral pain responses encompass the range of psychologic and physiologic attributes associated with individual responses to nociception (Dalton, Keefe, Carlson, & Youngblood, 2004). Linking assessment measurements to treatment, Dalton and Keefe (2004) observed that matching a person’s pain responses to specific treatments had the potential to improve outcomes. Biobehavioral pain responses provide a set of clinical indicators that clinicians would find easy to follow and use.
BIOBEHAVIORAL PAIN PROFILE In support of current guidelines to improve treatment outcomes in the management of chronic pain, the Biobehavioral Pain Profile (BPP) instrument was developed (Dalton, Fuerstein, Carlson, & Roghmann, 1994). The BPP is composed of six distinct subscales, each of which summarizes chronic pain responses (Dalton et al., 1994). Each subscale has its own utility for categorizing pain responses to match the appropriate treatment (Dalton et al., 2004). The BPP was tested with a group of persons with chronic pain conditions, including CSP (Dalton et al., 1994). The BPP was also used to tailor treatment for a group of individuals with chronic cancer pain (Dalton et al., 2004). The result was a significant improvement in pain, function, and quality of life. However, the BPP has not only been tested on persons with CSP. Because the identification of the BPP could be useful for guiding treatment to improve clinical outcomes, it is important to understand pain response patterns with the use of the BPP with these individuals. The purposes of this study were: 1) to describe BPP in individuals with CSP; and 2) to examine the associations between BPP and important clinical outcomes, including chronic pain, disability, and quality of life.
METHODS Design and Participants This study used a cross-sectional design. Convenience sampling was used to recruit participants from a private pain clinic in an urban area of Western New York. Participants in this study were $18 years old with an established diagnosis of CSP and English speaking. Exclusion criteria included the following: pain lasting
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From the School of Nursing, State University of New York, University at Buffalo, Buffalo, New York. Address correspondence to Yu-Ping Chang, PhD, RN, Assistant Professor, School of Nursing, University at Buffalo, 3435 Main Street, Wende Hall Rm 201E, Buffalo, NY 14214. E-mail: [email protected] Received August 20, 2011; Revised June 25, 2012; Accepted June 26, 2012. 1524-9042/$36.00 Ó 2014 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2012.06.009
Deborah Matteliano, PhD, ANP, FNP, BC, Yvonne Krall Scherer, EdD, CNS, and Yu-Ping Chang, PhD, RN
ABSTRACT:
Pain in the spine is the most frequently described pain problem in primary care, afflicting at least 54 million Americans. When spinal pain becomes chronic, the prognosis for recovery is poor, often leading to disability and reduced quality of life. Clinical treatment is inadequate, often focusing on physical pathology alone. To improve treatment outcomes for chronic pain as recommended by current guidelines, the Biobehavioral Pain Profile (BPP), which includes six pain response subscales, was developed to guide cognitive behavioral therapy (CBT). The purpose of this study was to describe the BPP in 100 individuals with chronic spine pain and examine the associations between the BPP and important clinical outcomes, including chronic pain, disability, and quality of life. Participants reported a high level of pain, a low quality of life, and a high level of disability despite receiving treatment with opioids. Scores on BPP subscales including evaluating loss of control, past and current experience, physiologic responsivity, and thoughts of disease progression were elevated, indicating a need for CBT. Five of the six BPP subscales had a significant association with quality of life, chronic pain, and disability with the thought of disease progression being a strong factor for most of the clinical outcome variables. By identifying BPP, clinicians can provide appropriate treatments to improve individuals’ quality of life and prevent further disability. Further study using the BPP to guide CBT is needed. Ó 2014 by the American Society for Pain Management Nursing Pain in the spine is the most frequently described pain problem in primary care, afflicting at least 54 million Americans (Deyo, Mirza, & Martin, 2006; Long, 2006). It is estimated that 80% of adults experience back pain during their lives. Those who do not improve go on to develop chronic spine pain (CSP). For individuals with CSP who continue to suffer after 1 year, the prognosis for recovery is poor (Wright & Gatchel, 2002). According to Luo, Pietrobon, Sun, Liu, and Hey (2004), the total annual health care cost of this disorder was 91 billion US dollars in 1998. Long-term negative consequesces of the CSP include persistently high levels of pain intensity, increased disability, and reduced physical and mental quality of Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 97-106
98
Matteliano, Scherer, and Chang
life measures (Martin, Deyo, Mirza, Turner, Comstock, Hollingworth, & Sullivan, 2008; Turk & Monarch, 2002). Many patients with CSP experience difficulty in adapting to their condition (Klapow, Slater, Patterson, Atkinson, Weickgenant, Grant, & Garfin, 1995; Robinson & Vetter, 2010). Family relationships erode when roles change, and individuals may beome socially isolated owing to high levels of pain and lack of capacity to do what they used to in their usual roles. Negative pain responses such as these have more of an impact on the evolution of disability and poor quality of life than any physical pathology for those suffering with CSP (Fanciullo, Hanscom, Weinstein, Chawarski, Jamison, & Baird, 2003; Koleck, Mazaux, Rascle, & Bruchon-Schweitzer, 2006; Linton, 2000). The problem of CSP continues to grow, because clinical treatment addressing physical pathology alone is inadequate (Hush, 2008; Pruit & von Korff, 2002). Currently, clinical assessment involves an acute care approach focusing on structural abnormalities with physical exam findings, imaging studies, and the patient’s perception of levels of pain intensity (Nicholas & George, 2011). These factors are used as clinical indicators leading to treatment strategies such as rest, surgery, and pain medication. However, rest has been found to be an inappropriate treatment modality for CSP, surgery outcomes are poor, and emphasis on prescribing more pain medications has been implicated in worsening the disability and reducing role function (BenDebba, Torgerson, Boyd, Dawson, Hardy, Robertson, . Long, 2002; Martin et al., 2008; Pruit & von Korff, 2002). Koes, Van Tulder, and Ostelo (2001) published an evidence-based summary examining the international guidelines for management of spine pain. Unanimously, the guidelines from 12 different countries promoted measurement of psychosocial factors to determine the risk associated with diminished quality of life and subsequent chronic disability. However, the guidelines lacked any descripton of how these factors should be measured and what should be done when providing treatment using psychosocial factors (Koes et al., 2001). In addition, catastrophizing and preoccupation with fear of disease progression were noted risks for poor outcomes in individuals with CSP (Dennison, Aselof, Sandborgh, & Lindberg, 2007). To address the growing problem of poor outcomes, clinical assessment of the pain responses associated with poor outcomes is necessary so that more effective treatment can be provided to prevent chronic impairment (Feuerstein, Hartzell, Rogers, & Marcus, 2006; Nicholas, & George, 2011). These pain responses are described using a biobehavioral approach that considers the interactive role of various biological,
environmental, cultural, and psychosocial aspects (Moore, 2010). A profile of biobehavioral pain responses for clinical appreciation was developed previously as a potential avenue for assessing persons with chronic pain (Fuerstein & Beattie, 1995). Biobehavioral pain responses encompass the range of psychologic and physiologic attributes associated with individual responses to nociception (Dalton, Keefe, Carlson, & Youngblood, 2004). Linking assessment measurements to treatment, Dalton and Keefe (2004) observed that matching a person’s pain responses to specific treatments had the potential to improve outcomes. Biobehavioral pain responses provide a set of clinical indicators that clinicians would find easy to follow and use.
BIOBEHAVIORAL PAIN PROFILE In support of current guidelines to improve treatment outcomes in the management of chronic pain, the Biobehavioral Pain Profile (BPP) instrument was developed (Dalton, Fuerstein, Carlson, & Roghmann, 1994). The BPP is composed of six distinct subscales, each of which summarizes chronic pain responses (Dalton et al., 1994). Each subscale has its own utility for categorizing pain responses to match the appropriate treatment (Dalton et al., 2004). The BPP was tested with a group of persons with chronic pain conditions, including CSP (Dalton et al., 1994). The BPP was also used to tailor treatment for a group of individuals with chronic cancer pain (Dalton et al., 2004). The result was a significant improvement in pain, function, and quality of life. However, the BPP has not only been tested on persons with CSP. Because the identification of the BPP could be useful for guiding treatment to improve clinical outcomes, it is important to understand pain response patterns with the use of the BPP with these individuals. The purposes of this study were: 1) to describe BPP in individuals with CSP; and 2) to examine the associations between BPP and important clinical outcomes, including chronic pain, disability, and quality of life.
METHODS Design and Participants This study used a cross-sectional design. Convenience sampling was used to recruit participants from a private pain clinic in an urban area of Western New York. Participants in this study were $18 years old with an established diagnosis of CSP and English speaking. Exclusion criteria included the following: pain lasting
