41
Pain, 41 (1990) 41-46 Elsevier PAIN 01560
Effectiveness of an interdisciplinary pain management program for the treatment of chronic pelvic pain Linda D. Kames a Department
a, Andrea J. Rapkin b, Bruce D. Naliboff and Theresa Ferrer-Brechner a
a,c, Simin Afifi a
ofAnesthesiology, and
b Department of Obstetrics and Gynecology, Unioersity of California, Los Angeies, CA (U.S.A.), and ’ Se~u~ueda Veterans A~inistrat~on Medical Center, Se~u~~eda. CA (U.S.A.)
(Received 7 April 1989, revision received 31 October 1989, accepted 10 November 1989)
SummarY Chronic pelvic pain has rarely been discussed in the pain management literature, although it is extremely common in general gynecological practice and often refractory to traditional medical and surgical therapy. A chronic pelvic pain program was developed to offer an alternative treatment approach for women for whom standard gynecologicrd procedures were inappropriate or unsuccessful. Sixteen subjects completed the full 6-8 week interdisciplinary program, which included both somatic and behavioral therapies, Compared to a waiting list control the results showed a dramatic decrease in reported levels of pain following treatment. Anxiety and depression also decreased and psychosocial functioning improved, including return to work, increased social activities, and improved sexual activity. The outcome suggests that the interdisciplinary pain management approach is effective for the treatment of chronic pelvic pain. Key words: Chronic pelvic pain; Interdisciplinary pain management treatment
Introduction
Chronic pelvic pain (CPP), although one of the most common presenting complaints in general gynecological practice, has been slow to be recognized as appropriate for pain management treatment. The treatment of CPP remains controversial as it is often refractory to traditional modes of medical and surgical therapy 13,231. Yet, prolonged pain and non-productive treatments can lead to multiple surgeries, severe disability, or
Correspondence to: Linda D. Kames, Psy.D., 12304 Santa Monica Blvd., Suite 211, Los Angeles, CA 90025, U.S.A. Reprint requests to: Andrea J. Rapkin, M.D., Division of Women’s Health, Department of Obstetrics and Gynecology, UCLA Center for Health Sciences, 10833 Le Come Avenue, Los Angeles, CA ~24-17#, U.S.A. 0304-3959/90/%03.50
even loss of reproductive capacity [4,9,23]. The pain literature also reflects the lack of focus on this problem. A review of the journal Pizin over the last 10 years yields no articles devoted to the treatment of CPP. Chronic pelvic pain is a confusing entity in that the pain is often unrelated to the underlying gynecological pathology. Patients with severe pathology may report little pain, while others with mild to moderate tissue distortion may be experiencing severe pain [9,21]. Studies of laparoscopy performed for CPP, reveal that approximately l/3 of patients have endometriosis, l/3 have adhesions, and l/3 have no obvious pathology [14l&21,23]. The pain may be intermittent, such as with dysmenorrhea, or may be of the chronic continuous type. Traditional medical treatment for these problems includes hormonal m~pulation and non-
0 1990 Elsevier Science Publishers B.V, (Biomedical Division)
steroidal anti-inflammatories (NSAIDs). Conservative surgical approaches may include the removal of endometrial implants, performance of presacral neurectomy, and lysis of adhesions. Not surprisingly, these treatments have been effective for endometriosis and primary dysmenorrhea, but have been less successful with patients with adhesions or chronic pelvic pain without obvious pathology [3,23]. Hysterectomy is often performed as the last resort. Thirty percent of patients who present with CPP have already undergone total abdominal hysterectomy [3]. Thus, there are many patients for whom the traditional gynecological treatments are not appropriate (e.g.. allergies to NSAIDs, wish to retain childbearing capacity). or have failed. A few specific pain management modalities have begun to be applied to CPP. Acupuncture has been used to treat dysmenorrhea with good results [6,10]. Trigger point injections have been utilized with reported success with CPP patients [24]. However. there have been no accounts of multidisciplinary treatment. The UCLA Pain Management Center developed a chronic pelvic pain program to offer an alternative approach for women for whom standard gynecological procedures were inappropriate or unsuccessful. The CPP program was adapted from the experience of other interdisciplinary programs for chronic and complicated pain problems. such as low back pain, headache, and cancer pain (4,5,7,8]. It is based on a model of chronic pain as a complex and multifaceted psychophysiological phenomenon, requiring both somatic and psychological interventions. The philosophy and rationale for this program have been explained fully elsewhere [22]. The purpose of the present study is to assess the effectiveness of the CPP program. Outcome measures were chosen to reflect the multidimensional nature of pain and included ratings of pain, mood, and psychosocial functioning.
chronic pelvic pain. Of the initial subjects, 6 dropped before completing the program: 3 due to financial constraints, 2 due to time constraints. and 1 due to an uncontrolled drug problem. Patients ranged in age from 20 to 40 years (mean 29.9 years, S.D. 5.4). The mean duration of pain was 4.5 years (range l--18, S.D. 3.9). Forty-five percent were married, 23% were single, and 324, were divorced. Twenty-three percent of these patients were post-hysterectomy, and 59% showed tissue pathology on laparoscopy. They fell into 5 diagnostic categories (see Table I). Fourteen subjects were available at 6 month follow-up. One had been lost to an unrelated death, and another moved without leaving a forwarding address.
Methods
Dysmenorrhea Endometriosis Adhesions CPPWOP Vulvar
Subjects
Subjects were 22 women Pain Management Center
referred to the UCLA for the treatment of
Meusures
Patients completed several psychological measures prior to beginning treatment. These were: the Minnesota Multiphasic Personality Inventory (MMPI), the Chronic Illness Problem Inventory (CIPI, a measure of psychosocial problems) [12], the Beck Depression Inventory (BDI) [2], the State-Trait Anxiety Inventory (STAI) [25], the McGill Pain Questionnaire (MPQ) [19], and visual analog scales (VAS) [ll] for pain, bothersomeness. and activities interference. At post-treatment and 6 month follow-up, subjects again completed the CIPI, BDI, STAI. VAS pain and bothersomeness, MPQ, and a rating of improvement in social and sexual functioning (3-point scale: worse, same, better). For comparison purposes, a group of subjects (N = 8), 6 of whom also served as patients in the treatment study, completed the measures after a 2 month waiting list period, before any treatment had been conducted.
TABLE
I
DIAGNOSTIC
CATEGORIES
3 9 4 5 1
13 41 IX 23 5
43
Treatment program The program was conducted in 3 phases: evaluation, treatment, and follow-up. The extensive evaluation included psychological testing and the completion of pain questionnaires. A history and physical including a myofascial trigger point exam [26] were performed. A differential epidural block was performed to determine the neural elements involved in the pain experience (somatic vs. sympathetic vs. central). Diagnostic laparoscopy was performed prior to referral and these results were also utilized. Finally, a psychological evaluation, including interviews with and without significant others, was undertaken. The outpatient treatment program was based on a structured protocol and usually lasted 6-8 weeks. All patients received acupuncture 2 times/week, and psychological therapy once/ week. Tricyclic antidepressants were utilized in approximately 50% of cases. Other medications were tailored as necessary: narcotics were reduced until they were eliminated and NSAIDs were used in approximately l/3 of the patients. A small percentage of patients also received trigger point injections. Psychological therapy utilized a broad spectrum behavioral approach. Stress management, self-control procedures such as relaxation and hypnosis, anxiety and depression control, activity management, sex education, and cognitive therapy were offered to all patients. The treatment course was structured, but not uniform. Early sessions focused on the rationale of pain management, the teaching of relaxation skills, and the identification of stressors and triggers to pain. The middle phase of therapy emphasized goal setting and involvement in appropriate activities (e.g., working to quota, not tolerance), cognitive therapy techniques aimed at reducing thoughts that maintain negative feelings and exacerbate pain, and a discussion of the sexual concerns involved in chronic pelvic pain. Later sessions focused on individual issues based on both psychological status and the type of pain experienced. For example, for intermittent pain, such as dysmenorrhea, stress inoculation [18] was utilized, with menstrually related events as the stress producing agents. For chronic continuous pain, the focus was on general behavioral pain
management coping skills. In addition, marital and sex therapy, crisis intervention, and/or resolution of trauma were used with a small number of patients.
Results Table II contains the means and standard deviations for the outcome measures at pre-waiting list, pre-treatment, post-treatment, and 6 month follow-up. Significance tests for each measure were performed by testing the mean difference between the pre-treatment value and each of the other time points in a pairwise manner, using T tests. It was necessary to do pairwise tests as there were different numbers of subjects at each time frame. Since this involved 3 a priori tests per measure (prewaiting list to pre-treatment, pre-treatment to post-treatment, and pre-treatment to 6 month follow-up), a Bonferroni adjustment was performed on the type I error rejection rate (chosen error rejection rate of P < 0.05/3 = P < 0.0167) [13]. No significant changes in any of the evaluation measures were found over the waiting list period. In fact, although not significant, the mean values tended to increase from pre-waiting list to pretreatment. Following treatment, significant decreases were found on the STAI, BDI, MPQ-affective, VAS-usual, VAS-bothersomeness, CIPI-total, and activity interference measures. Only the MPQ-sensory and total score did not significantly change after treatment. The follow-up values for most of the measures remained at post-treatment levels and, with the exception of the STAI-state and MPQ-affective scales, were still significantly lower than at pre-treatment. Treatment effects were also assessed by examining the frequency of employment and self-reported improvement in pain, social activity and sexual activity. Using a VAS cutoff of 40% change as improvement, 67% of patients reported pain improvement at post-treatment and 65% at 6 month follow-up. The percentage of patients not working declined over the study period from 45% at pre-treatment to 38% at post-treatment to 29% at 6 month follow-up. Social and sexual activity also improved across the 6 month follow-up
44
TABLE
II
MEANS
( f SD.)
FOR OUTCOME
EVALUATION
Note: all significance hne.
tests are paired
Variable
N
Pre-waiting
State Anxiety
7 15 14
41.7 + 11.5
Trait Anxiety
7 15 14
40.0 i
Depression
8 15 13
9.3 k
MPQ-sensory
t tests vs. pre-treatment.
5.8
13.2 + 7.8
8 17 14
4.5 + 5.2
8 17 14
24.5 k 13.8
VASusual pain
7 1X 14
50.1 * 11.7
VAS-bothersameness
6 15 14
41.5 + 13.7
CIPI-total
8 16 13
1.4+
9 18 14
3.7 *
MPQ-total
Activity interference
list
x.3
X 17 14
MPQ-affect
MEASURES
1.0
0.5
* P < 0.0167 (type I error rejection level adjusted method, see Kirk [13], pp. 106-107).
Pre-treatment
means are those used in the pairwise
test on the same
Pre-treatment
Post-treatment
6 months
39.9 + 12.4 44.7 + 14.2 45.2 + 13.3
33.9 + 13.2 *
3X.7 *
44.1 + 1.6 46.3 & 10.7 47.1 + 10.5
37.X + 8.1 *
37.3 + 7.2 *
follow-up
9.5
13.3 f 9.7 12.5 i 11.x 13.2 + 12.24
5.7 t_ 9.5 *
3.2 i
5.4 *
18.3 + 6.9 15.8 k 7.6 16.4 i 7.X
9.9 +
5.9
9.7 *
7.0
8.3 F 4.5 5.0 5 5.2 5.1 + 5.0
1.4+
1.1 *
1.x*
1.4
33.8 i 13.6 25.4 i 15.3 26.0 i 15.1
15.3 k
52.4 I 10.3 54.0 i: 22.2 53.4 i 23.3
26.0 F 20.0 *
22.8 k 22.7 *
65.2 i 19.4 68.3 i 20.0 67.8 i 20.5
24.4 + 22.3 *
23.1 i 20.8 *
0.9 + 0.6 1.2 * 0.8 12.k 0.7
0.8 + 0.5 *
0.6 +_ 0.3 *
3.X + 3.7 f 3.6 +
2.7 f
2.3 f
for 3 planned
period. improved social activity was reported by 44% at post-treatment and 65% at 6 month followup. Improved sexual activity was reported by 27% at post-treatment and 79% at 6 month follow-up. Overall satisfaction with the program was very high. All but one of the patients rated themselves as improved and the treatment satisfactory or highly satisfactory at 6 month follow-up (92%). In fact. several patients without substantial changes
1.0 1.1 1.2 comparisons
8.1
1.0 *
per dependent
in VAS pain beneficial.
14.3 i 11.2
variable
levels rated
according
0.8 *
to the Bonferroni
the treatment
as highly
Discussion The results of this study suggest that the interdisciplinary pain management program may be an
45
effective treatment strategy for patients with chronic pelvic pain, with and without obvious pathology. The CPP program was successful in reducing pain intensity and pain bothersomeness, decreasing the anxiety and depression experienced with the pain, and in enabling patients to increase participation in daily psychosocial activities, such as return to work, increased social activities, and improved sexual activity. The affective experience of the pain, as measured by the MPQ, was greatly reduced. Nearly all subjects reported improvement and stated they were satisfied with their treatment, affirming that the emotionality surrounding the pain had been ameliorated. The comparison group showed no improvement over the baseline period, indicating the stability of the measures over time in a group without treatment. Although a better comparison would be a random allocation to two groups, treatment vs. no treatment, and although these numbers are small, the results are suggestive that the positive outcomes do indicate treatment effects. The data on improvement compare favorably to other types of pain management treatment [10,24]. While other studies report self-reported pain level, this study also assesses treatment outcome in several areas of functioning, such as mood and activities. One dramatic finding was in the area of improved sexual activity. Although 67% of patients stated that they were experiencing sexual problems at the pre-treatment assessment, 79% reported improved sexual activity at 6 month follow-up. A promising aspect of these data is the finding that improvement on most outcome measures maintains or continues to increase at 6 months post-treatment. Studies on response to surgery and other traditional medical therapies generally find positive effects to fade after a few weeks to a few months [9,23]. Several important questions need to be addressed. As with all multidisciplinary treatment programs, it is unclear whether one of the individual components is chiefly responsible for the pain improvement or if the interdisciplinary approach is necessary to effect change. Clinically, it appeared to us that when, because of outside circumstances, either the somatic or psychological treatments were begun first, no improvement was
obtained until all aspects of the treatment were in effect. However, it will be important to substantiate this clinical observation with controlled data. Another area that needs further investigation is the relationship among the various medical and psychological findings and the impact these relationships have on outcome. It is unknown whether there are differences in psychological status for those with and without physical findings. Furthermore, how psychological findings affect prognosis, whether there is a difference in response for those with pathology compared with those with no obvious pathology, and how various diagnostic groups react to treatment are all additional questions that must be answered. It might be expected that those with known disease may respond better than those with no medical findings, but it will be necessary to study large groups in each diagnostic category to fully address these issues. The small number of subjects in this study reflects the low rate of referrals of CPP to the UCLA Pain Management Center relative to other pain problems. We can only speculate as to the reasons that such a frequently seen problem in general practice presents so infrequently to a pain center. It may be that gynecologists have been reluctant to admit frustration and/or defeat with these patients. They may feel responsible to cure rather than manage these pain problems, attempting all medical and surgical possibilities. Or perhaps they are unaware of a realistic alternative. Thus, education for gynecologists on the nature of chronic pain may be another important task. In conclusion, there remain many issues to be explored and questions to be answered regarding the treatment of this difficult and complex pain problem. Hopefully, more pain centers and pain specialists will apply the interdisciplinary model of pain treatment to chronic pelvic pain. As more treatment becomes available, referrals should increase, enabling more controlled studies to be completed on the pain treatment of this population.
References 1 Adhesion Study Group NICHD, Reduction of postoperative pelvic adhesions with intraperitoneal 32% dextran 70:
2 3
4 5
6 7
X
9
IO
II
12
13
a prospective randomized clinical trial, Fertil. Steril.. 40 (1983) 612-619. Beck, A.T.. Depression Inventory, Center for Cognitive Therapy, Philadelphia, PA. 1978. Chamberlain. A. and LaFerla. J.. The gynecologist’s approach to chronic pelvic pain. In: G.D. Burrows, D. Elton and G.V. Stanley (Eds.), Handbook of Chronic Pain Management. Vol. 33, Elsevier. Amsterdam. 1987, pp. 37l 382. Ferrer-Brechner. T., The management of pain associated with malignancy. Sem. Anesthesiol., 4 (1985) 313. Fordyce. W.E. and Steger, J.C.. Chronic pain. In: O.F. Pomerow and J.B. Brody (Eds.), Behavioral Medicine: Theory and Practice, William and Wilkins, Baltimore, MD, 1979. pp. 1255153. Forman A.. Acupuncture for the treatment of dysmenorrhea, Am. J. Acupunct., 6 (1978) 1399141. Gottlieb. H.. Strife, L., Keller. R.. Madorsky. A.. Nockersmith, V., Kleeman. M. and Wagner, J., Comprehensive rehabilitation of patients having low back pain, Arch. Phys. Med. Rehab., 58 (1977) 101-108. Graff-Radford, S.B.. Jaeger, B., Reeves, J. and Singer, E.. Management of headache: effectiveness of a systematic musculoskeletal rehabilitation program, Pain, Suppl. 2 ( 1984) S89. Guzinski, G.M., Advances in the diagnosis and treatment of chronic pelvic pain, Adv. Psychosom. Med.. 12 (1985) 1244135. Helms, J.M., Acupuncture for the management of primary dysmenorrhea, Obstet. Gynecol., 69 (1987) 51-56. Huskisson. E.C., Visual analog scales. In: R. Melzack (Ed.), Pam Measurement and Assessment, Raven Press, New York, 1983. Kames, L.D., Naliboff, B.D.. Heimich, R.L. and Schag. C.C., The Chronic Illness Problem Inventory: problem-oriented psychological assessment of patients with chronic illness, Int. J. Psychiat. Med., 14 (1984) 65575. Kirk. R.E.. Experimental Design: Procedures for the Be-
14
15
16
17
havioral Sciences (2nd edn.), Brooks/Cole, Monterrey. CA. 1982. Kresch, A.J.. Seifer, D.B., Sachs, L.B. and Barrese, 1.. Laparoscopy in 100 women with chronic pelvic pain, Ohstet. Gynecol.. 64 (1984) 672-674. Lindberg, W.I., Wall, J.E. and Mathers, J.E., Laparoscopy in the evaluation of pelvic pain. Obstet. Gynecol.. 42 (19731 X72-876. Liston. W.A., Bradford. W.P. and Downie. J.. Laparoscopy in a general gynecologic unit, Am. J. Obstet. Gynecol.. 113 (1972) 672-677. Love. A.W. and Peck. C.L., The MMPI and psychological factors in chronic low back pain: a review. Pain. 28 (1987)
18 Meichenbaum, D., Cognitive Behavior Modification, Plenum Press, New York, 1977. 19 Melzack, R.. The McGill Pain Questionnaire: major properties and scoring methods, Pain, 1 (1975) 277-299. 20 Naliboff, B.D.. Cohen, M.J. and Yellen, A.N.. Does the MMPI differentiate chronic illness from chronic pain. Pain. 13 (1982) 333-341. 21 Rapkin, A.J., Adhesions and pelvic pain: a retrospective study, Obstet. Gynecol., 68 (1986) 13-15. 22 Rapkin, A.R. and Kames, L.D.. The pain management approach to chronic pelvic pain, J. Reprod. Med.. 32 (1987) 323 -327. 23 Renaer, M., Chronic Pelvic Pain in Women. Springer, Neu York. 1981. 24 Slocumb. J.C., Neurologrc factors in chrome pelvic pain: trigger points and the abdominal pelvic pain syndrome. Am. J. Obstet. Gynecol.. 149 (1984) 536-543. 25 Spielberger, C.D., Corsuch, R.L. and Lushene. R.E.. STAI Manual for the State-Trait Anxiety Inventory. Consulting Psychologists Press, Palo Alto, CA, 1970. 26 Travell, J. and Simons, D.G.. Myofascial Pain and Dysfunction, the Trigger Point Manual. Williams and Wilkins. Baltimore. MD. 1983.
Pain, 41 (1990) 41-46 Elsevier PAIN 01560
Effectiveness of an interdisciplinary pain management program for the treatment of chronic pelvic pain Linda D. Kames a Department
a, Andrea J. Rapkin b, Bruce D. Naliboff and Theresa Ferrer-Brechner a
a,c, Simin Afifi a
ofAnesthesiology, and
b Department of Obstetrics and Gynecology, Unioersity of California, Los Angeies, CA (U.S.A.), and ’ Se~u~ueda Veterans A~inistrat~on Medical Center, Se~u~~eda. CA (U.S.A.)
(Received 7 April 1989, revision received 31 October 1989, accepted 10 November 1989)
SummarY Chronic pelvic pain has rarely been discussed in the pain management literature, although it is extremely common in general gynecological practice and often refractory to traditional medical and surgical therapy. A chronic pelvic pain program was developed to offer an alternative treatment approach for women for whom standard gynecologicrd procedures were inappropriate or unsuccessful. Sixteen subjects completed the full 6-8 week interdisciplinary program, which included both somatic and behavioral therapies, Compared to a waiting list control the results showed a dramatic decrease in reported levels of pain following treatment. Anxiety and depression also decreased and psychosocial functioning improved, including return to work, increased social activities, and improved sexual activity. The outcome suggests that the interdisciplinary pain management approach is effective for the treatment of chronic pelvic pain. Key words: Chronic pelvic pain; Interdisciplinary pain management treatment
Introduction
Chronic pelvic pain (CPP), although one of the most common presenting complaints in general gynecological practice, has been slow to be recognized as appropriate for pain management treatment. The treatment of CPP remains controversial as it is often refractory to traditional modes of medical and surgical therapy 13,231. Yet, prolonged pain and non-productive treatments can lead to multiple surgeries, severe disability, or
Correspondence to: Linda D. Kames, Psy.D., 12304 Santa Monica Blvd., Suite 211, Los Angeles, CA 90025, U.S.A. Reprint requests to: Andrea J. Rapkin, M.D., Division of Women’s Health, Department of Obstetrics and Gynecology, UCLA Center for Health Sciences, 10833 Le Come Avenue, Los Angeles, CA ~24-17#, U.S.A. 0304-3959/90/%03.50
even loss of reproductive capacity [4,9,23]. The pain literature also reflects the lack of focus on this problem. A review of the journal Pizin over the last 10 years yields no articles devoted to the treatment of CPP. Chronic pelvic pain is a confusing entity in that the pain is often unrelated to the underlying gynecological pathology. Patients with severe pathology may report little pain, while others with mild to moderate tissue distortion may be experiencing severe pain [9,21]. Studies of laparoscopy performed for CPP, reveal that approximately l/3 of patients have endometriosis, l/3 have adhesions, and l/3 have no obvious pathology [14l&21,23]. The pain may be intermittent, such as with dysmenorrhea, or may be of the chronic continuous type. Traditional medical treatment for these problems includes hormonal m~pulation and non-
0 1990 Elsevier Science Publishers B.V, (Biomedical Division)
steroidal anti-inflammatories (NSAIDs). Conservative surgical approaches may include the removal of endometrial implants, performance of presacral neurectomy, and lysis of adhesions. Not surprisingly, these treatments have been effective for endometriosis and primary dysmenorrhea, but have been less successful with patients with adhesions or chronic pelvic pain without obvious pathology [3,23]. Hysterectomy is often performed as the last resort. Thirty percent of patients who present with CPP have already undergone total abdominal hysterectomy [3]. Thus, there are many patients for whom the traditional gynecological treatments are not appropriate (e.g.. allergies to NSAIDs, wish to retain childbearing capacity). or have failed. A few specific pain management modalities have begun to be applied to CPP. Acupuncture has been used to treat dysmenorrhea with good results [6,10]. Trigger point injections have been utilized with reported success with CPP patients [24]. However. there have been no accounts of multidisciplinary treatment. The UCLA Pain Management Center developed a chronic pelvic pain program to offer an alternative approach for women for whom standard gynecological procedures were inappropriate or unsuccessful. The CPP program was adapted from the experience of other interdisciplinary programs for chronic and complicated pain problems. such as low back pain, headache, and cancer pain (4,5,7,8]. It is based on a model of chronic pain as a complex and multifaceted psychophysiological phenomenon, requiring both somatic and psychological interventions. The philosophy and rationale for this program have been explained fully elsewhere [22]. The purpose of the present study is to assess the effectiveness of the CPP program. Outcome measures were chosen to reflect the multidimensional nature of pain and included ratings of pain, mood, and psychosocial functioning.
chronic pelvic pain. Of the initial subjects, 6 dropped before completing the program: 3 due to financial constraints, 2 due to time constraints. and 1 due to an uncontrolled drug problem. Patients ranged in age from 20 to 40 years (mean 29.9 years, S.D. 5.4). The mean duration of pain was 4.5 years (range l--18, S.D. 3.9). Forty-five percent were married, 23% were single, and 324, were divorced. Twenty-three percent of these patients were post-hysterectomy, and 59% showed tissue pathology on laparoscopy. They fell into 5 diagnostic categories (see Table I). Fourteen subjects were available at 6 month follow-up. One had been lost to an unrelated death, and another moved without leaving a forwarding address.
Methods
Dysmenorrhea Endometriosis Adhesions CPPWOP Vulvar
Subjects
Subjects were 22 women Pain Management Center
referred to the UCLA for the treatment of
Meusures
Patients completed several psychological measures prior to beginning treatment. These were: the Minnesota Multiphasic Personality Inventory (MMPI), the Chronic Illness Problem Inventory (CIPI, a measure of psychosocial problems) [12], the Beck Depression Inventory (BDI) [2], the State-Trait Anxiety Inventory (STAI) [25], the McGill Pain Questionnaire (MPQ) [19], and visual analog scales (VAS) [ll] for pain, bothersomeness. and activities interference. At post-treatment and 6 month follow-up, subjects again completed the CIPI, BDI, STAI. VAS pain and bothersomeness, MPQ, and a rating of improvement in social and sexual functioning (3-point scale: worse, same, better). For comparison purposes, a group of subjects (N = 8), 6 of whom also served as patients in the treatment study, completed the measures after a 2 month waiting list period, before any treatment had been conducted.
TABLE
I
DIAGNOSTIC
CATEGORIES
3 9 4 5 1
13 41 IX 23 5
43
Treatment program The program was conducted in 3 phases: evaluation, treatment, and follow-up. The extensive evaluation included psychological testing and the completion of pain questionnaires. A history and physical including a myofascial trigger point exam [26] were performed. A differential epidural block was performed to determine the neural elements involved in the pain experience (somatic vs. sympathetic vs. central). Diagnostic laparoscopy was performed prior to referral and these results were also utilized. Finally, a psychological evaluation, including interviews with and without significant others, was undertaken. The outpatient treatment program was based on a structured protocol and usually lasted 6-8 weeks. All patients received acupuncture 2 times/week, and psychological therapy once/ week. Tricyclic antidepressants were utilized in approximately 50% of cases. Other medications were tailored as necessary: narcotics were reduced until they were eliminated and NSAIDs were used in approximately l/3 of the patients. A small percentage of patients also received trigger point injections. Psychological therapy utilized a broad spectrum behavioral approach. Stress management, self-control procedures such as relaxation and hypnosis, anxiety and depression control, activity management, sex education, and cognitive therapy were offered to all patients. The treatment course was structured, but not uniform. Early sessions focused on the rationale of pain management, the teaching of relaxation skills, and the identification of stressors and triggers to pain. The middle phase of therapy emphasized goal setting and involvement in appropriate activities (e.g., working to quota, not tolerance), cognitive therapy techniques aimed at reducing thoughts that maintain negative feelings and exacerbate pain, and a discussion of the sexual concerns involved in chronic pelvic pain. Later sessions focused on individual issues based on both psychological status and the type of pain experienced. For example, for intermittent pain, such as dysmenorrhea, stress inoculation [18] was utilized, with menstrually related events as the stress producing agents. For chronic continuous pain, the focus was on general behavioral pain
management coping skills. In addition, marital and sex therapy, crisis intervention, and/or resolution of trauma were used with a small number of patients.
Results Table II contains the means and standard deviations for the outcome measures at pre-waiting list, pre-treatment, post-treatment, and 6 month follow-up. Significance tests for each measure were performed by testing the mean difference between the pre-treatment value and each of the other time points in a pairwise manner, using T tests. It was necessary to do pairwise tests as there were different numbers of subjects at each time frame. Since this involved 3 a priori tests per measure (prewaiting list to pre-treatment, pre-treatment to post-treatment, and pre-treatment to 6 month follow-up), a Bonferroni adjustment was performed on the type I error rejection rate (chosen error rejection rate of P < 0.05/3 = P < 0.0167) [13]. No significant changes in any of the evaluation measures were found over the waiting list period. In fact, although not significant, the mean values tended to increase from pre-waiting list to pretreatment. Following treatment, significant decreases were found on the STAI, BDI, MPQ-affective, VAS-usual, VAS-bothersomeness, CIPI-total, and activity interference measures. Only the MPQ-sensory and total score did not significantly change after treatment. The follow-up values for most of the measures remained at post-treatment levels and, with the exception of the STAI-state and MPQ-affective scales, were still significantly lower than at pre-treatment. Treatment effects were also assessed by examining the frequency of employment and self-reported improvement in pain, social activity and sexual activity. Using a VAS cutoff of 40% change as improvement, 67% of patients reported pain improvement at post-treatment and 65% at 6 month follow-up. The percentage of patients not working declined over the study period from 45% at pre-treatment to 38% at post-treatment to 29% at 6 month follow-up. Social and sexual activity also improved across the 6 month follow-up
44
TABLE
II
MEANS
( f SD.)
FOR OUTCOME
EVALUATION
Note: all significance hne.
tests are paired
Variable
N
Pre-waiting
State Anxiety
7 15 14
41.7 + 11.5
Trait Anxiety
7 15 14
40.0 i
Depression
8 15 13
9.3 k
MPQ-sensory
t tests vs. pre-treatment.
5.8
13.2 + 7.8
8 17 14
4.5 + 5.2
8 17 14
24.5 k 13.8
VASusual pain
7 1X 14
50.1 * 11.7
VAS-bothersameness
6 15 14
41.5 + 13.7
CIPI-total
8 16 13
1.4+
9 18 14
3.7 *
MPQ-total
Activity interference
list
x.3
X 17 14
MPQ-affect
MEASURES
1.0
0.5
* P < 0.0167 (type I error rejection level adjusted method, see Kirk [13], pp. 106-107).
Pre-treatment
means are those used in the pairwise
test on the same
Pre-treatment
Post-treatment
6 months
39.9 + 12.4 44.7 + 14.2 45.2 + 13.3
33.9 + 13.2 *
3X.7 *
44.1 + 1.6 46.3 & 10.7 47.1 + 10.5
37.X + 8.1 *
37.3 + 7.2 *
follow-up
9.5
13.3 f 9.7 12.5 i 11.x 13.2 + 12.24
5.7 t_ 9.5 *
3.2 i
5.4 *
18.3 + 6.9 15.8 k 7.6 16.4 i 7.X
9.9 +
5.9
9.7 *
7.0
8.3 F 4.5 5.0 5 5.2 5.1 + 5.0
1.4+
1.1 *
1.x*
1.4
33.8 i 13.6 25.4 i 15.3 26.0 i 15.1
15.3 k
52.4 I 10.3 54.0 i: 22.2 53.4 i 23.3
26.0 F 20.0 *
22.8 k 22.7 *
65.2 i 19.4 68.3 i 20.0 67.8 i 20.5
24.4 + 22.3 *
23.1 i 20.8 *
0.9 + 0.6 1.2 * 0.8 12.k 0.7
0.8 + 0.5 *
0.6 +_ 0.3 *
3.X + 3.7 f 3.6 +
2.7 f
2.3 f
for 3 planned
period. improved social activity was reported by 44% at post-treatment and 65% at 6 month followup. Improved sexual activity was reported by 27% at post-treatment and 79% at 6 month follow-up. Overall satisfaction with the program was very high. All but one of the patients rated themselves as improved and the treatment satisfactory or highly satisfactory at 6 month follow-up (92%). In fact. several patients without substantial changes
1.0 1.1 1.2 comparisons
8.1
1.0 *
per dependent
in VAS pain beneficial.
14.3 i 11.2
variable
levels rated
according
0.8 *
to the Bonferroni
the treatment
as highly
Discussion The results of this study suggest that the interdisciplinary pain management program may be an
45
effective treatment strategy for patients with chronic pelvic pain, with and without obvious pathology. The CPP program was successful in reducing pain intensity and pain bothersomeness, decreasing the anxiety and depression experienced with the pain, and in enabling patients to increase participation in daily psychosocial activities, such as return to work, increased social activities, and improved sexual activity. The affective experience of the pain, as measured by the MPQ, was greatly reduced. Nearly all subjects reported improvement and stated they were satisfied with their treatment, affirming that the emotionality surrounding the pain had been ameliorated. The comparison group showed no improvement over the baseline period, indicating the stability of the measures over time in a group without treatment. Although a better comparison would be a random allocation to two groups, treatment vs. no treatment, and although these numbers are small, the results are suggestive that the positive outcomes do indicate treatment effects. The data on improvement compare favorably to other types of pain management treatment [10,24]. While other studies report self-reported pain level, this study also assesses treatment outcome in several areas of functioning, such as mood and activities. One dramatic finding was in the area of improved sexual activity. Although 67% of patients stated that they were experiencing sexual problems at the pre-treatment assessment, 79% reported improved sexual activity at 6 month follow-up. A promising aspect of these data is the finding that improvement on most outcome measures maintains or continues to increase at 6 months post-treatment. Studies on response to surgery and other traditional medical therapies generally find positive effects to fade after a few weeks to a few months [9,23]. Several important questions need to be addressed. As with all multidisciplinary treatment programs, it is unclear whether one of the individual components is chiefly responsible for the pain improvement or if the interdisciplinary approach is necessary to effect change. Clinically, it appeared to us that when, because of outside circumstances, either the somatic or psychological treatments were begun first, no improvement was
obtained until all aspects of the treatment were in effect. However, it will be important to substantiate this clinical observation with controlled data. Another area that needs further investigation is the relationship among the various medical and psychological findings and the impact these relationships have on outcome. It is unknown whether there are differences in psychological status for those with and without physical findings. Furthermore, how psychological findings affect prognosis, whether there is a difference in response for those with pathology compared with those with no obvious pathology, and how various diagnostic groups react to treatment are all additional questions that must be answered. It might be expected that those with known disease may respond better than those with no medical findings, but it will be necessary to study large groups in each diagnostic category to fully address these issues. The small number of subjects in this study reflects the low rate of referrals of CPP to the UCLA Pain Management Center relative to other pain problems. We can only speculate as to the reasons that such a frequently seen problem in general practice presents so infrequently to a pain center. It may be that gynecologists have been reluctant to admit frustration and/or defeat with these patients. They may feel responsible to cure rather than manage these pain problems, attempting all medical and surgical possibilities. Or perhaps they are unaware of a realistic alternative. Thus, education for gynecologists on the nature of chronic pain may be another important task. In conclusion, there remain many issues to be explored and questions to be answered regarding the treatment of this difficult and complex pain problem. Hopefully, more pain centers and pain specialists will apply the interdisciplinary model of pain treatment to chronic pelvic pain. As more treatment becomes available, referrals should increase, enabling more controlled studies to be completed on the pain treatment of this population.
References 1 Adhesion Study Group NICHD, Reduction of postoperative pelvic adhesions with intraperitoneal 32% dextran 70:
2 3
4 5
6 7
X
9
IO
II
12
13
a prospective randomized clinical trial, Fertil. Steril.. 40 (1983) 612-619. Beck, A.T.. Depression Inventory, Center for Cognitive Therapy, Philadelphia, PA. 1978. Chamberlain. A. and LaFerla. J.. The gynecologist’s approach to chronic pelvic pain. In: G.D. Burrows, D. Elton and G.V. Stanley (Eds.), Handbook of Chronic Pain Management. Vol. 33, Elsevier. Amsterdam. 1987, pp. 37l 382. Ferrer-Brechner. T., The management of pain associated with malignancy. Sem. Anesthesiol., 4 (1985) 313. Fordyce. W.E. and Steger, J.C.. Chronic pain. In: O.F. Pomerow and J.B. Brody (Eds.), Behavioral Medicine: Theory and Practice, William and Wilkins, Baltimore, MD, 1979. pp. 1255153. Forman A.. Acupuncture for the treatment of dysmenorrhea, Am. J. Acupunct., 6 (1978) 1399141. Gottlieb. H.. Strife, L., Keller. R.. Madorsky. A.. Nockersmith, V., Kleeman. M. and Wagner, J., Comprehensive rehabilitation of patients having low back pain, Arch. Phys. Med. Rehab., 58 (1977) 101-108. Graff-Radford, S.B.. Jaeger, B., Reeves, J. and Singer, E.. Management of headache: effectiveness of a systematic musculoskeletal rehabilitation program, Pain, Suppl. 2 ( 1984) S89. Guzinski, G.M., Advances in the diagnosis and treatment of chronic pelvic pain, Adv. Psychosom. Med.. 12 (1985) 1244135. Helms, J.M., Acupuncture for the management of primary dysmenorrhea, Obstet. Gynecol., 69 (1987) 51-56. Huskisson. E.C., Visual analog scales. In: R. Melzack (Ed.), Pam Measurement and Assessment, Raven Press, New York, 1983. Kames, L.D., Naliboff, B.D.. Heimich, R.L. and Schag. C.C., The Chronic Illness Problem Inventory: problem-oriented psychological assessment of patients with chronic illness, Int. J. Psychiat. Med., 14 (1984) 65575. Kirk. R.E.. Experimental Design: Procedures for the Be-
14
15
16
17
havioral Sciences (2nd edn.), Brooks/Cole, Monterrey. CA. 1982. Kresch, A.J.. Seifer, D.B., Sachs, L.B. and Barrese, 1.. Laparoscopy in 100 women with chronic pelvic pain, Ohstet. Gynecol.. 64 (1984) 672-674. Lindberg, W.I., Wall, J.E. and Mathers, J.E., Laparoscopy in the evaluation of pelvic pain. Obstet. Gynecol.. 42 (19731 X72-876. Liston. W.A., Bradford. W.P. and Downie. J.. Laparoscopy in a general gynecologic unit, Am. J. Obstet. Gynecol.. 113 (1972) 672-677. Love. A.W. and Peck. C.L., The MMPI and psychological factors in chronic low back pain: a review. Pain. 28 (1987)
18 Meichenbaum, D., Cognitive Behavior Modification, Plenum Press, New York, 1977. 19 Melzack, R.. The McGill Pain Questionnaire: major properties and scoring methods, Pain, 1 (1975) 277-299. 20 Naliboff, B.D.. Cohen, M.J. and Yellen, A.N.. Does the MMPI differentiate chronic illness from chronic pain. Pain. 13 (1982) 333-341. 21 Rapkin, A.J., Adhesions and pelvic pain: a retrospective study, Obstet. Gynecol., 68 (1986) 13-15. 22 Rapkin, A.R. and Kames, L.D.. The pain management approach to chronic pelvic pain, J. Reprod. Med.. 32 (1987) 323 -327. 23 Renaer, M., Chronic Pelvic Pain in Women. Springer, Neu York. 1981. 24 Slocumb. J.C., Neurologrc factors in chrome pelvic pain: trigger points and the abdominal pelvic pain syndrome. Am. J. Obstet. Gynecol.. 149 (1984) 536-543. 25 Spielberger, C.D., Corsuch, R.L. and Lushene. R.E.. STAI Manual for the State-Trait Anxiety Inventory. Consulting Psychologists Press, Palo Alto, CA, 1970. 26 Travell, J. and Simons, D.G.. Myofascial Pain and Dysfunction, the Trigger Point Manual. Williams and Wilkins. Baltimore. MD. 1983.
