The impact of pain on health-related quality of life 3 months after stroke Wai-Kwong Tang1, Chieh Grace Lau1, Vincent Mok2, Gabor S. Ungvari3,4, Ka-Sing Wong2 1
Department of Psychiatry, Chinese University of Hong Kong, China, 2Department of Medicine and Therapeutics, Chinese University of Hong Kong, China, 3School of Psychiatry & Clinical Neurosciences, University of Western Australia, Perth, Australia, 4University of Notre Dame Australia/Marian Centre, Perth, Australia Background: Pain is common in stroke; however, its impacts on health-related quality of life (HRQoL) are unclear due to the limitations of previous studies. Objectives: The current study aims to examine and compare the demographic and clinical characteristics of Chinese stroke patients with and without pain and explore the correlations between poststroke pain and HRQoL. Method: Four hundreds and forty-one participants recruited in an acute stroke unit in a regional hospital. They were assessed 3 months after the index stroke with the following instruments. HRQoL was measured using the Short Form-12 (SF-12). The Chinese version of the Faces Pain Rating Scale-Revised (FPS-R) was used to determine the presence and intensity of pain. The demographic and clinical characteristics of patients were obtained using Barthel Index (BI), Fatigue Severity Scale (FSS), Geriatric Depression Scale (GDS), Anxiety subscale of the Hospital Anxiety and Depression Scale (HADSA), Instrumental Activities of Daily Living (IADL), Mini Mental State Examination (MMSE), Modified Rankin Scale (MRS), and National Institutes of Health Stroke Scale (NIHSS). Results: Of all participants screened, 167 reported pain and 69 had novel pain. The pain group had significantly lower physical component summary (PCS) scores after adjusting for sex, education, DSM-IV depression and BI, GDS, HADSA, and FSS scores. The FPS score was negatively correlated with a lower PCS score in patients with pain and with novel pain. Conclusion: The presence and intensity of pain have significant negative effects on HRQoL in stroke survivors. Interventions for pain could make a valuable contribution to improving HRQoL in stroke survivors.
Keywords: Pain, Stroke, Health-related quality of life
Introduction 1–4
Pain is common in various medical conditions. For instance, the prevalence of pain in diabetes and multiple sclerosis is 57.8%1 and 66%,4 respectively. Pain is an important variable in stroke, spinal cord injury and multiple sclerosis. It is associated with depression,5,6 physical dysfunction,4,7,8 emotional functioning,4,9 sleep disturbance,9,10 and social functioning.9,10 The prevalence of poststroke pain (PSP) is between 33.3 and 49%.2,3,11 Two major types of pain after stroke are distinguished, local and central pain.12,13 The former is the pain felt in the joints, usually in the shoulders,12 while the latter felt on the skin on the side affected by stroke.13 Local pain is caused by the actual damage to
Correspondence to: W. K. Tang, Department of Psychiatry, Shatin Hospital, Shatin, N.T., Hong Kong SAR, China. Email: [email protected]
194
ß W. S. Maney & Son Ltd 2015 DOI 10.1179/1074935714Z.0000000024
body tissue13 or the malposition of a joint.12 Central pain is a type of neuropathic pain which is produced within the central nervous system. Central pain may be intensified by touch, movement, or other forms of stimuli due to the incorrect interpretation of the signals sent to the CMS.12,13 Novel pain, the pain that develops after index stroke, was found in 39% of stroke survivors.6 The characteristics associated with PSP include female sex,2,4 higher education level,2 fatigue,3,14 and anxiety symptoms.15 Surprisingly, depressive symptoms and daily functioning may not be correlated with PSP.16 PSP is associated with deterioration of cognitive and motor abilities6 and increased mortality.14 The impact of PSP on health-related quality of life (HRQoL) has received scant attention. Although one study17 identified pain as a predictive factor for HRQoL in stroke patients, another14 failed to replicate Topics in Stroke Rehabilitation
2015
VOL .
22
NO .
3
Tang et al.
this finding. The contradictory results may be explained by the different study designs. Naess et al.17 evaluated common medical complaints and symptoms in 328 stroke survivors 1 year after the index stroke using a postal questionnaire. Pain was a common symptom and was significantly correlated with HRQoL. However, poor reliability of postal questionnaires limits the generalizability of these findings. A second study,18 which examined HRQoL in 43 stroke patients with long-term pain was limited by its small sample size and lack of a control group. The aim of the current study was to examine the associations between PSP and demographic and clinical characteristics, and the effect of PSP on HRQoL in a large sample of stroke survivors 3 months following their index stroke.
Methods A sample of 441 consecutively admitted stroke patients was recruited from the Acute Stroke Unit of the Prince of Wales Hospital (PWH) between January 2009 and September 2011. PWH is a university-affiliated regional hospital serving a population of 800 000 in the Shatin district of Hong Kong. The diagnosis of stroke was made by qualified neurologists, based on clinical presentation and CT or MRI scan of the brain. PWH is a universityaffiliated regional hospital serving a population of 800 000 in the Shatin district of Hong Kong. The inclusion criteria for the study were: (1) Chinese ethnicity; (2) Cantonese as the primary language; (3) aged 18 years or above; and (4) well-documented stroke occurring within 7 days before admission to the study. The exclusion criteria were: (1) history of a central nervous system disease such as tumor, trauma, hydrocephalus, or Parkinson’s disease; (2) significant aphasia or dysarthria (National Institutes of Health Stroke Scale (NIHSS) best language score i2 or dysarthria score i2)19 to the extent of precluding meaningful communication; (3) physical frailty that prevented attending the interview; (4) cognitive impairment, defined as a Mini-Mental State Examination (MMSE)20 score less than 20; and (5) severe co-morbid disease (e.g. malignant tumor, decompensated heart failure, or chronic respiratory failure) that could affect follow-up assessment. The study protocol was approved by the Clinical Research Ethics Committee of the Chinese University of Hong Kong. All of the participants signed a consent form. All assessments were conducted within 3 months after the index stroke. Patients’ demographic and clinical characteristics were collected by a trained research assistant. The severity of stroke was assessed with the
PSP and HRQoL 3 months after stroke
Modified Rankin Scale (MRS)21 and the NIHSS.19 The clinical diagnosis of depression was made by a psychiatrist (Wai-Kwong Tang) using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).22 The Short Form-12 (SF-12) Health Survey was used to measure patients’ HRQoL. The scale has been validated in stroke23 and in Chinese patient populations.24 The SF-12 comprises physical component summary (PCS) and mental component summary (MCS) scales. There are 12 items constituting eight subscales: physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. The weighted item scores for each item contribute to the two component scores.25 Each component score ranges from 0 to 100, with higher scores indicating better health. Pain was evaluated by the Chinese version of the Faces Pain Rating Scale-Revised (FPS-R). The FPS-R is a self-report measure that was originally used to assess the intensity of pain in children.26 The FPS-R has been used to measure pain in Chinese older adults27–29 and stroke patients.30,31 The FPS-R consists of two questions and six line-drawn faces with expressions ranging from a neutral face to a grimacing face. Patients are instructed to point to the face that best represents the intensity of their most painful site. Scores of 0, 2, 4, 6, 8, and 10 are assigned to each face consecutively, with higher numbers representing more pain. Differentiation of central from peripheral pain was not performed in this study. The presence of novel pain was distinguished from pain with the question in FPS-R ‘‘Did the pain exist before the latest stroke?’’ The Fatigue Severity Scale (FSS) had been used to evaluate fatigue in stroke.32–35 It contains nine items (e.g. ‘‘My motivation is lower when I am fatigued’’, ‘‘Exercise brings on my fatigue,’’ and ‘‘I am easily fatigued’’) rated on a seven-point Likert scale, with higher scores indicating more severe fatigue. Item scores are averaged to produce a global fatigue score. The Lubben Social Network Scale (LSNS) is a composite scale designed for use in the elderly.36 It measures the level of social support patients receive and their social interactions with relatives and friends. The LSNS has been translated into Chinese and validated in the Hong Kong elderly.37 The total score of LSNS ranges from 0–50, with higher scores indicating greater social support. The Barthel Index (BI)38 and the Instrumental Activities of Daily Living (IADL)39 scale were used to assess the extent of patients’ disability in performing daily functions. The BI covers ten items: personal hygiene, bathing, feeding, toileting, stair climbing, dressing, bowel control, bladder control, ambulation or Topics in Stroke Rehabilitation
2015
VOL .
22
NO .
3
195
Tang et al.
PSP and HRQoL 3 months after stroke
wheelchair use, and chair-bed transfer. Total scores range from 0 to 20, with higher scores indicating more independent self-care. The IADL assesses the level of independence in community living such as shopping, cooking and managing finances. It contains eight items and its summary score ranges from 0 to 8, with lower scores indicating higher functional level. The IADL has excellent inter-rater reliability (0.85).39 The Cantonese version of the MMSE20 was used to evaluate patients’ global cognitive functions. Its score ranges from 0–30, with higher scores indicating less cognitive impairment. The Cronbach’s alpha and test– retest reliability of the Chinese version of the MMSE were reported as 0.86 and 0.78, respectively, and its inter-rater reliability was measured by intraclass correlation as 0.99.20 The Chinese version of the 15-item Geriatric Depression Scale (GDS)40 was used to rate depressive symptoms. The GDS identifies depressive symptoms in adults,41,42 and it has good psychometric properties. Its score ranges from 0 to 63, with higher scores indicating more depressive symptoms. The Cronbach’s alpha and test–retest reliability were reported to be 0.89 and 0.85, respectively.43 The anxiety subscale of the Hospital Anxiety and Depression Scale (HADSA)44 was used to measure anxiety symptoms. The responses to the items 1, 2, 3, 6, and 7 are scored on a Likert scale ranging from 0 to 3, where 05‘‘not at all’’; 15‘‘occasionally’’; 25‘‘quite often’’; and 35‘‘very often indeed.’’ Items 4 and 5 have reversed scoring where 05‘‘very often indeed’’; 15‘‘quite often’’; 25‘‘occasionally’’; and 35‘‘not at all.’’ The responses to each of the seven items are based on the relative frequency of anxiety symptoms over the past week. The total score ranges from 0 to 21, with higher scores indicating more severe anxiety. This scale has an excellent sensitivity of 80% and specificity of 90%.44 Its overall misclassification rate is 12%, and its positive and negative predictive values are 67% and 95%, respectively.44 Statistical analyses were performed using the IBM SPSS Statistics, Version 20. Descriptive data are presented as means or proportions, as appropriate. For continuous variables, independent t-tests were performed between the pain and no-pain groups and Chi-square tests were used for categorical variables. Multivariate analysis was used to examine group differences in SF-12 PCS and MCS scores after adjusting for sex, education, depression and BI, GDS, HADSA, and FSS scores. Patients’ SF12 PCS and MCS scores were correlated with their AFPS score using Pearson’s correlation. The level of significance was set at 0.05 (two-tailed). 196
Topics in Stroke Rehabilitation
2015
VOL .
22
NO .
3
Results Patients were assessed within a mean of 126.5+ 33.5 days (median: 122.0 days) after the onset of the index stroke. Of the 441 patients screened, 167 (37.9%) and 69 (15.6%) reported pain regardless of its onset and novel pain that developed after the index stroke, respectively. Patients who reported pain were more likely than those without pain to be women with a lower education level (53.0% versus 35.0%, Pv0.001; and 5.5+ 4.6 versus 6.7+ 5.0 years, P50.023, respectively). The FSS, HADSA, and GDS mean scores were significantly higher in the pain group than in the no-pain group (3.9+ 1.5 versus 3.4+ 1.4, Pv0.001; 3.7+ 5.0 versus 2.3+ 3.7, P50.003; and 5.2+ 4.0, 4.2+ 4.1, P50.009, respectively), whereas the mean MMSE score was significantly lower (27.0+ 2.7 versus 27.5+ 2.5, P50.038). In the pain group, 13.3% of patients were diagnosed with depression according to DSM-IV, compared with 8.1% in the no-pain group (P50.081) (Table 1). The PCS and MCS scores were lower in the pain group than in the no-pain group (36.1+ 10.7 versus 42.1+ 10.5, Pv0.001 and 48.7+ 12.3 versus 51.8 + 10.5, P50.096, respectively). Furthermore, the pain group had lower PCS scores before (Pv0.001) and after (Pv0.001) adjustment for sex, education, depression and BI, GDS, HADSA, and FSS scores (Table 1). FPS-R scores in patients with pain and new pain were 4.57+ 1.98 and 4.22+ 1.67, respectively. Table 2 shows the results of the univariate correlation analysis between the FPS and SF12 scores of the patients with pain. There was a negative association between FPS scores and PCS scores in patients with pain (r50.260, Pv0.001) and those with novel pain (r5{0.445, Pv0.001).
Discussion This is the first study of HRQoL in PSP involving a large sample size, a psychiatric interview and a control group. The main finding was that both the presence and the intensity of PSP were associated with poor HRQoL in stroke patients. Previous studies in stroke populations have reported mean PCS and MCS scores of 35.6–37.1 and 41.3–47.4, respectively.45,46 The reported figure for PCS was similar to the score in our sample (36.1–42.1), but the MCS scores in our study were considerably higher (48.7–51.8), indicating that pain has a greater effect on physical health than on mental health. Female sex and low education level were found to be significant predictors of PSP. Furthermore, PSP was associated with more depressive, anxiety and fatigue symptoms, and poor cognitive ability and physical health.
Tang et al.
PSP and HRQoL 3 months after stroke
Table 1 Comparison of socio-demographic and clinical variables between stroke survivors with and without pain
Variables Age Sex (female) Education (years) Married Cohabitation Diabetes mellitus Hypertension Hyperlipidaemia History of stroke Psychiatric history DSM-IV depression NIHSS (n5433) IADL (n5294) BI (n5302) GDS (n5306) HADSA (n5283) FSS (n5302) LSNS (n5302) MLES (n5305) MMSE (n5307) SF-12 PCS SF-12 MCS SF-12 PCS SF-12 MCS
No pain N5274
With pain N5167
Mean/n
Mean/n
66.1+ 10.3 96 (35.0%) 6.7+ 5.0 212 (80.0%) 237 (89.1%) 93 (34.2%) 196 (71.8%) 146 (53.5%) 37 (13.6%) 12 (4.5%) 22 (8.1%) 3.5+ 3.3 0.2+ 0.5 19.4+ 1.9 4.2+ 4.1 2.3+ 3.7 3.4+ 1.4 31.9+ 7.3 1.7+ 0.9 27.5+ 2.5 42.1+ 10.5 51.8+ 10.5 42.1+ 10.5 51.8+ 10.5
66.1+ 9.7 88 (53.0%) 5.5+ 4.6 125 (76.7%) 147 (90.2%) 59 (35.5%) 125 (75.3%) 81 (48.8%) 19 (11.4%) 13 (7.9%) 22 (13.3%) 3.6+ 3.9 0.4+ 0.7 19.0+ 2.5 5.2+ 4.0 3.7+ 5.0 3.9+ 1.5 31.2+ 7.9 1.9+ 1.2 27.0+ 2.7 36.1+ 10.7 48.7+ 12.3 36.1+ 10.7 48.7+ 12.3
P
0.964b v0.001a 0.023c 0.416a 0.855a 0.712a 0.422a 0.341a 0.521a 0.147a 0.081a 0.697b 0.298c 0.090b 0.009b 0.003c v0.001b 0.366b 0.121c 0.038b v0.001b 0.096b 0.001d 0.494d
Note:a Chi-square test. b t-test. c Mann–Whitney U test. d Multivariate adjusted for sex, education, DSM-IV depression, BI, GDS, HADSA, and FSS. BI5Barthel Index; DSM-IV5Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; FSS5Fatigue Severity Scale; GDS5Geriatric Depression Scale; HADSA5Anxiety subscale of the Hospital Anxiety Depression Scale; IADL5Instrumental Activities of Daily Living; LSNS5Lubben Social Network Scale; MMSE5Mini Mental State Examination; MRS5Modified Rankin Scale; NIHSS5National Institutes of Health Stroke Scale; SF-12 MCS5SF-12 Health Survey mental component summary; SF-12 PCS5SF12 Health Survey physical component summary. Table 2 Correlation between FPS and SF 12 scores FPS Variables
r
Patients with pain, n5167 SF-12 PCS {0.260b SF-12 MCS {0.145a Patients with new pain, n569 SF-12 PCS {0.445c SF-12 MCS {0.228
P 0.001 0.071 v0.001 0.061
Note:a Pv0.10. b Pv0.05. c Pv0.001. FPS5Facial Pain Scale; SF-12 MCS5SF-12 Health Survey mental component summary; SF-12 PCS5SF-12 Health Survey physical component summary.
Of the 441 participants, 37.9% reported pain and 15.6% reported novel pain. Previous studies have found a similar prevalence of PSP (range: 41–44.6%)16,47 between four and six months after stroke. The frequency of novel pain reported in this study is also comparable to the 39–45.8% reported previously.6,16,48 Pain was rated as 4.57 out of 10, which could be considered as reflecting moderate intensity.
In line with most,2,4 but not all5 studies, female patients in our sample had a higher risk of developing PSP. Contrary to earlier findings,2 we found that low education level was associated with PSP. In accord with the literature,3,14 patients with pain had more severe fatigue. Our study also confirmed the correlation between depression and anxiety49 and poststroke pain,3,5,15 and novel pain.6 However, our results are at variance with those of Kong et al.,16 who found that the severity of depressive symptoms was unrelated to PSP at 6-month follow-up. However, others reported that the clinical diagnosis of prior and current depression are associated with PSP.3,5 Also, self-reported depression was associated with the development of novel pain.6 It would appear that pain causes symptoms that attributed to depression, for instance, sleep problems50 and difficulties in physical activity.50 Anxiety symptoms are commonly seen in stroke survivors;6,51 and anxiety is a predictor of pain in stroke.15 The intensity of pain is associated with anxiety in abused women.52 The current finding is Topics in Stroke Rehabilitation
2015
VOL .
22
NO .
3
197
Tang et al.
PSP and HRQoL 3 months after stroke
consistent with previous finding that patients with pain have a higher FSS score,3 others also addressed the association between pain and physical fatigue.14 The association between pain and impaired cognition has also been reported previously in stroke53 and chronic pain.54 Moriarty et al.54 reviewed that cognitive process is required for the experience of pain as well as the performance of cognitive activities. The shared anatomical, neurochemical, and molecular mechanisms of cognitive and pain processing prevent normal cognitive functioning.55,56 The mean PCS and MCS scores in pain group were 36.1 and 48.7, in no pain group, were 42.1 and 51.8, respectively. The figures were compatible to the existing studies with stroke survivors, PCS and MCS were ranging from 35.6 to 37.1 and 41.3 to 47.4, respectively.45,46 It is understanding that pain group had a poor PCS and MCS than no pain group. Pain is an unpleasant sensation that could be constant and severe that interferes with physical. Also, the affected brain may misinterpret the sensory input of normal touch as painful,12 patients and carers may isolate themselves from social interaction and caregiving, and resulted in poor mental health in patients. The results concerning the role of pain as a determinant of HRQoL are conflicting, with some studies supporting17,57 and others16 opposing it. Kong et al.16 suggested that pain is less likely to be reported in patients who experience a longer duration of post-stroke pain because they have adapted to their pain and thus rate it as less severe. This study found that the severity of pain negatively affected patients’ physical but not mental health. The pain group had lower PCS scores than the non-pain group, which is to be expected because bodily pain is a manifestation of physical discomfort. Kong et al.16 reported that the subscore for bodily pain was the only difference in HRQoL between the pain and nopain groups in a sample of stroke patients. The disparity between our study and that of Kong et al. may be because our assessments were conducted relatively soon after the index stroke, when patients may not have fully adapted to the pain. We were unable to find any data on the effect of novel pain on HRQoL after stroke. Our findings revealed a significant association between FPS and PCS scores in this group of stroke survivors, implying that novel pain also had a considerable influence on patients’ physical health; that is, the adverse effects of pain were not limited to longstanding pain. Also, the correlation between FPS and PCS in patients with novel pain is stronger than those of longstanding and novel pains. This may imply that 198
Topics in Stroke Rehabilitation
2015
VOL .
22
NO .
3
the effect of pain developed after index stroke is more intense, because the combination of the physical inability that result from stroke and the newly onset of pain alter patients’ physical activities to a greater level. For those patients with novel pain, they have to adapt their impaired physical and the feeling of pain after index stroke, when those with longstanding pain may already able to ease their discomfort from pain. The major limitation of the study is that the crosssectional design did not allow the causality of the associations to be examined. Other limitations include the subjective evaluation of pain, the relatively narrow range of demographic and clinical variables examined, and the short period between the index stroke and the assessments.
Clinical and research implications The psychological burden induced by pain in general and in stroke patients in particular should not be neglected. Early identification of pain using the biopsychosocial approach58 to understand its development, nature, and effects could lead to better post-stroke pain management. As post-stroke pain can be worsened by emotion and physical stress,59 learning how to manage emotion and stress effectively should become a strategy for easing pain. Interventions for reducing or eliminating pain, such as deep brain stimulation,60 motor cortex stimulation61 or cognitive behavioural therapy,62 could also make a valuable contribution to improving the HRQoL of stroke survivors. A comprehensive pain management programme for stroke survivors is recommended.63 This programme consists of education and practice guidelines. Patients with pain are encouraged to practise the skills and exercises they have learnt in their own environment. Progress is monitored and reviewed regularly by a health worker. With guidance, patients are able to change their activities and style of thinking to cope better with pain, thereby improving their HRQoL. Future longitudinal studies are warranted to investigate the long-term effects of pain on HRQOL. Intervention trials on PSP should include assessment of HRQOL as an outcome indicator.
Conclusion The findings of the study show that the presence and intensity of pain have significant negative effects on HRQoL in stroke survivors. Further studies are needed, particularly concerning the courses of pain developing before and after stroke and the effectiveness on interventions in order to improve the HRQoL in stroke survivors.
Tang et al.
Disclaimer Statements Contributors WKT designed the study. WKT and CGL wrote the protocol and the first draft. CGL conducted data collection, statistical analysis and results interpretation. VM and KSW helped design the study and collect the data. GSU helped write the paper and give critical revision of the manuscript. All authors reviewed the first draft of the paper and approved the final edition of the manuscript.
Funding None.
Conflicts of interest The authors report no conflict of interest.
Ethics approval The study protocol was approved by the Clinical Research Ethics Committee of the Chinese University of Hong Kong.
References 1 Bair MJ, Brizendine EJ, Ackermann RT, Shen C, Kroenke K, Marrero DG. Prevalence of pain and association with quality of life, depression and glycaemic control in patients with diabetes. Diabet Med. 2010;27:578–584. 2 Berges IM, Seale G, Ostir GV. Positive affect and pain ratings in persons with stroke. Rehabil Psychol. 2011;56:52–57. 3 Naess H, Lunde L, Brogger J, Waje-Andreassen U. Post-stroke pain on long-term follow-up: the Bergen stroke study. J Neurol. 2010;257:1446–1452. 4 Ehde D, Osborne TL, Hanley MA, Jensen MP, Kraft GH. The scope and nature of pain in persons with multiple sclerosis. Mult Scler. 2006;12:629–638. 5 Appelros P. Prevalence and predictors of pain and fatigue after stroke: a population-based study. Int J Rehabil Res. 2006;29: 329–333. 6 Klit H, Finnerup NB, Overvad K, Andersen G, Jensen TS. Pain following stroke: a population-based follow-up study. PLoS One. 2011;6:e27607. 7 Oster G, Harding G, Dukes E, Edelsberg J, Cleary P. Pain, medication use, and health-related quality of life in older persons with postherpetic neuralgia: results from a population-based survey. J Pain Symptom Manage. 2005;6: 356–363. 8 Jensen MP, Hoffman AJ, Cardenas DD. Chronic pain in individuals with spinal cord injury: a survey and longitudinal study. Spinal Cord. 2005;43:704–712. 9 Raichle KA, Osbourne TL, Jensen MP, Cardenas D. The reliability and validity of pain interference measures in persons with spinal cord injury. J Pain Symptom Manage. 2006;7: 179–186. 10 Widerstrom-Noga EG, Felipe-Cuervo E, Yezierski R. Chronic pain after spinal injury: interference with sleep and daily activities. Arch Phys Med Rehabil. 2001;82:1571–1577. 11 Lundstrom E, Smits A, Terent A, Borg J. Risk factors for stroke-related pain 1 year after first-ever stroke. Eur J Neurol. 2009;16:188–193. 12 National Stroke Association. Recovery After Stroke: Dealing with Pain. Englewood, Colorado: National Stroke Association; 2006. 13 National Stroke Foundation. Pain Management after Stroke. Melbourne, Vic.: National Stroke Foundation National Office; 2012.
PSP and HRQoL 3 months after stroke
14 Hoang CL, Salle JY, Mandigout S, Hamonet J, Macian-Montoro F, Daviet JC. Physical factors associated with fatigue after stroke: an exploratory study. Top Stroke Rehabil. 2012;19:369–376. 15 Morris JH, van Wijck F, Joice S, Donaghy M. Predicting health related quality of life 6 months after stroke: the role of anxiety and upper limb dysfunction. Disabil Rehabil. 2013;35: 291–299. 16 Kong KH, Woon VC, Yang SY. Prevalence of chronic pain and its impact on health-related quality of life in stroke survivors. Arch Phys Med Rehabil. 2004;85:35–40. 17 Naess H, Lunde L, Brogger J. The effects of fatigue, pain, and depression on quality of life in ischemic stroke patients: the Bergen Stroke Study. Vasc Health Risk Manag. 2012;8: 407–413. 18 Widar M, Ahlstro¨m G, Ek AC. Health-related quality of life in persons with long-term pain after a stroke. J Clin Nurs. 2004; 13:497–505. 19 Brott T, Adams H Jr, Olinger C, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989; 20:864–870. 20 Chiu HFK, Lee HC, Chung WS, Kwong PK. Reliability and validity of the Cantonese version of the mini-mental state examination: a preliminary study. Hong Kong J Psychiatry. 1994;4:25–28. 21 van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988;19:604–607. 22 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994. 23 Cunillera O, Tresserras R, Rajmil L, et al. Discriminative capacity of the EQ-5D, SF-6D, and SF-12 as measures of health status in population health survey. Qual Life Res. 2010;19:853–864. 24 Lam CL, Tse EY, Gandek B. Is the standard SF-12 health survey valid and equivalent for a Chinese population? Qual Life Res. 2005;14:539–547. 25 Ware JE, Kosinki M, Keller SD. SF-12: How to Score the SF-12 Physical and Mental Health Summary Scales. Boston, MA: The Health Institute, New England Medical Centre; 1995. 26 Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain. 2001;93: 173–183. 27 Chan SF, Ho SM, Poon KW, Ip A, Cheung OY. Pilot assessment of pain of orthopaedic patients in Hong Kong. Psychol Rep. 2005;96:527–532. 28 Li L, Herr K, Chen P. Postoperative pain assessment with three intensity scales in Chinese elders. J Nurs Scholarsh. 2009;41: 241–249. 29 Li L, Liu X, Herr K. Postoperative pain intensity assessment: a comparison of four scales in Chinese adults. Pain Med. 2007;8:223–234. 30 Benaim C, Froger J, Cazottes C, et al. Use of the Faces Pain Scale by left and right hemispheric stroke patients. Pain. 2007;128:52–58. 31 Dogan SK, Ay S, Oztuna D, Aytur YK, Evcik D. The utility of the Faces Pain Scale in the assessment of shoulder pain in Turkish stroke patients: its relation with quality of life and psychologic status. Int J Rehabil Res. 2010;33:363–367. 32 Choi-Kwon S, Han SW, Kwon SU, Kim JS. Poststroke fatigue: characteristics and related factors. Cerebrovasc Dis. 2005; 19:84–90. 33 Naess H, Lunde L, Brogger J, Waje-Andreassen U. Fatigue among stroke patients on long-term follow-up. The Bergen Stroke Study. J Neurol Sci. 2012;312:138–141. 34 Schepers VP, Visser-Meily AM, Ketelaar M, Lindeman E. Poststroke fatigue: course and its relation to personal and stroke-related factors. Arch Phys Med Rehabil. 2006;87: 184–188. 35 van de Port IG, Kwakkel G, Schepers VP, Heinemans CT, Lindeman E. Is fatigue an independent factor associated with activities of daily living, instrumental activities of daily living and health-related quality of life in chronic stroke? Cerebrovasc Dis. 2007;23:40–45.
Topics in Stroke Rehabilitation
2015
VOL .
22
NO .
3
199
Tang et al.
PSP and HRQoL 3 months after stroke
36 Lubben J. Assessing social network among elderly populations. Fam Community Health. 1998;11:42–52. 37 Chi I. Mental health of the old-old in Hong Kong. Clin Gerontol. 1995;15:31–44. 38 Mahoney F, Barthel D. Functional evaluation: the Barthel index. Maryland State Med J. 1965;14:61–65. 39 Lawton M, Brody E. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9: 179–186. 40 Tang WK, Chan SSM, Chiu HFK, et al. Can the geriatric depression scale detect poststroke depression in Chinese elderly? J. Affect. Disord. 2004;81:153–156. 41 Bass DS, Attix DK, Phillips-Bute B, Monk TG. An efficient screening tool for preoperative depression: the Geriatric Depression Scale-Short Form. Anesth Analg. 2008;106:805–809. 42 Weintraub D, Saboe K, Stern MB. Effect of age on geriatric depression scale performance in Parkinson’s disease. Mov Disord. 2007;22:1331–1335. 43 Chan AC. Clinical validation of the Geriatric Depression Scale (GDS): Chinese version. J. Aging Health. 1996;8:238–253. 44 Lam CL, Pan P, Chan AW, Chan SY, Munro C. Can the Hospital Anxiety and Depression (HAD) Scale be used on Chinese elderly in general practice? Fam Pract. 1995;12: 149–154. 45 Lim LL, Fisher JD. Use of the 12-item short-form (SF-12) Health Survey in an Australian heart and stroke population. Qual Life Res. 1999;8:1–8. 46 Xie J, Wu EQ, Zheng ZJ, et al. Impact of stroke on healthrelated quality of life in the noninstitutionalized population in the United States. Stroke. 2006;37:2567–2572. 47 Jo¨nsson AC, Lindgren I, Hallstro¨m B, Norrving B, Lindgren A. Prevalence and intensity of pain after stroke: a population based study focusing on patients’ perspectives. J Neurol Neurosurg Psychiatry. 2006;77:590–595. 48 Hansen AP, Marcussen NS, Klit H, Andersen G, Finnerup NB, Jensen TS. Pain following stroke: a prospective study. Eur J Pain. 2012;16:1128–1136. 49 Kwa VI, Limburg M, de Haan RJ. The role of cognitive impairment in the quality of life after ischaemic stroke. J Neurol. 1996;243:599–604. 50 Pilowsky I, Bassett DL. Pain and depression. Br J Psychiatry. 1982;141:30–36.
200
Topics in Stroke Rehabilitation
2015
VOL .
22
NO .
3
51 Barker-Collo SL. Depression and anxiety 3 months post stroke: Prevalence and correlates. Arch Clin Neuropsychol. 2007;22: 519–531. 52 Symes L, McFarlane J, Nava A, Gilroy H, Maddoux J. The association of pain severity and pain interference levels with abuse experiences and mental health symptoms among 300 mothers: baseline data analysis for a 7-year prospective study. Issues Ment Health Nurs. 2013;34:2–16. 53 Povedano M, Gasco´n J, Ga´lvez R, Ruiz M, Rejas J. Cognitive function impairment in patients with neuropathic pain under standard conditions of care. J Pain Symptom Manage. 2007; 33:78–89. 54 Moriarty O, McGuire BE, Finn DP. The effect of pain on cognitive function: a review of clinical and preclinical research. Prog Neurobiol. 2011;93:385–404. 55 Hart RP, Martelli MF, Zasler ND. Chronic pain and neuropsychological functioning. Neuropsychol Rev. 2000;10: 131–149. 56 Eccleston C, Crombez G. Pain demands attention: a cognitiveaffective model of the interruptive function of pain. Psychol Bull. 1999;125:356–366. 57 Algure´n B, Fridlund B, Cieza A, Sunnerhagen KS, Christensson L. Factors associated with health-related quality of life after stroke: a 1-year prospective cohort study. Neurorehabil Neural Repair. 2012;26:266–274. 58 Novy DM, Nelson DV, Francis DJ, Turk DC. Perspectives of chronic pain: an evaluative comparison of restrictive and comprehensive models. Psychol Bull. 1995;118:238–247. 59 Boivie J, Leijon G, Johansson J. Abnormalities in sensibility accompanying central post-stroke pain. Pain. 1987;Suppl. 4:S405. 60 Boccard SG, Pereira EA, Moir L, Aziz TZ, Green AL. Long-term outcomes of deep brain stimulation for neuropathic pain. Neurosurgery. 2013;72(2):221–230. 61 Rasche D, Ruppolt M, Stippich C, Unterberg A, Tronnier V. Motor cortex stimulation for long-term relief of chronic neuropathic pain: a 10 year experience. Pain. 2006;121:43–52. 62 Morley S. Efficacy and effectiveness of cognitive behaviour therapy for chronic pain: progress and some challenges. Pain. 2011;152:S99–S106. 63 de C Williams AC, Adams J, Cavill G, et al. Recommended guidelines for Pain Management Programmes for Adults. London: The British Pain Society; 2010.
Department of Psychiatry, Chinese University of Hong Kong, China, 2Department of Medicine and Therapeutics, Chinese University of Hong Kong, China, 3School of Psychiatry & Clinical Neurosciences, University of Western Australia, Perth, Australia, 4University of Notre Dame Australia/Marian Centre, Perth, Australia Background: Pain is common in stroke; however, its impacts on health-related quality of life (HRQoL) are unclear due to the limitations of previous studies. Objectives: The current study aims to examine and compare the demographic and clinical characteristics of Chinese stroke patients with and without pain and explore the correlations between poststroke pain and HRQoL. Method: Four hundreds and forty-one participants recruited in an acute stroke unit in a regional hospital. They were assessed 3 months after the index stroke with the following instruments. HRQoL was measured using the Short Form-12 (SF-12). The Chinese version of the Faces Pain Rating Scale-Revised (FPS-R) was used to determine the presence and intensity of pain. The demographic and clinical characteristics of patients were obtained using Barthel Index (BI), Fatigue Severity Scale (FSS), Geriatric Depression Scale (GDS), Anxiety subscale of the Hospital Anxiety and Depression Scale (HADSA), Instrumental Activities of Daily Living (IADL), Mini Mental State Examination (MMSE), Modified Rankin Scale (MRS), and National Institutes of Health Stroke Scale (NIHSS). Results: Of all participants screened, 167 reported pain and 69 had novel pain. The pain group had significantly lower physical component summary (PCS) scores after adjusting for sex, education, DSM-IV depression and BI, GDS, HADSA, and FSS scores. The FPS score was negatively correlated with a lower PCS score in patients with pain and with novel pain. Conclusion: The presence and intensity of pain have significant negative effects on HRQoL in stroke survivors. Interventions for pain could make a valuable contribution to improving HRQoL in stroke survivors.
Keywords: Pain, Stroke, Health-related quality of life
Introduction 1–4
Pain is common in various medical conditions. For instance, the prevalence of pain in diabetes and multiple sclerosis is 57.8%1 and 66%,4 respectively. Pain is an important variable in stroke, spinal cord injury and multiple sclerosis. It is associated with depression,5,6 physical dysfunction,4,7,8 emotional functioning,4,9 sleep disturbance,9,10 and social functioning.9,10 The prevalence of poststroke pain (PSP) is between 33.3 and 49%.2,3,11 Two major types of pain after stroke are distinguished, local and central pain.12,13 The former is the pain felt in the joints, usually in the shoulders,12 while the latter felt on the skin on the side affected by stroke.13 Local pain is caused by the actual damage to
Correspondence to: W. K. Tang, Department of Psychiatry, Shatin Hospital, Shatin, N.T., Hong Kong SAR, China. Email: [email protected]
194
ß W. S. Maney & Son Ltd 2015 DOI 10.1179/1074935714Z.0000000024
body tissue13 or the malposition of a joint.12 Central pain is a type of neuropathic pain which is produced within the central nervous system. Central pain may be intensified by touch, movement, or other forms of stimuli due to the incorrect interpretation of the signals sent to the CMS.12,13 Novel pain, the pain that develops after index stroke, was found in 39% of stroke survivors.6 The characteristics associated with PSP include female sex,2,4 higher education level,2 fatigue,3,14 and anxiety symptoms.15 Surprisingly, depressive symptoms and daily functioning may not be correlated with PSP.16 PSP is associated with deterioration of cognitive and motor abilities6 and increased mortality.14 The impact of PSP on health-related quality of life (HRQoL) has received scant attention. Although one study17 identified pain as a predictive factor for HRQoL in stroke patients, another14 failed to replicate Topics in Stroke Rehabilitation
2015
VOL .
22
NO .
3
Tang et al.
this finding. The contradictory results may be explained by the different study designs. Naess et al.17 evaluated common medical complaints and symptoms in 328 stroke survivors 1 year after the index stroke using a postal questionnaire. Pain was a common symptom and was significantly correlated with HRQoL. However, poor reliability of postal questionnaires limits the generalizability of these findings. A second study,18 which examined HRQoL in 43 stroke patients with long-term pain was limited by its small sample size and lack of a control group. The aim of the current study was to examine the associations between PSP and demographic and clinical characteristics, and the effect of PSP on HRQoL in a large sample of stroke survivors 3 months following their index stroke.
Methods A sample of 441 consecutively admitted stroke patients was recruited from the Acute Stroke Unit of the Prince of Wales Hospital (PWH) between January 2009 and September 2011. PWH is a university-affiliated regional hospital serving a population of 800 000 in the Shatin district of Hong Kong. The diagnosis of stroke was made by qualified neurologists, based on clinical presentation and CT or MRI scan of the brain. PWH is a universityaffiliated regional hospital serving a population of 800 000 in the Shatin district of Hong Kong. The inclusion criteria for the study were: (1) Chinese ethnicity; (2) Cantonese as the primary language; (3) aged 18 years or above; and (4) well-documented stroke occurring within 7 days before admission to the study. The exclusion criteria were: (1) history of a central nervous system disease such as tumor, trauma, hydrocephalus, or Parkinson’s disease; (2) significant aphasia or dysarthria (National Institutes of Health Stroke Scale (NIHSS) best language score i2 or dysarthria score i2)19 to the extent of precluding meaningful communication; (3) physical frailty that prevented attending the interview; (4) cognitive impairment, defined as a Mini-Mental State Examination (MMSE)20 score less than 20; and (5) severe co-morbid disease (e.g. malignant tumor, decompensated heart failure, or chronic respiratory failure) that could affect follow-up assessment. The study protocol was approved by the Clinical Research Ethics Committee of the Chinese University of Hong Kong. All of the participants signed a consent form. All assessments were conducted within 3 months after the index stroke. Patients’ demographic and clinical characteristics were collected by a trained research assistant. The severity of stroke was assessed with the
PSP and HRQoL 3 months after stroke
Modified Rankin Scale (MRS)21 and the NIHSS.19 The clinical diagnosis of depression was made by a psychiatrist (Wai-Kwong Tang) using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).22 The Short Form-12 (SF-12) Health Survey was used to measure patients’ HRQoL. The scale has been validated in stroke23 and in Chinese patient populations.24 The SF-12 comprises physical component summary (PCS) and mental component summary (MCS) scales. There are 12 items constituting eight subscales: physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. The weighted item scores for each item contribute to the two component scores.25 Each component score ranges from 0 to 100, with higher scores indicating better health. Pain was evaluated by the Chinese version of the Faces Pain Rating Scale-Revised (FPS-R). The FPS-R is a self-report measure that was originally used to assess the intensity of pain in children.26 The FPS-R has been used to measure pain in Chinese older adults27–29 and stroke patients.30,31 The FPS-R consists of two questions and six line-drawn faces with expressions ranging from a neutral face to a grimacing face. Patients are instructed to point to the face that best represents the intensity of their most painful site. Scores of 0, 2, 4, 6, 8, and 10 are assigned to each face consecutively, with higher numbers representing more pain. Differentiation of central from peripheral pain was not performed in this study. The presence of novel pain was distinguished from pain with the question in FPS-R ‘‘Did the pain exist before the latest stroke?’’ The Fatigue Severity Scale (FSS) had been used to evaluate fatigue in stroke.32–35 It contains nine items (e.g. ‘‘My motivation is lower when I am fatigued’’, ‘‘Exercise brings on my fatigue,’’ and ‘‘I am easily fatigued’’) rated on a seven-point Likert scale, with higher scores indicating more severe fatigue. Item scores are averaged to produce a global fatigue score. The Lubben Social Network Scale (LSNS) is a composite scale designed for use in the elderly.36 It measures the level of social support patients receive and their social interactions with relatives and friends. The LSNS has been translated into Chinese and validated in the Hong Kong elderly.37 The total score of LSNS ranges from 0–50, with higher scores indicating greater social support. The Barthel Index (BI)38 and the Instrumental Activities of Daily Living (IADL)39 scale were used to assess the extent of patients’ disability in performing daily functions. The BI covers ten items: personal hygiene, bathing, feeding, toileting, stair climbing, dressing, bowel control, bladder control, ambulation or Topics in Stroke Rehabilitation
2015
VOL .
22
NO .
3
195
Tang et al.
PSP and HRQoL 3 months after stroke
wheelchair use, and chair-bed transfer. Total scores range from 0 to 20, with higher scores indicating more independent self-care. The IADL assesses the level of independence in community living such as shopping, cooking and managing finances. It contains eight items and its summary score ranges from 0 to 8, with lower scores indicating higher functional level. The IADL has excellent inter-rater reliability (0.85).39 The Cantonese version of the MMSE20 was used to evaluate patients’ global cognitive functions. Its score ranges from 0–30, with higher scores indicating less cognitive impairment. The Cronbach’s alpha and test– retest reliability of the Chinese version of the MMSE were reported as 0.86 and 0.78, respectively, and its inter-rater reliability was measured by intraclass correlation as 0.99.20 The Chinese version of the 15-item Geriatric Depression Scale (GDS)40 was used to rate depressive symptoms. The GDS identifies depressive symptoms in adults,41,42 and it has good psychometric properties. Its score ranges from 0 to 63, with higher scores indicating more depressive symptoms. The Cronbach’s alpha and test–retest reliability were reported to be 0.89 and 0.85, respectively.43 The anxiety subscale of the Hospital Anxiety and Depression Scale (HADSA)44 was used to measure anxiety symptoms. The responses to the items 1, 2, 3, 6, and 7 are scored on a Likert scale ranging from 0 to 3, where 05‘‘not at all’’; 15‘‘occasionally’’; 25‘‘quite often’’; and 35‘‘very often indeed.’’ Items 4 and 5 have reversed scoring where 05‘‘very often indeed’’; 15‘‘quite often’’; 25‘‘occasionally’’; and 35‘‘not at all.’’ The responses to each of the seven items are based on the relative frequency of anxiety symptoms over the past week. The total score ranges from 0 to 21, with higher scores indicating more severe anxiety. This scale has an excellent sensitivity of 80% and specificity of 90%.44 Its overall misclassification rate is 12%, and its positive and negative predictive values are 67% and 95%, respectively.44 Statistical analyses were performed using the IBM SPSS Statistics, Version 20. Descriptive data are presented as means or proportions, as appropriate. For continuous variables, independent t-tests were performed between the pain and no-pain groups and Chi-square tests were used for categorical variables. Multivariate analysis was used to examine group differences in SF-12 PCS and MCS scores after adjusting for sex, education, depression and BI, GDS, HADSA, and FSS scores. Patients’ SF12 PCS and MCS scores were correlated with their AFPS score using Pearson’s correlation. The level of significance was set at 0.05 (two-tailed). 196
Topics in Stroke Rehabilitation
2015
VOL .
22
NO .
3
Results Patients were assessed within a mean of 126.5+ 33.5 days (median: 122.0 days) after the onset of the index stroke. Of the 441 patients screened, 167 (37.9%) and 69 (15.6%) reported pain regardless of its onset and novel pain that developed after the index stroke, respectively. Patients who reported pain were more likely than those without pain to be women with a lower education level (53.0% versus 35.0%, Pv0.001; and 5.5+ 4.6 versus 6.7+ 5.0 years, P50.023, respectively). The FSS, HADSA, and GDS mean scores were significantly higher in the pain group than in the no-pain group (3.9+ 1.5 versus 3.4+ 1.4, Pv0.001; 3.7+ 5.0 versus 2.3+ 3.7, P50.003; and 5.2+ 4.0, 4.2+ 4.1, P50.009, respectively), whereas the mean MMSE score was significantly lower (27.0+ 2.7 versus 27.5+ 2.5, P50.038). In the pain group, 13.3% of patients were diagnosed with depression according to DSM-IV, compared with 8.1% in the no-pain group (P50.081) (Table 1). The PCS and MCS scores were lower in the pain group than in the no-pain group (36.1+ 10.7 versus 42.1+ 10.5, Pv0.001 and 48.7+ 12.3 versus 51.8 + 10.5, P50.096, respectively). Furthermore, the pain group had lower PCS scores before (Pv0.001) and after (Pv0.001) adjustment for sex, education, depression and BI, GDS, HADSA, and FSS scores (Table 1). FPS-R scores in patients with pain and new pain were 4.57+ 1.98 and 4.22+ 1.67, respectively. Table 2 shows the results of the univariate correlation analysis between the FPS and SF12 scores of the patients with pain. There was a negative association between FPS scores and PCS scores in patients with pain (r50.260, Pv0.001) and those with novel pain (r5{0.445, Pv0.001).
Discussion This is the first study of HRQoL in PSP involving a large sample size, a psychiatric interview and a control group. The main finding was that both the presence and the intensity of PSP were associated with poor HRQoL in stroke patients. Previous studies in stroke populations have reported mean PCS and MCS scores of 35.6–37.1 and 41.3–47.4, respectively.45,46 The reported figure for PCS was similar to the score in our sample (36.1–42.1), but the MCS scores in our study were considerably higher (48.7–51.8), indicating that pain has a greater effect on physical health than on mental health. Female sex and low education level were found to be significant predictors of PSP. Furthermore, PSP was associated with more depressive, anxiety and fatigue symptoms, and poor cognitive ability and physical health.
Tang et al.
PSP and HRQoL 3 months after stroke
Table 1 Comparison of socio-demographic and clinical variables between stroke survivors with and without pain
Variables Age Sex (female) Education (years) Married Cohabitation Diabetes mellitus Hypertension Hyperlipidaemia History of stroke Psychiatric history DSM-IV depression NIHSS (n5433) IADL (n5294) BI (n5302) GDS (n5306) HADSA (n5283) FSS (n5302) LSNS (n5302) MLES (n5305) MMSE (n5307) SF-12 PCS SF-12 MCS SF-12 PCS SF-12 MCS
No pain N5274
With pain N5167
Mean/n
Mean/n
66.1+ 10.3 96 (35.0%) 6.7+ 5.0 212 (80.0%) 237 (89.1%) 93 (34.2%) 196 (71.8%) 146 (53.5%) 37 (13.6%) 12 (4.5%) 22 (8.1%) 3.5+ 3.3 0.2+ 0.5 19.4+ 1.9 4.2+ 4.1 2.3+ 3.7 3.4+ 1.4 31.9+ 7.3 1.7+ 0.9 27.5+ 2.5 42.1+ 10.5 51.8+ 10.5 42.1+ 10.5 51.8+ 10.5
66.1+ 9.7 88 (53.0%) 5.5+ 4.6 125 (76.7%) 147 (90.2%) 59 (35.5%) 125 (75.3%) 81 (48.8%) 19 (11.4%) 13 (7.9%) 22 (13.3%) 3.6+ 3.9 0.4+ 0.7 19.0+ 2.5 5.2+ 4.0 3.7+ 5.0 3.9+ 1.5 31.2+ 7.9 1.9+ 1.2 27.0+ 2.7 36.1+ 10.7 48.7+ 12.3 36.1+ 10.7 48.7+ 12.3
P
0.964b v0.001a 0.023c 0.416a 0.855a 0.712a 0.422a 0.341a 0.521a 0.147a 0.081a 0.697b 0.298c 0.090b 0.009b 0.003c v0.001b 0.366b 0.121c 0.038b v0.001b 0.096b 0.001d 0.494d
Note:a Chi-square test. b t-test. c Mann–Whitney U test. d Multivariate adjusted for sex, education, DSM-IV depression, BI, GDS, HADSA, and FSS. BI5Barthel Index; DSM-IV5Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; FSS5Fatigue Severity Scale; GDS5Geriatric Depression Scale; HADSA5Anxiety subscale of the Hospital Anxiety Depression Scale; IADL5Instrumental Activities of Daily Living; LSNS5Lubben Social Network Scale; MMSE5Mini Mental State Examination; MRS5Modified Rankin Scale; NIHSS5National Institutes of Health Stroke Scale; SF-12 MCS5SF-12 Health Survey mental component summary; SF-12 PCS5SF12 Health Survey physical component summary. Table 2 Correlation between FPS and SF 12 scores FPS Variables
r
Patients with pain, n5167 SF-12 PCS {0.260b SF-12 MCS {0.145a Patients with new pain, n569 SF-12 PCS {0.445c SF-12 MCS {0.228
P 0.001 0.071 v0.001 0.061
Note:a Pv0.10. b Pv0.05. c Pv0.001. FPS5Facial Pain Scale; SF-12 MCS5SF-12 Health Survey mental component summary; SF-12 PCS5SF-12 Health Survey physical component summary.
Of the 441 participants, 37.9% reported pain and 15.6% reported novel pain. Previous studies have found a similar prevalence of PSP (range: 41–44.6%)16,47 between four and six months after stroke. The frequency of novel pain reported in this study is also comparable to the 39–45.8% reported previously.6,16,48 Pain was rated as 4.57 out of 10, which could be considered as reflecting moderate intensity.
In line with most,2,4 but not all5 studies, female patients in our sample had a higher risk of developing PSP. Contrary to earlier findings,2 we found that low education level was associated with PSP. In accord with the literature,3,14 patients with pain had more severe fatigue. Our study also confirmed the correlation between depression and anxiety49 and poststroke pain,3,5,15 and novel pain.6 However, our results are at variance with those of Kong et al.,16 who found that the severity of depressive symptoms was unrelated to PSP at 6-month follow-up. However, others reported that the clinical diagnosis of prior and current depression are associated with PSP.3,5 Also, self-reported depression was associated with the development of novel pain.6 It would appear that pain causes symptoms that attributed to depression, for instance, sleep problems50 and difficulties in physical activity.50 Anxiety symptoms are commonly seen in stroke survivors;6,51 and anxiety is a predictor of pain in stroke.15 The intensity of pain is associated with anxiety in abused women.52 The current finding is Topics in Stroke Rehabilitation
2015
VOL .
22
NO .
3
197
Tang et al.
PSP and HRQoL 3 months after stroke
consistent with previous finding that patients with pain have a higher FSS score,3 others also addressed the association between pain and physical fatigue.14 The association between pain and impaired cognition has also been reported previously in stroke53 and chronic pain.54 Moriarty et al.54 reviewed that cognitive process is required for the experience of pain as well as the performance of cognitive activities. The shared anatomical, neurochemical, and molecular mechanisms of cognitive and pain processing prevent normal cognitive functioning.55,56 The mean PCS and MCS scores in pain group were 36.1 and 48.7, in no pain group, were 42.1 and 51.8, respectively. The figures were compatible to the existing studies with stroke survivors, PCS and MCS were ranging from 35.6 to 37.1 and 41.3 to 47.4, respectively.45,46 It is understanding that pain group had a poor PCS and MCS than no pain group. Pain is an unpleasant sensation that could be constant and severe that interferes with physical. Also, the affected brain may misinterpret the sensory input of normal touch as painful,12 patients and carers may isolate themselves from social interaction and caregiving, and resulted in poor mental health in patients. The results concerning the role of pain as a determinant of HRQoL are conflicting, with some studies supporting17,57 and others16 opposing it. Kong et al.16 suggested that pain is less likely to be reported in patients who experience a longer duration of post-stroke pain because they have adapted to their pain and thus rate it as less severe. This study found that the severity of pain negatively affected patients’ physical but not mental health. The pain group had lower PCS scores than the non-pain group, which is to be expected because bodily pain is a manifestation of physical discomfort. Kong et al.16 reported that the subscore for bodily pain was the only difference in HRQoL between the pain and nopain groups in a sample of stroke patients. The disparity between our study and that of Kong et al. may be because our assessments were conducted relatively soon after the index stroke, when patients may not have fully adapted to the pain. We were unable to find any data on the effect of novel pain on HRQoL after stroke. Our findings revealed a significant association between FPS and PCS scores in this group of stroke survivors, implying that novel pain also had a considerable influence on patients’ physical health; that is, the adverse effects of pain were not limited to longstanding pain. Also, the correlation between FPS and PCS in patients with novel pain is stronger than those of longstanding and novel pains. This may imply that 198
Topics in Stroke Rehabilitation
2015
VOL .
22
NO .
3
the effect of pain developed after index stroke is more intense, because the combination of the physical inability that result from stroke and the newly onset of pain alter patients’ physical activities to a greater level. For those patients with novel pain, they have to adapt their impaired physical and the feeling of pain after index stroke, when those with longstanding pain may already able to ease their discomfort from pain. The major limitation of the study is that the crosssectional design did not allow the causality of the associations to be examined. Other limitations include the subjective evaluation of pain, the relatively narrow range of demographic and clinical variables examined, and the short period between the index stroke and the assessments.
Clinical and research implications The psychological burden induced by pain in general and in stroke patients in particular should not be neglected. Early identification of pain using the biopsychosocial approach58 to understand its development, nature, and effects could lead to better post-stroke pain management. As post-stroke pain can be worsened by emotion and physical stress,59 learning how to manage emotion and stress effectively should become a strategy for easing pain. Interventions for reducing or eliminating pain, such as deep brain stimulation,60 motor cortex stimulation61 or cognitive behavioural therapy,62 could also make a valuable contribution to improving the HRQoL of stroke survivors. A comprehensive pain management programme for stroke survivors is recommended.63 This programme consists of education and practice guidelines. Patients with pain are encouraged to practise the skills and exercises they have learnt in their own environment. Progress is monitored and reviewed regularly by a health worker. With guidance, patients are able to change their activities and style of thinking to cope better with pain, thereby improving their HRQoL. Future longitudinal studies are warranted to investigate the long-term effects of pain on HRQOL. Intervention trials on PSP should include assessment of HRQOL as an outcome indicator.
Conclusion The findings of the study show that the presence and intensity of pain have significant negative effects on HRQoL in stroke survivors. Further studies are needed, particularly concerning the courses of pain developing before and after stroke and the effectiveness on interventions in order to improve the HRQoL in stroke survivors.
Tang et al.
Disclaimer Statements Contributors WKT designed the study. WKT and CGL wrote the protocol and the first draft. CGL conducted data collection, statistical analysis and results interpretation. VM and KSW helped design the study and collect the data. GSU helped write the paper and give critical revision of the manuscript. All authors reviewed the first draft of the paper and approved the final edition of the manuscript.
Funding None.
Conflicts of interest The authors report no conflict of interest.
Ethics approval The study protocol was approved by the Clinical Research Ethics Committee of the Chinese University of Hong Kong.
References 1 Bair MJ, Brizendine EJ, Ackermann RT, Shen C, Kroenke K, Marrero DG. Prevalence of pain and association with quality of life, depression and glycaemic control in patients with diabetes. Diabet Med. 2010;27:578–584. 2 Berges IM, Seale G, Ostir GV. Positive affect and pain ratings in persons with stroke. Rehabil Psychol. 2011;56:52–57. 3 Naess H, Lunde L, Brogger J, Waje-Andreassen U. Post-stroke pain on long-term follow-up: the Bergen stroke study. J Neurol. 2010;257:1446–1452. 4 Ehde D, Osborne TL, Hanley MA, Jensen MP, Kraft GH. The scope and nature of pain in persons with multiple sclerosis. Mult Scler. 2006;12:629–638. 5 Appelros P. Prevalence and predictors of pain and fatigue after stroke: a population-based study. Int J Rehabil Res. 2006;29: 329–333. 6 Klit H, Finnerup NB, Overvad K, Andersen G, Jensen TS. Pain following stroke: a population-based follow-up study. PLoS One. 2011;6:e27607. 7 Oster G, Harding G, Dukes E, Edelsberg J, Cleary P. Pain, medication use, and health-related quality of life in older persons with postherpetic neuralgia: results from a population-based survey. J Pain Symptom Manage. 2005;6: 356–363. 8 Jensen MP, Hoffman AJ, Cardenas DD. Chronic pain in individuals with spinal cord injury: a survey and longitudinal study. Spinal Cord. 2005;43:704–712. 9 Raichle KA, Osbourne TL, Jensen MP, Cardenas D. The reliability and validity of pain interference measures in persons with spinal cord injury. J Pain Symptom Manage. 2006;7: 179–186. 10 Widerstrom-Noga EG, Felipe-Cuervo E, Yezierski R. Chronic pain after spinal injury: interference with sleep and daily activities. Arch Phys Med Rehabil. 2001;82:1571–1577. 11 Lundstrom E, Smits A, Terent A, Borg J. Risk factors for stroke-related pain 1 year after first-ever stroke. Eur J Neurol. 2009;16:188–193. 12 National Stroke Association. Recovery After Stroke: Dealing with Pain. Englewood, Colorado: National Stroke Association; 2006. 13 National Stroke Foundation. Pain Management after Stroke. Melbourne, Vic.: National Stroke Foundation National Office; 2012.
PSP and HRQoL 3 months after stroke
14 Hoang CL, Salle JY, Mandigout S, Hamonet J, Macian-Montoro F, Daviet JC. Physical factors associated with fatigue after stroke: an exploratory study. Top Stroke Rehabil. 2012;19:369–376. 15 Morris JH, van Wijck F, Joice S, Donaghy M. Predicting health related quality of life 6 months after stroke: the role of anxiety and upper limb dysfunction. Disabil Rehabil. 2013;35: 291–299. 16 Kong KH, Woon VC, Yang SY. Prevalence of chronic pain and its impact on health-related quality of life in stroke survivors. Arch Phys Med Rehabil. 2004;85:35–40. 17 Naess H, Lunde L, Brogger J. The effects of fatigue, pain, and depression on quality of life in ischemic stroke patients: the Bergen Stroke Study. Vasc Health Risk Manag. 2012;8: 407–413. 18 Widar M, Ahlstro¨m G, Ek AC. Health-related quality of life in persons with long-term pain after a stroke. J Clin Nurs. 2004; 13:497–505. 19 Brott T, Adams H Jr, Olinger C, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989; 20:864–870. 20 Chiu HFK, Lee HC, Chung WS, Kwong PK. Reliability and validity of the Cantonese version of the mini-mental state examination: a preliminary study. Hong Kong J Psychiatry. 1994;4:25–28. 21 van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988;19:604–607. 22 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994. 23 Cunillera O, Tresserras R, Rajmil L, et al. Discriminative capacity of the EQ-5D, SF-6D, and SF-12 as measures of health status in population health survey. Qual Life Res. 2010;19:853–864. 24 Lam CL, Tse EY, Gandek B. Is the standard SF-12 health survey valid and equivalent for a Chinese population? Qual Life Res. 2005;14:539–547. 25 Ware JE, Kosinki M, Keller SD. SF-12: How to Score the SF-12 Physical and Mental Health Summary Scales. Boston, MA: The Health Institute, New England Medical Centre; 1995. 26 Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The Faces Pain Scale-Revised: toward a common metric in pediatric pain measurement. Pain. 2001;93: 173–183. 27 Chan SF, Ho SM, Poon KW, Ip A, Cheung OY. Pilot assessment of pain of orthopaedic patients in Hong Kong. Psychol Rep. 2005;96:527–532. 28 Li L, Herr K, Chen P. Postoperative pain assessment with three intensity scales in Chinese elders. J Nurs Scholarsh. 2009;41: 241–249. 29 Li L, Liu X, Herr K. Postoperative pain intensity assessment: a comparison of four scales in Chinese adults. Pain Med. 2007;8:223–234. 30 Benaim C, Froger J, Cazottes C, et al. Use of the Faces Pain Scale by left and right hemispheric stroke patients. Pain. 2007;128:52–58. 31 Dogan SK, Ay S, Oztuna D, Aytur YK, Evcik D. The utility of the Faces Pain Scale in the assessment of shoulder pain in Turkish stroke patients: its relation with quality of life and psychologic status. Int J Rehabil Res. 2010;33:363–367. 32 Choi-Kwon S, Han SW, Kwon SU, Kim JS. Poststroke fatigue: characteristics and related factors. Cerebrovasc Dis. 2005; 19:84–90. 33 Naess H, Lunde L, Brogger J, Waje-Andreassen U. Fatigue among stroke patients on long-term follow-up. The Bergen Stroke Study. J Neurol Sci. 2012;312:138–141. 34 Schepers VP, Visser-Meily AM, Ketelaar M, Lindeman E. Poststroke fatigue: course and its relation to personal and stroke-related factors. Arch Phys Med Rehabil. 2006;87: 184–188. 35 van de Port IG, Kwakkel G, Schepers VP, Heinemans CT, Lindeman E. Is fatigue an independent factor associated with activities of daily living, instrumental activities of daily living and health-related quality of life in chronic stroke? Cerebrovasc Dis. 2007;23:40–45.
Topics in Stroke Rehabilitation
2015
VOL .
22
NO .
3
199
Tang et al.
PSP and HRQoL 3 months after stroke
36 Lubben J. Assessing social network among elderly populations. Fam Community Health. 1998;11:42–52. 37 Chi I. Mental health of the old-old in Hong Kong. Clin Gerontol. 1995;15:31–44. 38 Mahoney F, Barthel D. Functional evaluation: the Barthel index. Maryland State Med J. 1965;14:61–65. 39 Lawton M, Brody E. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9: 179–186. 40 Tang WK, Chan SSM, Chiu HFK, et al. Can the geriatric depression scale detect poststroke depression in Chinese elderly? J. Affect. Disord. 2004;81:153–156. 41 Bass DS, Attix DK, Phillips-Bute B, Monk TG. An efficient screening tool for preoperative depression: the Geriatric Depression Scale-Short Form. Anesth Analg. 2008;106:805–809. 42 Weintraub D, Saboe K, Stern MB. Effect of age on geriatric depression scale performance in Parkinson’s disease. Mov Disord. 2007;22:1331–1335. 43 Chan AC. Clinical validation of the Geriatric Depression Scale (GDS): Chinese version. J. Aging Health. 1996;8:238–253. 44 Lam CL, Pan P, Chan AW, Chan SY, Munro C. Can the Hospital Anxiety and Depression (HAD) Scale be used on Chinese elderly in general practice? Fam Pract. 1995;12: 149–154. 45 Lim LL, Fisher JD. Use of the 12-item short-form (SF-12) Health Survey in an Australian heart and stroke population. Qual Life Res. 1999;8:1–8. 46 Xie J, Wu EQ, Zheng ZJ, et al. Impact of stroke on healthrelated quality of life in the noninstitutionalized population in the United States. Stroke. 2006;37:2567–2572. 47 Jo¨nsson AC, Lindgren I, Hallstro¨m B, Norrving B, Lindgren A. Prevalence and intensity of pain after stroke: a population based study focusing on patients’ perspectives. J Neurol Neurosurg Psychiatry. 2006;77:590–595. 48 Hansen AP, Marcussen NS, Klit H, Andersen G, Finnerup NB, Jensen TS. Pain following stroke: a prospective study. Eur J Pain. 2012;16:1128–1136. 49 Kwa VI, Limburg M, de Haan RJ. The role of cognitive impairment in the quality of life after ischaemic stroke. J Neurol. 1996;243:599–604. 50 Pilowsky I, Bassett DL. Pain and depression. Br J Psychiatry. 1982;141:30–36.
200
Topics in Stroke Rehabilitation
2015
VOL .
22
NO .
3
51 Barker-Collo SL. Depression and anxiety 3 months post stroke: Prevalence and correlates. Arch Clin Neuropsychol. 2007;22: 519–531. 52 Symes L, McFarlane J, Nava A, Gilroy H, Maddoux J. The association of pain severity and pain interference levels with abuse experiences and mental health symptoms among 300 mothers: baseline data analysis for a 7-year prospective study. Issues Ment Health Nurs. 2013;34:2–16. 53 Povedano M, Gasco´n J, Ga´lvez R, Ruiz M, Rejas J. Cognitive function impairment in patients with neuropathic pain under standard conditions of care. J Pain Symptom Manage. 2007; 33:78–89. 54 Moriarty O, McGuire BE, Finn DP. The effect of pain on cognitive function: a review of clinical and preclinical research. Prog Neurobiol. 2011;93:385–404. 55 Hart RP, Martelli MF, Zasler ND. Chronic pain and neuropsychological functioning. Neuropsychol Rev. 2000;10: 131–149. 56 Eccleston C, Crombez G. Pain demands attention: a cognitiveaffective model of the interruptive function of pain. Psychol Bull. 1999;125:356–366. 57 Algure´n B, Fridlund B, Cieza A, Sunnerhagen KS, Christensson L. Factors associated with health-related quality of life after stroke: a 1-year prospective cohort study. Neurorehabil Neural Repair. 2012;26:266–274. 58 Novy DM, Nelson DV, Francis DJ, Turk DC. Perspectives of chronic pain: an evaluative comparison of restrictive and comprehensive models. Psychol Bull. 1995;118:238–247. 59 Boivie J, Leijon G, Johansson J. Abnormalities in sensibility accompanying central post-stroke pain. Pain. 1987;Suppl. 4:S405. 60 Boccard SG, Pereira EA, Moir L, Aziz TZ, Green AL. Long-term outcomes of deep brain stimulation for neuropathic pain. Neurosurgery. 2013;72(2):221–230. 61 Rasche D, Ruppolt M, Stippich C, Unterberg A, Tronnier V. Motor cortex stimulation for long-term relief of chronic neuropathic pain: a 10 year experience. Pain. 2006;121:43–52. 62 Morley S. Efficacy and effectiveness of cognitive behaviour therapy for chronic pain: progress and some challenges. Pain. 2011;152:S99–S106. 63 de C Williams AC, Adams J, Cavill G, et al. Recommended guidelines for Pain Management Programmes for Adults. London: The British Pain Society; 2010.
