A hotly debated question in some pain management clinicians minds is whether to simply address pain intensity, or to focus on ‘other’ issues such as improved function, reduced distress, reduced fear, better mood and so on. Well, to me it’s no debate, actually. I can’t provide pain reduction strategies per se – I’m not a physiotherapist, I’m not a doctor, and although I care deeply about reducing suffering, I’m not especially bothered about reducing pain. Why? Well, pain intensity fluctuates depending on a whole lot of things, including mood, distress (feeling fed up with the situation), fatigue, attention, the meaning of the pain, expectations, the degree of perceived control - as the King in ‘The King and I’ – etcetera, etcetera, etcetera…!
So, I don’t really look at pain intensity with people except in passing…
Well, in looking through my in-tray I came across this paper written by several Swedish researchers who have conducted a series of studies with participants attending the Pain and Rehabilitation Clinic, University Hospital, Uppsala, Sweden. It’s an interesting study comparing a group of participants referred to the clinic (a total of nearly 300, actually), with a ‘Reference’ group of people drawn from the general population of Sweden (these people were studied some years ago).
The dimensions being examined were Life Satisfaction, as measured by the LiSat questionnaire developed by Fulg-Mayer et al (2002); the relationship between life satisfaction and demographic data such as gender, age, immigration status, educational level, and vocational status; and the relationship between life satisfaction and pain intensity.
Sweden must be an amazing country in some ways – they have a National Quality Registry for Pain Rehabilitation that has established a set of questionnaires that need to be used within pain rehabilitation. Amongst the questionnaires are the West-Haven Yale Multidimensional Pain Inventory, the Disability Rating Indenx, the Hospital Anxiety and Depression Scale, the Modified Somatic Pain Questionnaire, and the Visual Analogue Scale, along with socio-demographic data. I can’t imagine this quite lengthy set of questionnaires being completed by many of the people I come into contact with every day, let along a group of clinicians agreeing on a set of questionnaires that everyone should use!! That aside, it’s a great opportunity for cross-comparisons between different providers, and to review trends in time as well.
The original ‘Reference’ group for the LiSat questionnaire were drawn from the general population. About 12% of these respondents reported they had persistent pain of some kind (although details are not known about their pain). Questionnaires from participants were completed between medical assessment and multidisciplinary assessment, and before treatment.
And the results?
Firstly, the Reference group and patient groups differed on some counts: patients were less likely to be employed, first of all, which has quite a significant on life satisfaction generally. Then patients were less satisfied with their lives – not unexpectedly. The ‘fit’ of the factors differed slightly between the two groups, suggesting that there were some differences in the way people answered the questions between patients and the Reference group, but not a large difference. In addition, patients from outside Northern Europe were less satisfied than those born in Northern Europe – no-one really knows why. Finally, the only LiSat domains that correlated with pain intensity (and then only weakly) were financial situation and physical health.
Areas that didn’t differ? Well, life as a whole, vocation, leisure, contacts with friends and acquaintances, sexual life, ADL, family life, partner relationships, and pyschological health.
OK, so the patient group generally didn’t feel as satisfied as people from the general population – but the difference between people within the patient group wasn’t about pain intensity as much as it might have been expected. Pain intensity on the Visual Analogue Scale was a mean of 60.6 (SD 19.3) and a mode of 62 (IR 24.5), so there were some people who had quite high levels of pain. Even fiddling about with cut-off scores (cut-off of 62), and then using four groups (VAS 0 – 40; 41 – 60; 61 – 80; 81 – 100), made little difference – the only two differences were in financial situation and physical health, with similar but only minimal associations when correlating with individual LiSat domains.
Hmmm. What’s going on here? Well, it’s not surprising that life satisfaction was lower in the patient group – seeking treatment may very well be an expression of lower life satisfaction. The main areas of difference between the patient group and the Reference group were in ‘physical health’ and ‘psychological health’, with ‘life as a whole’, ‘vocation’ and ‘leisure’ also being quite different. What we don’t know is whether the pain caused low life satisfaction, or whether life satisfaction influenced treatment seeking, or whether in fact, low life satisfaction is a risk factor for developing persistent pain.
In terms of overall life satisfacgtion and demographic factors, the findings confirmed previous findings by the developer of the LiSat scale (Fulg-Meyer, 2002) that first generation immigrants have a higher level of risk for having lower levels of satisfaction with life. Men also scored lower than women with their satisfaction with ‘economy’ – that may be because it is more important to a man to be providing economically for their family, or some other reason – we don’t know. But this finding was unrelated to education, although age was positively associated with vocational and financial satisfaction in the original study.
Because the Reference group included 12% of respondents who identified that they had persistent pain, the authors indicate that they can’t really tell whether long-term pain alone was responsible for the lower life control scores. However, it was clear that pain intensity, whether above or below the cut-off score, or even within the group sub-groups, had little relationship with overall life satisfaction, except with the physical health subscale. They also found that it was reasonable that pain is associated slightly with lower satisfaction with financial situation – perhaps this is about having higher sick leave therefore a lower income, or perhaps about worries about future employability.
We don’t know whether life satisfaction changes over the course of having chronic pain – these participants had pain for an average of six and a half years. Perhaps life satisfaction reduces initially, then improves as people adjust, or perhaps it is high initially and gradually deteriorates as people become settled into a pattern of chronicity and low mood.
What the authors, and I, conclude from this study is that within a group like this, pain intensity is a poor indicator of life satisfaction. As they say, and I can only agree, ‘This emphasises the importance of interventions for patients with long-term pain but also that pain intensity does not necessarily indicate those with the highest needs, at least if an increased life satisfaction is the goal…this does not exclude that interventions to reduce pain may increase life satisfacton for the individual.’
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Annika Silvemark, Håkan Kallmen, Kamilla Portala, Carl Molander (2008). Life satisfaction in patients with long-term non-malignant pain-relation to demographic factors and pain intensity Disability & Rehabilitation, 30 (25), 1929-1937 DOI: 10.1080/09638280701748773