quality of life

The impact of pain management on quality of life


ResearchBlogging.org

What exactly is quality of life? And what is pain management? This article, presented at a 2002 Roundtable on ‘The role of coxibs in successful pain management’ is written by a medical researcher, which should give you a bit of a clue about how pain management is defined for the purpose of this paper (i.e. pain control). Much of the discussion about quality of life measures, however, is useful, and the article itself is reasonably short – and it talks the language of doctors, which I thought gives an interesting slant.

Firstly, the point is made that quality of life involves assessment over multiple dimensions, with the World Health Organisation’s ‘Domains and factors of quality of life’ being used as an example of the domains that can be considered. For those who haven’t reviewed this recently, there are six domains:
1. Physical
2. Psychological
3. Level of independence
4. Social relationships
5. Environmental health
6. Spirituality
and a final ‘general’ facet that evaluates ‘overall perceptions of health and quality of life’.  This link to WHOQOL leads directly to the Seattle Quality of Life Group website.

The point is made that pain affects cognitive, motivational, affective, behavioural and physical components, and quality of life has a similarly all-encompassing nature. Katz points out that ‘quality of life … can be defined as an individual’s ability to perform a range of roles in society and to reach an acceptable level of satisfaction from functionoing in those roles’, but at the same time recognising that quality of life research is relatively new, and the effects of pain on quality of life is only just beginning to be investigated.

When we’re choosing any assessment tool, there are some practical things to consider – quite apart from the psychometric properties of the instruments we may think of. Katz nicely identifies some considerations:
1. Which is more applicable – a disease-specific or generic instrument? He identifies that there are both advantages in specific measures (for example, able to detect more subtle change) as well as disadvantages (difficulty comparing across patient groups). The SF-36 (Medical Outcomes Study Short Form 36) is suggested as a general health status measure that combines the ‘best’ of both worlds.
2. What dimensions of quality of life need to be measured? Katz acknowledges that quality of life measures are multi-dimensional since ‘an instrument that does not include several dimensions will make it impossible to determine the nature of a score change’. The areas of physical, psychological, social, somatic, and spiritual are thought to be important, and again the SF-36 is identified as a key contender because of the breadth of dimensions included.
3. How much responder burden is acceptable? This refers to the amount of work needed to complete the questionnaires – an important consideration when we recognise that many people don’t like paperwork, or have relatively low reading levels.
4. What administrative issues need to be considered? Ahhh, now that’s an excellent point! A very comprehensive database that I know of has been abandoned from time to time because of difficulty obtaining clerical time to score and enter questionnaires, and in the mists of time, some of the original scoring ‘rules’ have been lost… Questionnaires used in pain outcome measurement need to be applied at least twice, more appropriately three or four times – and ‘compliance’ or the number of people who complete all of the measures all of the time reduces over time…
5. Has the instrument been validated, and is it reliable? Well, this goes without saying… and should be a ‘given’ for people working in the area of pain management.

There are a number of issues that this paper does not cover well.
Firstly, there is an assumption that if quality of life is reduced when pain is experienced, an individual’s quality of life should improve simply by reducing pain intensity. While this intuitively makes sense, it assumes that pain intensity alone is responsible for loss of quality of life. Reports of pain intensity are influenced by things like psychological distress, fear of injury, fear of being out of control, low mood, health anxiety and so on (e.g. Severeijns, Vlaeyen, van den Hout & Weber, 2001). When analgesia is used, while it may reduce pain intensity it may not address underlying issues such as low mood, health anxiety, and most especially fear of injury. The latter is one reason some patients tell me they don’t want to take medication, because it ‘masks’ pain!

Katz suggests that ‘analgesic agents should be compared … incorporating the use of symptom distress scales, which may be the most sensitive way of discriminating among analgesics in effects of quality of life’. I suggest that distress scales may not be the most appropriate measure of effectiveness in quality of life, and in fact changes across several domains such as Physical, Psychological, Level of Independence, and Social Relationships should be observed before an intervention should be considered ‘successful’.

Another issue is that although Katz indicates that taking repeated measures is important, he makes little mention of the need for longer-term followup. At least part of the initial response from any intervention is likely to be due to the ‘meaning response’, or expectancies or placebo response that people have simply from having been given a treatment. As a result, it’s important to measure changes in quality of life (and any other outcome measure) some months or even years later after the treatment is first initiated. The risk otherwise is that an initial lifting of mood, sense of hope, even physiological changes secondary to placebo can subside over time – and in the end, it’s the effects that are sustained that are important.

However, it’s difficult to argue with Katz on this: quality of life measures should be included as a key variable in future pharmacological research. Personally, I think it should be included as an outcome measurement of any pain management intervention.

For further information on a broader range of outcome measures that are being considered for pain management, this article by Dworkin and colleagues provides some insights into the areas that the IMMPACT group recommend: (1) pain; (2) physical functioning; (3) emotional functioning; (4) participant ratings of improvement and satisfaction with treatment; (5) symptoms and adverse events; and (6) participant disposition.  Worth a read – and they’re continuing to publish more on this area.

Katz, N. (2002). The Impact of Pain Management
on Quality of Life. Journal of Pain and Symptom Management, 24(1S), S38-S47.

Severeijns, R., Vlaeyen, JWS., van den Hout MA., & Weber, JWA., (2001)Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment. The Clinical journal of pain vol. 17, no2, pp. 165-172

Accepting Low Back Pain: Is It Related to a Good Quality of Life?


ResearchBlogging.org

Victoria L. Mason, Beth Mathias, and Suzanne M. Skevington

This study examines an area of disability ‘adjustment’ that is becoming increasingly important in to therapists and others interested in what helps someone develop readiness to adopt self management rather than an ongoing search for a ‘cure’.

Acceptance refers to ‘a willingness to have pain without feeling the need to control or eliminate it’, and is associated with ‘acknowledging that one has pain, giving up unproductive attempts to control pain, acting as if pain does not necessarily imply disability, and being able to commit one’s efforts towards living a satisfying life, despite pain.’ (McCracken, 1998; McCracken, Spertus, Janeck, et al. 1999; McCracken & Vowles, 2006)

Over the last 10 years or so, there has been a growing use of patient-centred measures of outcome for measuring the impact of programmes for chronic pain, including the WHOQOL, which is an instrument developed by the World Health Organisation covering 25 dimensions of life including pain and discomfort. This study was intended to explore the relationship between a more pain-specific addition to the WHOQOL tool and a measure of pain acceptance previously developed by McCracken and colleagues, and to identify the clinical implications of the findings.

Measures 

The Short-form Pain Acceptance Questionnaire or SFPAQ is a psychometrically robust questionnaire that has been used to measure the degree of acceptance that people with chronic pain have towards their pain. The original CPAQ total score is associated with standardized measures of emotional distress and daily function. It contains items such as ‘‘My life is going well, even though I have chronic pain’’ and ‘‘It’s not necessary for me to control my pain in order to handle my life well.’’ The SFPAQ uses 20 of the original 34 items, obtained by factor analysis, and has superior psychometric properties to the original version. The two factor structure of the SFPAQ measures ‘activity engagement’ or the willingness to pursue activities despite pain, and ‘pain willingness’ which is a measure of the recognition that avoidance and control are unworkable ways to adapt to a life with pain.

The authors point out that reliability results obtained from pain samples using the WHOQOL pointed to a need for developing a specific module of extra items that would elaborate the QoL, and that could be added to the WHOQOL core instrument when used by chronic pain patients. This would enable a more detailed account of pain and discomfort related to QoL to be explored by people with pain within the framework proposed by theWHOQOL group.

The participants

Pragmatically, an ‘opportunistic, purposive sample of patients with diagnosis of CLBP’ was recruited from two outpatient pain clinics at local General Hospitals: an epidural clinic (Salisbury) and a pain management clinic (Bath). Exclusion criteria for the study were minimal and consisted of psychiatric conditions and conditions where fatigue is a major factor. Of 162 patients invited to participate, 86 took part (response rate 53%). This is quite a low response rate, but given that they were sent a letter and asked to complete a questionnaire and post back or hand it in at the appointment, probably quite reasonable. Unfortunately no details of the nonresponders were able to be collected.

The respondent group appear very similar to those referred to any tertiary pain management centre – more women than men, the majority were married, ranging in age from 17 years to 92 years (mean 54.3 years), not in paid work, considering themselves to be unwell, with pain being ‘discomforting’ and ‘continuous’. Lower back and spine pain was the most frequent pain site (90.7%), with the legs (70.9%) and pelvis (25.6%) the next more common pain site.

Findings 

Results? Glad you asked! Unsurprisingly, acceptance is strongly and positively associated with QoL. Strongest associations were found for the SF-CPAQ (r=0.582, P<0.001) and the subscales of pain willingness (r=0.493, P<0.001), and activities engagement (r=0.455, P<0.001). Higher QoL scores were also associated with lower pain intensity.

“To summarize, engagement in activity is an important predictor of psychologic, independence, and environmental QoL, in addition to pain-related facets assessed by the PDM. Willingness to recognize that avoidance and control may be unworkable explain, in part, physical and environmental QoL and pain-related facets (PDM). Overall, acceptance contributed significantly
to explain QoL relating to level of independence, the environment, and PDM facets, but less so for other domains, particularly social relationships and spirituality, which did not appear to be explained by either present pain level or acceptance. Present pain level seems to be
an important predictor of the physical, social, and painrelated dimensions of QoL. Although R2 change values indicate that present pain level also contributed significantly to explain levels of independence, the effect of pain level decreases when acceptance is included in the model,
indicating shared variance here”.

What does this mean for you and me as clinicians?

Methodological criticisms aside (cross-sectional studies, convenience samples, small number of participants and low response rates) this study demonstrates that people who accept their pain seem to have a greater quality of life (or perhaps that people with better quality of life achieve greater acceptance?).  Because pain intensity has an important influence on QoL, it suggests that pain reduction strategies should continue to be pursued at least until the well-established ones relevant to the specific condition have been tried.  However, at some point, it seems important to stop continuing with pain reduction and move towards pain management, and most of this should be self management rather than relying on others (or external locus of control) to do so.  This is because, despite pain intensity having an influence, it’s influence was weaker than acceptance and QoL.

This study demonstrates the utility and psychometric robustness of both the WHOQOL-Pain and the SF-CPAQ in a clinical sample.  Both of these measures can be employed within pain management programmes to monitor individual progress and to look at how patients from different diagnostic groups change during treatment.  The authors also suggest they can be used ‘to benefit chronic pain research, clinical trials, clinical governance, and audit’. (Mason, Mathias & Skevington, 2008).

As I noted above, this study can’t answer whether QoL is influenced by acceptance, or whether acceptance is influenced by QoL.  This will require further study – and this sort of study will also help identify whether acceptance-based interventions improve QoL, as well as which aspects of pain acceptance (activity engagement or pain willingness) are most influential.

My one concern with this study is this:

  • it’s already difficult to get some biomedical practitioners to consider anything other than pain intensity (reported often immediately after a procedure!), or to refer to cognitive behavioural pain management,
  • that to introduce another measure (however theoretically sound or patient-centred) on another dimension (that is new and relatively difficult to implement) is going to be fraught with difficulty.

I haven’t yet really come to grips with how to present acceptance or contextual cognitive behavioural therapy to patients.  I need to learn more about this – so expect some more posts as I get my head around the concepts!!

References 

McCracken LM. (1998). Learning to live with the pain: acceptance of pain predicts adjustment in persons with chronic pain. Pain. 74, pp21–27.

McCracken LM, Spertus IL, Janeck AS, et al(1999). Behavioural dimensions to adjustment in persons with chronic pain: pain-related anxiety and acceptance. Pain. 80, pp283–289.

McCracken LM, Vowles KE. 2006. Acceptance of chronic pain. Current Pain Headache Reports. 10, pp90–94.

Skevington SM, Carse MS, Williams AC de C. (2001). Validation of the WHOQOL-100: pain management improves quality of life in chronic pain patients. Clinical Journal of Pain. 17, pp264–275

Mason, V.L., Mathias, B., Skevington, S.M. (2008). Accepting Low Back Pain: Is It Related to a Good Quality of Life?. Clinical Journal of Pain, 24(1), 22-29. DOI: 10.1097/AJP.0b013e318156d94f