The Utility of the Millon Behavioral Health Inventory in the Study of Chronic Headaches

SYNOPSIS
The present study evaluated the use of the Millon Behavioral Health Inventory (MBHI) in predicting response to a behavioral treatment program for headache reduction. A secondary goal was to also assess whether the MBHI could significantly differentiate among headache patients, patients with other types of chronic pain, and normal subjects. Twenty-three chronic headache sufferers were administered a behavioral treatment program which consisted of 16, one-hour weekly sessions. During the course of the treatment program, subjects were requested to keep daily records of four measures which later served as the treatment-outcome indices: (1) daily number of headaches, (2) duration of headaches, (3) intensity of headaches, (4) medications taken. Results demonstrated that a number of MBHI scales significantly predicted response to treatment. Also, it was found that the MBHI significantly differentiated the chronic headache patients from the normal controls and patients with other forms of chronic pain.     

The Brief Pain Inventory: pain's interference with functions is different in cancer pain compared with noncancer chronic pain

OBJECTIVES: The Brief Pain Inventory (BPI) is a highly recommended and frequently used multidimensional pain assessment tool. The BPI includes 2 dimensions: pain intensity and pain's interference with functions. Our aims were to explore how patients respond to pain interference items by comparing responses from patients who had cancer with patients who had noncancer chronic pain (NCCP), and to explore how different levels of health-related quality of life affect upon pain's interference with functions. METHODS: Three hundred patients with cancer and 286 patients with NCCP were asked to complete the BPI and the European Organization for Research and Treatment of Cancer's Quality of Life Questionnaire (EORTC QLQ-C30). The pain interference items were indexed into total interference, interference with physical functions, and interference with psychologic functions. Regression analyses were used to explore differences in pain's interference by group, pain intensity, and a possible interaction effect between them. The analyses were adjusted for age, sex, and all EORTC QLQ-C30 scales. RESULTS: The cancer patients reported higher values of physical interference than NCCP patients with the same level of pain intensity (P<0.001). NCCP patients reported higher values of psychologic interference than cancer patients (P=0.023). For total interference, these effects eliminated each other. When adjusting for age, sex, and the EORTC QLQ-C30 subscales, the results still remained significant except that adjusting for the subscale for physical function made the group effect insignificant for physical interference (P=0.30). DISCUSSION: The results indicate that patients are unable to report isolated pain's interference using the BPI. When reporting pain's interference with physical functioning, the level of physical functioning is more important than the level of pain. Patients' diagnoses have to be taken into account when interpreting reported pain's interference with functions.     

Determinants of vocational disability in patients with low back pain

Eighty-seven unemployed subjects with low back pain were recruited from an orthopedic back pain clinic and were given a battery of physical and psychologic tests. Subjects were contacted six months later to determine their current compensation status and whether they had returned to work. Age, length of time out of work, how much they had lifted in their previous job, the number of weeks they had been compensated, current activity levels, leg pain, and various psychologic factors significantly differentiated those who worked from those who did not. Physical examination findings and testing of the ability to lift were not significantly related to return to work. It is suggested that demographic, job-related, and psychologic factors should be emphasized, rather than only physical capacity, in the evaluation of vocational potential and the assessment of disability in patients with low back pain.     

STRETCH: a rehabilitative program for patients with breast cancer

Participants in an exercise-based rehabilitative program for women with breast cancer were evaluated for physical disability. Of 114 women who were evaluated initially, there was almost universal evidence of restriction of range of motion or abnormal posture. Of the 47 women who were available for evaluation after completion of the eight-week program, 42 showed increases in one or more movements with no concomitant decreases. Five patients had a decrease in a single measurement. Of 96 participants evaluated for psychosocial benefits, two thirds reported positive psychologic effects.     

Cosensitization of pain and psychiatric comorbidity in chronic daily headache

Chronic migraine occurs in approximately 20% of migraineurs, typically developing over a period of many years. The pathophysiology of this transformation is unknown. However, experts have associated chronic headache with analgesic overuse, physical injury, and psychologic trauma. Research in post-traumatic stress disorder has found that hippocampal sensitivity to stress alters and often amplifies future pain behaviors. Although the most obvious difference between migraine and chronic migraine is the frequency of headaches, this article discusses chronic migraine as a more pervasive neurologic disease in which the patient’s neurologic and psychologic function fails to return to a normal baseline. The sensory and affective components of pain are cosensitized, producing other neurologic and psychologic symptoms during and between episodes of headache. A staging paradigm is suggested that defines patients and assesses their overall neurologic function. The goal of this classification is to identify cosensitization early and pinpoint migraine patients who are at risk of developing chronic migraine.     

Change factors explaining reductions of "interference" in a multidisciplinary and an exercise prevention program for low back pain

OBJECTIVES: To identify relevant changes in process variables that are associated with outcome following an exercise and a multidisciplinary secondary prevention program for low back pain. METHODS: Data from a randomized controlled clinical trial to examine the effectiveness of an exercise and a multidisciplinary prevention program were analyzed using multiple regression analyses. The specific goal was to examine the amount of variance in changes in "interference" postintervention that could be explained by prechanges to postchanges in physical and psychologic parameters, and to determine if there are interactions between physical/psychologic parameters and the program type. RESULTS: One hundred sixty-two (89%) participants were included in the regression analyses. Reductions of interference at postmeasurement were explained best by reductions of pain intensity and catastrophizing in the multidisciplinary and the exercise prevention program. No significant interaction between the changes in process variables and the program type was found. The final model could explain 68.7% of variance. CONCLUSIONS: Owing to methodologic limitations, strong conclusions cannot be drawn from this study. The findings suggest that treatment success in exercise and multidisciplinary interventions might be influenced by the same change factors, namely changes in pain and psychologic factors. The results raise the question of whether the mechanism through which exercise works, is improve in physical variables, or rather a change in psychologic attributes, in that people correct their irrational cognitions by making experiences that differ from their expectations. If these findings can be confirmed in longitudinal studies with more measurement points, they would have implications for treatment refinement.     

Physical function and fear of falling after hip fracture rehabilitation in the elderly

OBJECTIVE: The purpose of this study was to determine the relationship between physical function and fall-related self-efficacy in older patients with a hip fracture who are undergoing an intensive rehabilitation program. DESIGN: We used a prospective cohort study over 12 mo to determine the effect of a specialized hip fracture rehabilitation program in a geriatric hospital on physical function and fear of falling. Fifty-six patients were admitted consecutively from acute care. Physical function was assessed using the Functional Independence Measure, and fall-related self-efficacy was measured using two scales: the Falls-Efficacy scale and the Activities-Specific Balance Confidence scale. We also used the Vitality scale to measure quality of life. All measures, represented by change scores, were determined at the beginning and end of the patients' rehabilitation programs. RESULTS: Significant improvement in physical function and fall self-efficacy was observed. The Vitality scale was also improved after rehabilitation. The Falls-Efficacy scale appeared to be more sensitive to change than the Activities-Specific Balance Confidence scale, whereas no correlation was found between changes in the fall-related self-efficacy measures and the Functional Independence Measure. CONCLUSIONS: These findings may represent a discrepancy between attention of the rehabilitation program on functional outcomes and less emphasis on confidence building behaviors. Restrictions in function from a fear of falling may negate any gains made through rehabilitation, and this could limit the long-term success of these programs and patient outcomes after hip fracture.     

A revised group exercise program for osteoarthritis of the knee

The purpose of this study was to determine the effectiveness of a group exercise program for subjects with osteoarthritis of the knee referred for physiotherapy in terms of pain, physical function and gait. This study was initiated after an initial group exercise program at this centre failed to demonstrate significant changes in pain, physical function or gait. The study was based on repeated measures with a two month follow up, carried out in the outpatients department of a large public hospital. Pain levels in various functional situations were assessed on visual analogue scales, physical function with the Stanford Health Assessment Questionnaire, and quantitative gait variables at a normal and a fast self-selected speed with an electric foot switch walkway. On completion of the program (n=40) more than 90% of the pain and physical function scores demonstrated significant improvements without increases in medication, use of walking aids or fatigue. The gait variables of velocity, cadence and stride length at both self-selected speeds demonstrated significant increases at this assessment without deterioration of gait symmetry. All improvements were maintained at the two month follow up assessments. This study suggests that a clinically realistic group exercise program supplemented with a home program can reduce pain, increase physical function and objective gait measures in subjects with osteoarthritis of the knee. Copyright © 1997 Whurr Publishers Ltd.     

Pharmacologic maintenance of abstinence in patients with alcoholism: no efficacy of 5-hydroxytryptophan or levodopa.

Pharmacologic enhancement of central nervous system serotonin and dopamine functions has been postulated to improve maintenance of abstinence in patients with alcoholism. To test this hypothesis, patients with alcoholism who completed a 42-day inpatient treatment program were randomized to be administered, in a double-blind fashion, either 5-hydroxytryptophan and carbidopa, levodopa and carbidopa, or placebo for 1 year. Eight of 31 patients who entered the analysis remained abstinent from alcohol for 1 year; however, there was no significant effect of the treatment condition on maintenance of abstinence. Baseline psychologic measures showed that patients who abstained from alcohol had more education and higher scores on memory function tests. Measures of cerebrospinal fluid obtained before the start of the study indicated that all patients who had higher concentrations of the dopamine metabolite homovanillic acid relapsed, suggesting that further research is needed to elucidate the role of dopamine in alcoholism.     

The effect of aerobic training on rehabilitation outcomes after recent severe brain injury: a randomized controlled evaluation

OBJECTIVE: To examine the impact of fitness training with recently brain-injured inpatients on exercise capacity and functional and psychologic outcome measures. DESIGN: A randomized controlled trial of exercise versus relaxation training for 3 months. Blind assessments were conducted before and after the end of a 12-week training program, as well as at follow-up assessment 12 weeks posttraining. SETTING: Four regional neurologic inpatient rehabilitation units. PATIENTS: Of 157 patients recruited 24 +/- 14 weeks after single-incident brain injury, 142 patients were assessed at week 12, and 128 patients at follow-up. INTERVENTIONS: Patients were randomized between cycle ergometer aerobic training and a relaxation training control condition, which was theoretically inert with respect to cardiovascular fitness. MAIN OUTCOME MEASURES: Validation of exercise training (peak work rate, peak heart rate, body mass index); mobility and physical function (modified Ashworth scale, Berg balance scale, Rivermead Mobility Index, 10-m walk velocity); disability and dependency (Barthel index, FIMtrade mark instrument, Nottingham Extended Activities of Daily Living); and psychologic function (fatigue questionnaire, Hospital Anxiety and Depression Scale). RESULTS: Significant improvements in exercise capacity (p <.05) in the exercise training group (n = 70) relative to the control group (n = 72) were not matched by greater improvements in functional independence, mobility, or psychologic function, at either 12 weeks or follow-up. CONCLUSIONS: The benefits of improved cardiovascular fitness did not appear to extend to measurable change in function or psychologic state.     

Patient education program to teach energy conservation behaviors to patients with rheumatoid arthritis: a pilot study

We report a prospective, randomized pilot study comparing a new workbook-based program, designed to teach patients with rheumatoid arthritis (RA) energy conservation behaviors, with standard occupational therapy (OT). Sixteen patients took part in the new program and nine received the standard therapy. Data on the number of tender or swollen joints, grip strength, walk time, activities of daily living, psychologic adjustment to illness, and daily activity log, were measured before and three months after intervention. Eleven percent of those who received standard therapy and 50% of those who received the workbook increased their amount of physically active time (p = .10). Twenty-two percent of the control group and 50% of those in the workbook group achieved a better balance of rest and physical activity (p = .07). We conclude that the adoption of energy conservation behaviors is different in the two groups. This initial study suggests that interrupting physical activity with rest periods may result in increased physical activity in patients with RA.     

The martial arts

Given the increasing popularity of the martial arts, it is likely that physicians in all specialties encounter patients who participate. From pediatric patients, to geriatric patients, to those living with various disabilities, the martial arts may offer physical, psychologic, and therapeutic benefits. An appreciation of the physical demands of the martial arts is crucial to understanding the pathogenesis of injury as well as to planning treatment and prevention strategies and to determining safe return to participation after injury.     

Managing somatic preoccupation.

Somatically preoccupied patients are a heterogeneous group of persons who have no genuine physical disorder but manifest psychologic conflicts in a somatic fashion; who have a notable psychologic overlay that accompanies or complicates a genuine physical disorder; or who have psychophysiologic symptoms in which psychologic factors play a major role in physiologic symptoms. In the primary care setting, somatic preoccupation is far more prevalent among patients than are the psychiatric disorders collectively referred to as somatoform disorders (e.g., somatization disorder, hypochondriasis). Diagnostic clues include normal results from physical examination and diagnostic tests, multiple unexplained symptoms, high health care utilization patterns and specific factors in the family and the social history. Treatment may include a physician behavior management strategy, antidepressants, psychiatric consultation and cognitive-behavior therapy.     

Pectus excavatum.

Pectus excavatum is a congenital chest wall defect that can cause a marked cosmetic defect with attendant psychologic trauma and limitations of peak physical performance. Close observation of pectus excavatum is indicated, because this condition may improve or even disappear without treatment in some patients. However, in appropriate patients, timely surgical repair can give good cosmetic results and improve cardiorespiratory function, providing both physical and psychologic benefits.     

老年脑卒中患者的心理状态及护理对策

目的：探讨老年脑卒中患的心理状态及与接受预防教育的关系。方法：采用问卷调查法，从老年脑卒中110例中筛选出心理异常，统计心理异常接受预防教育的情况，观察心理正常组与心理异常组患间病程的差异性。结果：110例患中心理异常发生率占69．31％，其中未接受预防教育占心理异常的95．71％，其心理异常发生率明显高于接受预防教育(48．57％)。心理异常患治疗过程中其运动、语言等功能的恢复明显低于心理正常。结论：老年脑卒中患心理异常发生率较高，其发生率与是否接受预防教育有明一显的相关性。且心理异常明显影响老年脑卒中患康复。适时做好预防教育及支持性心理护理。可有效地减少脑卒中发病率及缩短病程，加快患各项功能的恢复。提高生活质量。     

The usefulness of clinical measures of psychologic factors in patients with spinal pain

Objective

The purposes of this study were to investigate whether a screening procedure could capture important psychologic factors with minimum burden to the patient and to investigate whether correlations exist among the various psychologic factors.

Methods

A screening procedure consisting of the 11-item Tampa Scale for Kinesiophobia, a 2-question coping strategies screen, and the depression and anxiety subscales of the Bournemouth Disability Questionnaire was provided to consecutive patients with neck pain (NP) or low back pain (LBP) as part of the usual initial assessment process at a busy spine center, which includes chiropractic and physical therapy. Correlations and associations between these variables were determined.

Results

Data were collected on 95 patients with NP and 260 patients with LBP. Statistically significant correlations and associations were found between all measures in both cohorts with the exception of depression and coping in patients with NP. Statistically significant associations were found among all measures in both cohorts with the exception of depression and coping and coping and fear in patients with NP.

Conclusion

This study showed that a screening procedure may provide useful clinical information regarding psychologic factors that are of potential relevance in patients with NP and LBP.     

Self-perceived physical,psychologic, and general symptoms in survivors of testicular cancer 3 to 13 years after treatment

Due to the large group of patients with advanced testicular cancer now being cured, it is important to identify the men who are at risk of deteriorated health.The purposes of this study were: (1) to delineate and compare frequency of self-perceived physical, psychologic, and general symptoms in men treated for testicular cancer with those of a general population sample and (2) to compare self-perceived physical, psychologic, and general symptoms in relation to secondary Raynaud phenomena, sexual dysfunction, infertility, and self-perceived attractiveness in different treatment modalities. The subjects were 277 survivors of testicular cancer (M = 42.2 years) who had completed a self-reported questionnaire (75.5% response rate). A population survey comprising 392 men was used as a comparison group (M = 45 years).The result demonstrated that although survivors of testicular cancer as a group reported significantly less frequency of backache, leg pain, cough, and eye problems than did the general population sample, they described that they significantly more often felt cold. Men reporting secondary Raynaud phenomena, infertility, and/or feeling less attractive had experienced significantly more self-perceived symptoms. Oncologist nurses could play an important role in psychologic counseling for those men.     

Adding life to later years through exercise

Exercise should be part of everyone's daily routine. Most people can devise their own best program. However, geriatric patients often require the active participation of the physician, whose task is complicated by the special physical, psychologic, social, and economic needs of this age-group. A regular, safe program will make exercise more pleasant. Exercise and activity should be a way of life. Exercise can help to achieve better physical and mental health, thereby improving the quality of life.