Chronic pain in elderly nursing home residents: the need for nursing leadership

The incidence of chronic pain amongst elderly people in nursing homes is very high, making pain in this population a serious problem for aged care facilities. Research studies reveal a pattern of poor pain management in this setting despite the high incidence of pain suggesting that the management of pain in nursing homes is limited in scope and only partially effective. What is not fully appreciated by health professionals is the impact pain has on the lives of elderly people who live in nursing homes. In the study reported here a phenomenological method was used involving several in depth interviews with elderly people over a period of 9 months. Field notes of observations were also recorded as the participants went about their everyday lives in the nursing home. The discussion focuses on some of the themes drawn from the study with an emphasis on a key theme 'being constantly pained'. The findings of the study highlight what it is like to experience pain and how this impacts on everyday lives of elderly people. The paper concludes with some suggestions for health professional for improving care in this area.     

Cancer-related pain and disability: a longitudinal study

Context

Although the cross-sectional association between cancer-related pain and disability is well established, their longitudinal relationship has been less studied.

Objectives

Data from the Indiana Cancer Pain and Depression (INCPAD) trial were analyzed to determine whether baseline cancer-related pain and changes in pain over time predict disability over 12 months.

Methods

A total of 274 cancer survivors with cancer-related pain were accrued in the INCPAD trial. Data were collected at baseline, one, three, six, and 12 months by interviewers blinded to treatment arm. Disability outcomes included a continuous measure (Sheehan Disability Scale [SDS] score) and a categorical measure (≥14 days in the past four weeks with a ≥50% reduction in usual activities). Predictor variables, operationalized by the Brief Pain Inventory, included baseline pain severity and changes in pain severity scores between each time point. Multivariable analyses were conducted adjusting for treatment group, baseline disability, and selected covariates including depression.

Results

Baseline pain severity did not predict disability outcomes at 12 months. However, improvement in pain severity predicted less disability over 12 months both in terms of SDS scores (b = −0.17, t = −5.33, P < 0.001) and ≥14 disability days in the past month (odds ratio = 0.85; 95% confidence interval, 0.79–0.93; P < 0.001).

Conclusion

Disability over 12 months in patients with cancer-related pain is predicted by changes in pain severity over time. Results suggest that effective pain management may reduce subsequent disability among cancer survivors.     

The relationship between pain and functional disability in Black and White older adults

In this study we examined pain and disability in 115 community-dwelling, urban, older adults (mean age = 74 years; 52% Black, 48% White). Participants completed a survey of pain (pain presence, intensity, locations, and duration) and disability (Sickness Impact Profile). Sixty percent of the sample reported pain; Black and White adults did not differ on any pain variable. In structural equation models controlling for socioeconomic factors and health, pain did not mediate the relationship between race and disability. Race moderated the pain-disability relationship; pain was more associated with disability among Whites than Blacks. This study highlights the need for greater understanding of health disparities between Black and White older adults as they relate to pain and disability.     

Early maladaptive schema factors,pain intensity,depressiveness and pain disability: an analysis of biopsychosocial models of pain

Purpose: To test different biopsychosocial models of pain within two different samples. Method: Early maladaptive schemas, pain intensity, depressiveness and pain disability were assessed using questionnaire data from 271 first visit pain patients and 276 municipal employees as controls. Exploratory factor analysis was used as the early maladaptive schema factor extraction method and path analysis as the model specification and estimation method. Results: Cross-sectionally, early maladaptive schema factors were predictors of depressiveness in both groups. The effect size of depressiveness on pain disability was 11 times that of the pain intensity in the pain patient group. The situation was opposite in the control group, where effect size of pain intensity was 5.6 times that of depressiveness. In subgroups of pain duration, the effect size of pain intensity on pain disability became insignificant when pain duration was more than 2 years in pain patients. Conclusions: The study supported the importance of early emotional adversities in predicting depressiveness especially among pain patients. Depressiveness was the main predictor of pain disability in the pain patient group and as the pain duration increased, the significance of pain intensity on disability vanished. Pain intensity was the main predictor of pain disability in the control group.

Implications for Rehabilitation

• To decrease disability among chronic pain patients is mainly to treat their depressiveness.

• To decrease disability among people with mild pain is mainly to treat their pain intensity.

• The focus of psychotherapy among depressive chronic pain patients should be a pattern of inadequacy, shame, submission, failure, social isolation and dependence.

     

Self efficacy as a mediator of the relationship between pain intensity, disability and depression in chronic pain patients

To clarify the relationships between physical, and psychosocial components of chronic pain, a path analytic model was tested conceptualizing self efficacy as a mediator of disability. In turn, disability was hypothesized to mediate depression. This model could help explain the circumstances under which disability develops and why so many chronic pain patients become depressed. Questionnaires from 126 chronic pain patients (without prior depression) were reviewed from three pain clinics. Hypothesized and alternate models were tested using separate regression equations to identified models which best fit these data. Regression analysis supported that self efficacy partially mediates the relationship between pain intensity and disability. This model accounted for 47% of the explained variance in disability (P<0.001). Six additional variables that were significantly related to disability in preliminary analysis, added to the explained variance in disability (R²=0.56), with gender and pain location paths remaining significant. In separate regression analyses, disability was found to partially mediate the relationship between pain intensity and depression (b=0.47–0.33). This model accounted for 26% of the explained variance in depression. The addition of self efficacy to this model supported it as a stronger mediator (R²=0.32), and suggested that support for disability as a mediator of depression was a spurious finding. Both pain intensity and self efficacy contribute to the development of disability and depression in patients with chronic pain. Therefore, the lack of belief in ones own ability to manage pain, cope and function despite persistent pain, is a significant predictor of the extent to which individuals with chronic pain become disabled and/or depressed. Nevertheless, these mediators did not eliminate the strong impact that high pain intensity has on disability and depression. Therefore, therapy should target multiple goals, including: pain reduction, functional improvement and the enhancement of self efficacy beliefs.     

Differential changes in functional disability and pain intensity over the course of psychological treatment for children with chronic pain

Patients presenting for treatment of chronic pain often believe that pain reduction must be achieved before returning to normal functioning. However, treatment programs for chronic pain typically take a rehabilitative approach, emphasizing decreasing pain-related disability first with the expectation that pain reduction will follow. This information is routinely provided to patients, yet no studies have systematically examined the actual trajectories of pain and disability in a clinical care setting. In this study of youth with chronic pain (N = 94, 8 to 18 years), it was hypothesized that 1) functional disability and pain would decrease over the course of psychological treatment for chronic pain and 2) functional disability would decrease more quickly than pain intensity. Participants received cognitive behavioral therapy (CBT) for pain management (M = 5.6 sessions) plus standard medical care. The Functional Disability Inventory and a Numeric Rating Scale of average pain intensity were completed by the child at every CBT session. Hierarchical linear modeling was conducted to examine the longitudinal trajectories of disability and pain. Standardized estimates of the slopes of change were obtained to test differences in rates of change between pain and disability. Results showed an overall significant decline in functional disability over time. Although pain scores reduced slightly from pretreatment to posttreatment, the longitudinal decline over treatment was not statistically significant. As expected, the rate of change of disability was significantly more rapid than pain. Evidence for variability in treatment response was noted, suggesting the need for additional research into individual trajectories of change in pediatric pain treatment.     

Predictors of disability in migraineurs referred to a tertiary clinic: neck pain, headache characteristics, and coping behaviors

OBJECTIVE: The aim of this retrospective study was to determine if neck pain, select headache characteristics, and migraine-related coping response predicted disability in migraineurs referred to a tertiary headache clinic. METHODS: Patients seeking treatment at a neurology-based headache clinic were included if they met diagnostic criteria for migraine with or without aura according to the International Headache Society (1.1, 1.2). Subjects completed a self-report headache history form and a detailed headache and neurologic examination. The headache history form assessed: 1)weekly headache frequency; 2) number of weekly severe headaches; 3) presence of migraine-related neck pain; 4) photophobia; 5) phonophobia; 6) headache duration; 7) vomiting; 8) monthly headache-free days; and 9) behavioral coping style. Disability was assessed using a self-report inventory (HIT-6). RESULTS: Self-reported headache severity, frequency, and headache-free days were strongly associated with disability. The presence of neck pain during migraine and one's coping response to migraine significantly predicted disability independent of headache characteristics. CONCLUSIONS: These data suggest the need for prospective research exploring the causal mechanisms by which neck pain and coping response influence disability and underscores the importance of multidisciplinary approaches to headache management.     

Effect of music on power, pain, depression and disability

AIM: This paper reports a study testing the effect of music on power, pain, depression and disability, and comparing the effects of researcher-provided music (standard music) with subject-preferred music (patterning music). BACKGROUND: Chronic non-malignant pain is characterized by pain that persists in spite of traditional interventions. Previous studies have found music to be effective in decreasing pain and anxiety related to postoperative, procedural and cancer pain. However, the effect of music on power, pain, depression, and disability in working age adults with chronic non-malignant pain has not been investigated. METHOD: A randomized controlled clinical trial was carried out with a convenience sample of 60 African American and Caucasian people aged 21-65 years with chronic non-malignant pain. They were randomly assigned to a standard music group (n = 22), patterning music group (n = 18) or control group (n = 20). Pain was measured with the McGill Pain Questionnaire short form; depression was measured with the Center for Epidemiology Studies Depression scale; disability was measured with the Pain Disability Index; and power was measured with the Power as Knowing Participation in Change Tool (version II). RESULTS: The music groups had more power and less pain, depression and disability than the control group, but there were no statistically significant differences between the two music interventions. The model predicting both a direct and indirect effect for music was supported. CONCLUSION: Nurses can teach patients how to use music to enhance the effects of analgesics, decrease pain, depression and disability, and promote feelings of power.     

Chronic pain in adults with an intellectual disability: prevalence, impact, and health service use based on caregiver report

This study examined chronic pain in adults with an intellectual disability (ID), in terms of its prevalence, impact on physical and psychological functioning, and treatments used. Questionnaires were distributed to 2378 primary caregivers (caregivers) of community-dwelling adults with an ID. The questionnaires were used to gather data on demographics, general health, nature of pain, impact of pain, treatment, and health-related decision making. Responses were received from 753 caregivers (31.6% response rate). Caregivers reported that 15.4% of this sample was experiencing chronic pain, for an average of 6.3 years. Significantly more females than males were reported to experience chronic pain, although age, communication ability, and level of ID were not found to be associated with the presence of pain. However, the presence of pain was associated with cerebral palsy, physical disability, and reports of challenging behaviour. A significant proportion of individuals with chronic pain also experienced limitations in several aspects of daily living, and more than 78% of caregivers reported that the service user had become upset or distressed by pain. More than 80% of service users were receiving some form of treatment for their pain, with most seeing a family physician and using analgesics as the primary form of pain treatment. Results indicate that chronic pain is a significant problem for persons with an ID, with a proportion of service users living with daily pain for many years and experiencing limitations in daily functioning, emotional well-being, and quality of life.     

Responsiveness of pain, active range of motion, and disability in patients with acute nonspecific low back pain

Many parameters are now used for investigations in clinical settings, such as pain, active range of motion (AROM), and disability, but it is not yet known which parameters are responsive in patients with acute nonspecific low back pain (LBP). This study aimed to investigate the responsiveness of pain, AROM, and disability in patients with acute nonspecific LBP. Fifty subjects were assessed for pain, AROM, and disability at baseline and after 6 weeks. The effect size (ES) was calculated for each parameter. Also, patient’s perception of change was collected after 6 weeks for correlating it with change scores for each parameter. The most responsive parameter for detecting the change in patients with acute nonspecific LBP was pain (ES, 1.57) and disability (ES, 0.93). However, AROM was proved to be less responsive. This study indicated that pain and disability were responsive in detecting the changes in patients with acute nonspecific LBP over time.     

Effect of muscle energy technique and static stretching on pain and functional disability in patients with mechanical neck pain: A randomized controlled trial

BackgroundMechanical neck pain is one of the common musculoskeletal disorders. Muscle energy technique (MET) may be a useful intervention for treating such disorder.ObjectiveThe aim of this study was to compare the effect of MET with passive stretching on pain and functional disability in people with mechanical neck pain.MethodsA randomized controlled trial was undertaken. Sixty patients with mechanical neck pain were randomly allocated to either the MET group or control group. The former group received MET, and the latter group received static stretching. Both groups received conventional therapy. Treatment was given once a day for 6 days. A visual analogue scale (VAS) was used to measure the intensity of pain, and functional disability was assessed using the neck disability index (NDI) was immediately before treatment and again on the 6^th day.ResultsVAS and NDI scores showed a significant improvement in both MET and stretching groups on the 6^th day postintervention (p < 0.05). However, both VAS and NDI scores showed better improvement in the MET group as compared to the stretching group (p < 0.025).ConclusionMuscle energy technique was better than stretching technique in improving pain and functional disability in people with mechanical neck pain.     

The association between cognitive factors,pain and disability in patients with idiopathic chronic neck pain

Purpose.?The aim of this study was to establish the relationship between known cognitive factors and levels of pain and disability in patients with idiopathic chronic neck pain.

Method.?Ninety-four patients referred for physiotherapy because of chronic neck pain completed measures of pain, disability, catastrophising, pain-related fear, pain vigilance and awareness and self-efficacy beliefs. Hierarchical multiple regression analyses were then performed to establish whether the cognitive factors were significant determinants of levels of pain and disability.

Results.?The cognitive measures were significantly related to levels of pain and disability, explaining 23% of the variance in pain intensity and 30% of the variance in disability. Specifically, greater catastrophising (β?=?0.37, p?<?0.05) and lower pain vigilance and awareness (β?=???0.32, p?<?0.05) were associated with greater pain intensity. Moreover, greater catastrophising (β?=?0.26, p?<?0.05) and lower functional self-efficacy beliefs (β?=???0.34, p?<?0.001) were significantly associated with greater levels of disability.

Conclusions.?Cognitive factors were strongly related to levels of pain and disability in patients with chronic neck pain. In view of this, targeting the modification of these cognitive factors should be an integral part of therapy when treating patients with idiopathic chronic neck pain.     

The relationship between self-efficacy and disability in chronic low back pain patients

This study examined the reliability of an adapted version of the Arthritis Self-Efficacy Scale in a sample of 59 chronic low back pain patients. The present study also investigated the relationship between self-efficacy and measures of disability. Regression analyses indicated a significant negative relationship between self-efficacy and low back pain disability. That is, patients who report higher levels of self-efficacy have higher activity levels (R ²=0.34,P<0.01), work more hours (R ²=0.25,P<0.01), and have lower levels of psychological distress (R ²=0.29,P<0.01), pain severity (R ²=0.46,P<0.01), and pain behavior (R ²=0.27,P<0.01) after controlling for the demographic variables of gender, duration of back pain, and having a lawyer on retainer. The results support the use of the Back Pain Self-Efficacy Scale (BPSES) as a general measure of self-efficacy in the chronic low back pain population.     

Work status and chronic low back pain: exploring the international classification of functioning,disability and health

Purpose.?Exploring which variables are related to work status in patients with chronic low back pain (CLBP), classified according to the International Classification of Functioning, Disability and Health (ICF).

Method.?Ninety-two patients with CLBP filled out questionnaires inquiring after health status, impairments in body functions/structures, limitations in activities of daily living (ADL), participation in work, environmental and personal factors. Additionally, patients performed tests to measure physical fitness and performance of work-related activities. Univariate analyses were performed to investigate whether differences exist between working and non-working patients. Logistic linear regression analysis was performed to explain work status from the variables of functioning.

Results.?Non-working patients had a lower self-reported physical and mental health, lower physical fitness, more self-reported limitations in ADL, lower education, more depressive symptoms and higher psycho neuroticism than working patients. Self-reported physical and mental health and educational level correctly classified 84.5% of the patients as working or non-working. Performance of work-related activities was not significantly related with work-status.

Conclusions.?The relation between work status and CLBP is multidimensional, as was illustrated by using the bio-psychosocial model of the ICF. Patients with a low educational level, a low self-reported physical or mental health were more likely to be non-working. Self-reported limitations and physical and mental health are more important in explaining work status than objective measurements of performance.     

Socioeconomic status predicts functional disability in patients participating in a back pain trial

Purpose. To investigate whether socioeconomic status in patients with back pain participating in a randomised controlled trial was predictive of functional disability (Roland Disability Questionnaire, RDQ).

Method. Secondary analysis of data (n = 949) from a national primary care trial of physical treatments for back pain (UKBEAM trial) using multilevel modelling. The three indicators were Townsend scores, educational levels and work status.

Results. All indicators were significant predictors of outcome after adjusting for baseline variables. As Townsend scores increased (indicating greater deprivation) RDQ scores (functional disability related to back pain) increased. Lower levels of educational attainment were associated with higher RDQ scores. Those ‘Not in Work’ reported markedly higher levels of RDQ scores which increased over time. There was no evidence that one particular treatment was more suitable for participants of different socioeconomic status.

Conclusions. The findings from this study add to the body of literature which suggests the importance of socioeconomic factors as an influence on health, including resultant disability related to chronic musculoskeletal conditions such as back pain. Work status was particularly dominant in our findings and may suggest that helping patients with back pain back to work where appropriate, is an especially important part of the management process.     

Neck pain and disability: a cross-sectional survey of the demographic and clinical characteristics of neck pain seen in a rheumatology clinic

This hospital-based cross-sectional cohort study examines the clinical and demographic features of neck pain, disability (using the Northwick Park neck pain questionnaire) and relationships to handicap in employment. Of 173 consecutive referrals to a rheumatology clinic with neck pain, 70% had neck/arm pain without neurological involvement, 13% other conditions, 11% nerve involvement and 5% other spinal pain. 141 patients (mean age 50 years) had mechanical or degenerative neck pain, of which 13% was probably work-related and 13% was trauma-related. 44 had taken sickness absence for an average of 30 weeks. Comorbidities were frequent (lumbar pain 51%). Those in work were significantly less disabled than those not working (p = 0.001) and those off sick (p < 0.01). Those reporting sleep disturbance, tearfulness and crying were significantly more disabled (p = 0.0001) than those who did not. Neck pain in secondary care is complicated by physical and emotional comorbidities. Comprehensive management requires a biopsychosocial model of care.     

社区老年人慢性病患病状况及其对生活功能的影响

目的研究社区老年人慢性病患病现状及对日常生活功能的影响。方珐应用OARS问卷（中文版）对武汉市城区3个社区卫生服务中心辖区内648名60岁及以上的社区老年人慢性病患病状况及其对日常生活功能的影响进行调查。资料统计方法采用X^2检验和非条件Logistic回归模型分析。结果老年慢性病患病率为85．8％,居前5位的疾病是高血压病、关节炎与风湿疾病、消化系统疾病、慢性肺部疾病、心脏疾病。日常生活功能（activities of daily living,ADL）的受损率为55．1％,生理性日常活动功能（physical activities of daily living,PADL）的受损率为15．6％,工具性日常生活功能（instrumental activities of daily living,IADL）的受损率为54．8％。致老年人ADL功能障碍作用最强的疾病为慢性肺部疾病、消化系统疾病、关节炎及风湿疾病、心脏疾病、中风及青光眼,老年人患慢性病的数量越多,ADL受损率越高。培论慢性病是老年人的重要健康问题,对其日常生活功能有显著影响,应大力开展老年保健工作,提高老年人的生活质量。     

An estimation of the functional disability burden in elderly Chinese age 70 years and over

A cross-sectional survey of functional status among elderly Hong Kong Chinese aged 70 years and over was carried out to estimate the current burden of disability. Two thousand and thirty-two subjects (999 men, 1033 women) were recruited by random sampling of the old age and disability allowance schemes covering over 90% of the elderly population, stratified by sex and 5-year age groups. Functional ability was administered using the Barthel Index. The duration of disability, if any, was also noted. The prevalence of disability for different activities of daily living varied from 0.8% to 26% (lowest for feeding and highest for climbing stairs and bathing). The prevalence was higher for women than men, and higher in the older age group for both sexes. Men in the 80 + age group had shorter duration of disability compared with those in the 70–79 age group, and compared with women. Using disability years (estimated number of elderly with disability in the population × median duration of disability) as an estimate of disability burden, the number ranges from approximately 19000 (inability to feed) to 100000 (inability to climb stairs). This estimate may be useful in the planning of service provisions for the formal and informal care sector.