Cognitive shifts during a pain management programme

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A RANDOMISEDCONTROL TRIAL EVALUATINGIN- AND OUTPATIENTPAIN MANAGEMENTPROGRAMMES

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J.L. Peters* and R.G. Large, Department of Psychiatry and

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Behavioural Science, School of Medicine, University of Auckland, Auckland, New Zealand.

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AIM OF INVESTIGATION: This study (1) investigated the clinical efficacy of in- and outpatient pain management programmes in comparison to a control group; and (2) analysed tiie cost-benefit of treatments. Data from 68 patients suffering from chronic pain (26 men, 42 women; mean age 43.9 years, range 23-82 years) were obtained. METHODS: Following physical and psychosocial assessments, and after obtaining informed consent, patients were randomly assigned to one of three groups: (1) a four-week multidisciplinary inpatient pain management programme; (2) a nine session (2 hours per week) multidisciplinary outpatient pain management programme; or (3) a control group. Self-report, behavioural and physiological measures were taken pre- and posttreatment, and at 6 and 12 months follow-up. Costs of health care were obtained for the 12 months preceding entry into the study, and for the 12 months following (from patients, G.P's, hospital and statutory records). RESULTS: Patients in the treatment groups demonstrated significant improvement at. posttreatment on measures of psychological distress, pain behaviour, health-related disability and pain intensity following physical exertion when compared with the control condition. Little difference between groups was demonstrated on the remaining measures. Despite attrition, the 6 and 12 month follow-up data suggest that treatment gains were maintained. Analysis of cost-benefit data showed a reduction in utilisation of health-care services after treatment, and demonstrated the high costs of chronic pain incurred by patients, medical and statutory services. CONCLUSION: The pain management programmes produced both a substantial improvement ilt patient functioning and a subsequent reduction in utilisation of health-care services.

COGNITIVE SHIFTS DURING A PAIN MANAGEMENT PROGRAMME. P.H.Richa&c% M.K.Nicholas and A. C de C Williama, INPUT,SouthWesternHospital and Department of Academic Psychiatry, UMD8,I&cm University, St nKlnas's Hospital, m, sEl7EIl,uK.

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AIM OF INVEXIGATIa:ibis study assessedthe natureand deteminantsof cognitive changein 60 patients duringandafterm to an inpatient cognitive-behavimal paina=me=nt Programne.

MEMKCS: A reviewofthe recentpainliterature revealsfew studies whichhave sys~ticallyinvestigated cognitive changeresulting fmn painmaMgernentpmgrzrtnk?s. Patientsundergoinga faurWe&intensiveinpatient ce9nitivebebavianalpai.n nranagerneat p~ccrqtletedthePainCognitiansQuestiormaire(PQJ;Bostcm,Pearce and RicMa&nn, 1989)and otherm of pain, mod, self-efficacy and dysfunction priorto s&is&n, at discharge and at a faurWeek follaw-up.The resultswereanalysed to determine(a) whetherandwhatsort of cognitive changeoccurred, (b) wkther any such change persisted at follow-upand (c)whichfactors,if any (pain,affectorbehaviour) werepmdictiveof cognitive change. REsuLTs:Ofthe fourfactors on the pqltwoslmed evidenceof significantpasitivechange fnrnpreto post treatwent assessment. *were (i)activecopingstrategies (distraction, self--, pc&tivethi&ing - p(.OOl)and (ii)hopelessness (pC.001). changeson both these factors weremaintainedat follow-up. Ihe remainingtwo factors O~lplessness and support/trust) gave no evidence of significant change. of the pretreatment measures currentpain intensity and distressrat*6 werepositively correlated withincreases in theuse of active copingstrategies following treatnmt (PC.OOlin both cases); ad high initial scorn cmthe

SicknessInpact Pmfile wem predictive of mhsquent reductions in hopelessness(p<.Ol) . Noneof the other pretreamt measums waspredictive of cognitive change. Iapravedscores cmbothactive copingandhop&mess following treatment wereassociatedwithparallel irrprarerrrents in self-efficacy Pain Self-EfficacyQwstiamaire - Nicholas, 1988)and reductim in currenta&ety (Sl'AI1 and depression @IX) levels. OXCLU8IC?J: Significant cognitive shiftswere observedfollowin a four Week intensivepain managmt

progranneandweremaintaimdat follow up. Treatedpatients sbfwedgreater use of active copingstrateg$es and reducedendorsamt of hopelessnessaqnitions. Pretreatamt pain levels and dysfunctionwere shownto be predictive of treatment-induced cognitive shifts whichwerealso accc0panim.l by changeon other psychological measures.