S110
Abstracts
The Journal of Pain
G04 Interdisciplinary Approaches (536) A cognitive-behavioral based self-management approach to physical therapy: improving surgical spine outcomes K Archer, S Mathis, S Vanston, C Devin, D Spengler, M McGirt, J Cheng, O Aaronson, and S Wegener; Vanderbilt University Medical Center, Nashville, TN The purpose was to determine the efficacy of a cognitive-behavioral based physical therapy (CBPT) intervention in patients having surgery for a lumbar degenerative condition. Out of 249 eligible patients, 132 patients were consented preoperatively and screened for high fear of movement (Tampa Scale for Kinesiophobia > 39) between March 2012 and February 2013. Eighty-six patients, 22 to 81 years, were randomized into either the CBPT intervention group (n=43) or an education group (n=43). Surgical procedures included laminectomy with arthrodesis (71%) and without arthrodesis (29%). Patient assessments occurred preoperatively and at 6 weeks (baseline), 3 months (treatment completion), and 6 months after surgery. Assessors were unaware of the patient treatment condition. Outcomes were pain (Brief Pain Inventory), disability (Oswestry Disability Index), gait speed (4-Meter Walk), and functional mobility (Timed Up and Go). Patients were randomized using a stratified design based on screening TSK scores and type of surgery. Treatment sessions were delivered by a physical therapist. The first session was conducted in-person and the remaining 5 sessions were conducted over the phone. The manual-based CBPT intervention focused on goal-setting, problem-solving, cognitive restructuring strategies, and behavioral self-management. Analyses were intent-to-treat using mixed-effects models that adjusted for the baseline measurement of the outcome variable. No significant group differences were found for patient characteristics and baseline variables. The CBPT group demonstrated larger reductions in disability at 6 months and improvement in gait speed and functional mobility at 3 and 6 months compared to the education group (p < .05). No significant differences in pain were noted. A CBT-based self-management approach has the potential to improve surgical spine outcomes in patients atrisk for poor recovery. The CBPT intervention broadens the availability of effective pain self-management and behavior change strategies by expanding implementation to physical therapists and through a telephone delivery model.
(537) Reduced pain, improved functioning and psychological symptoms following adolescent hip preservation surgery H Richard, D Nguyen, A De La Rocha, and D Podeszwa; Texas Scottish Rite Hospital for Children, Dallas, TX Chronic hip pain is associated with psychological symptoms and maladaptive behaviors. These findings have been confirmed pre-operatively in adolescents undergoing hip preservation surgery (HPS). The current study investigated subsequent changes in pain, function, mood and maladaptive behaviors following adolescent HPS. 51 patients (32 females, 19 males; average age 17.6, range 1221) undergoing HPS for various orthopaedic diagnoses were assessed pre- and post-operatively using three psychological measures: Behavioral Assessment System for Children, 2nd Edition (BASC-2), Beck Youth Inventory, 2nd Edition (BYI-II), and Resiliency Scales for Children and Adolescents; and two functional measures: modified Harris Hip Score (mHHS) and UCLA activity score. Patients were also educated about surgery, rehabilitation and pain management by staff psychologists peri-operatively. At 12-month follow-up, patient sample reported reduced pain (mHHS: 23.50 to 32.70, p<.001) and improved function (UCLA: 7.11 to 8.82, p<.01; mHHS: 65.74 to 82.33, p<0001). Patient sample also reported reduced anxiety post-operatively (BASC-2: 49.20 to 45.51, p<.01; BYI-II: 47.47 to 44.80, p<.05). Resiliency Scales demonstrated reduced emotional reactivity (46.59 to 43.55, p<.05), increased mastery (50.51 to 53.31, p<.01) and increased resourcefulness (49.79 to 52.67, p<.01). Percentage of patient sample reporting depressive symptoms also decreased from 13% to 6%. Post-operative pain was positively correlated with anxiety, depression and emotional reactivity for patients who pre-operatively reported psychological symptoms. Conversely, post-operative function negatively correlated with psychological symptoms. However, these correlations are not evident when analyzing the entire patient sample. Findings suggest that it is important to identify psychologically at-risk patients prior to HPS to maximize perioperative intervention and post-operative outcomes. Research has demonstrated that pre-operative depression and anxiety scores were predictive of post-operative pain and patient satisfaction. Consequently, pre-operative psychological evaluation should be considered prior to surgery selection as mental health conditions may be undiagnosed and will likely influence pain and functional outcomes.
(538) Efficacy of an outpatient, multidisciplinary VA pain management clinic: findings from a one-year outcome study D Cosio and E Lin; Jesse Brown VA Medical Center, Chicago, IL Meta-analyses offer clear evidence that multidisciplinary chronic pain management programs offer patients the greatest opportunity for relief. However, according to the Committee for the Accreditation of Rehabilitation Facilities (CARF), the number of accredited programs in the U.S. has decreased in the last decade or specific practices have been "carved out." However, the outpatient Pain Management Clinic at Jesse Brown VA Medical Center opened in April 2009 and was staffed by a unique team composition, including pain physicians, a physician’s assistant, a psychologist, a pharmacist, an osteopath, and nursing staff. In light of the VA’s mission to engage in evidenced-based practice, the investigators evaluated the efficacy of this program. A total of 546 veterans were consulted to the clinic between February 1, 2010 and January 31, 2011. Veterans completed a pre-treatment intake and were asked to complete the post-treatment discharge upon completion of the program. At intake, 341 patients reported taking opioids regularly with an average duration of 4 ½ years of therapy and reported little to no relief with opioid use. Post-treatment, veterans reported a statistically significant decrease in pain severity and improvements in mobility, ADL’s, vitality, and affect. However, there was no significant difference found in levels of ‘‘fear.’’ The number of veterans on chronic opioids significantly decreased, and the degree of relief increased while maintaining the duration of treatment. Overall, patients enrolled in the clinic made significant improvements in most of the outcome measures. There were also fewer patients taking opioids by the end of the study, and those who remained on opioids reported higher relief with opioid use. Patients discharged from the clinic also reported high levels of satisfaction with the care they received. Despite some limitations, this study shows that participation in a clinic staffed by such a unique team composition resulted in overall improvement.
(539) The art of initial Biofeedback and Relaxation Training session within an Interdisciplinary Pain Management Program F Laevsky, C Gagnon, S Stanos, and J Atchison; Rehabilitation Institute of Chicago, Chicago, IL The majority of patients selected for the interdisciplinary pain management program had no prior experience with formal relaxation training or biofeedback and many had a limited understanding of what to expect from such training. In order to facilitate patient understanding of the training and to enable them to experience benefits during initial session, we developed a standardized sequence of education and techniques which were implemented during the first session. The following sequence was used for 70 patients: introduction/education, instant reduction of muscle tension (‘‘letting go’’), focused breathing, diaphragmatic breathing, and Imagery. At the same time patients were introduced to biofeedback as ‘‘computerized physiological mirror.’’ Measures included patient report of pain and tension, surface EMG, skin conductance (SC), respiration, and skin temperature collected prior to and following treatment. Pain ratings were also assessed during treatment. All data was analyzed using paired-samples t tests with significance set at p <.05. Statistically significant pre-post reductions were found for pain intensity (t= 8.29, p=.000), ratings of tension (t= 8.69, p=.000), sEMG (t= 2.16, p=.034), SC (t= 2.76, p=.007), and respiration (t= 16.77, p=.000). Skin temperature significantly increased, as expected (t= -2.23, p=.029). Pain ratings during treatment were also significantly reduced (t= 15.38, p=.000), with 71% reporting no pain. Examination of patient reports and data shows that patients’ first experience demonstrated their ability to reduce pain, in the majority of cases down to 0, and tension with good physiological response to relaxation. We think that we developed universal and very effective way to educate patients regardless their prior experience and diagnosis. Patients’ initial success may facilitate the development of self-confidence in their abilities to reduce pain and tension and in capabilities to improve physiological functions of their body and overall to cope with chronic pain much better.