Adjustment to Chronic Pain in Back Pain Patients Classified According to the Motivational Stages of Chronic Pain Management

The Journal of Pain, Vol 7, No 6 (June), 2006: pp 417-427 Available online at www.sciencedirect.com

Adjustment to Chronic Pain in Back Pain Patients Classified According to the Motivational Stages of Chronic Pain Management Stefanie Zenker,* Michael Petraschka,* Michael Schenk,* Anett Reißhauer,† Tanja Newie,‡ Kai Hermanns,‡ Klaus-Dieter Wernecke,§ and Claudia Spies* *Department of Anesthesiology and Intensive Care Medicine, † Department of Physical Medicine, ‡ Outpatient Clinics in Berlin, and § Department of Medical Biometrics, Charité Campus Mitte, University Hospital Charité, Charité-University Medicine Berlin, Germany.

Abstract: According to Prochaska’s transtheoretical model, the Freiburg Questionnaire stages of chronic pain management (FQ-STAPM) were used to classify chronic back patients into 4 distinct motivational stages. The FQ-STAMP was completed by 163 chronic back pain patients. Pain chronicity was measured by the Mainz Pain Staging System; pain intensity was measured by the numeric rating scale. Healthcare system expenses were considered as number of consulted physicians, number of stays in hospital, and number of rehabilitation programs. As psychometric tests, the lower pain disability index (PDI), the Hospital Anxiety and Depression Scale (HADS), and a quality of life score (SF36) were used. Patients were in the following motivational stages: precontemplation in 30%, preparation in 19%, action in 30%, maintenance in 21%. The intensity of pain in the precontemplation stage patients was significantly higher compared to patients in the maintenance stage. A lower pain chronicity was related to a significantly higher motivation. Moreover, there was a significant increase in healthcare system expenses by the lesser motivated patients. Patients in the maintenance stage used significantly less opioids than patients in the precontemplation stage. The higher motivated patients had a significantly lower PDI, a significantly lower HADS, and a significantly higher quality of life compared to less motivated patients. Perspective: The study indicates that the FQ-STAPM might be a useful tool to classify chronic back pain patients and to work out a strategy together with the patient relevant to the outcome of pain management among chronic back pain patients. © 2006 by the American Pain Society Key words: Chronic back pain, German Freiburg Questionnaire (FQ-STAPM), motivation.

B

ack pain is one of the most common health problems for which people consult their physician.13 The epidemic-like rise in chronic low back pain in Western industrial nations is less an expression of a medical

Received September 7, 2005; Revised December 30, 2005; Accepted January 18, 2006. The work was supported by the German Health Ministry BMG 217-437945/5 and the German Research Society (DFG-PE 892/2-1). Address reprint requests to: Claudia Spies, MD, Professor of Anesthesiology, Department of Anesthesiology and Intensive Care Medicine, Charité-University Medicine Berlin, Charité Campus Mitte, Schumannstrasse 20/21, 10098 Berlin, Germany. E-mail: claudia.spies@ charite.de. 1526-5900/$32.00 © 2006 by the American Pain Society doi:10.1016/j.jpain.2006.01.446

than a psychosocial phenomenon.4 Various biologic and psychosocial risk factors contribute to the continuing chronicity of pain, resulting in enormous direct and indirect costs totaling an estimated 45 billion USD annually.34 Chronic pain is an individually variable experience, incorporating physical, psychological, and social dimensions. The severity of chronic pain demonstrated significant correlation with psychological impairment, depression, disability, and time off work.27,7,11 More recent approaches of multimodal treatment, including medical, psychological, and cognitive-behavioral components such as a self-management approach, have shown a significant and lasting effect in patients with a high incidence of workplace incapaci417

418

Chronic Back Pain Patients: Assessment With the FQ-STAMP 4,12,32

tation and sick leave. However, as the multimodal treatment is an active treatment program demanding patient involvement, dropout rates between 5% and 70% are reported in the literature,32 which reduces therapeutic effectiveness and cost effectiveness. There has been growing interest in the chronic pain patient’s motivation and self-management training.21,20,12,18 The transtheoretical model (TTM) of behavioral change proposes that individuals may be at different stages of being prepared for behavior change and provides a useful way of understanding the concept of stages of change.28 The TTM might help to explain differences in a person’s success during treatment for a range of psychological and physical health problems.18 Kerns and colleagues20applied the transtheoretical model and the stages of change concept to chronic pain patients and developed the Pain Stages of Change Questionnaire (PSOCQ). The PSOCQ is composed of 4 reliable scales that are consistent with the stages (precontemplation, contemplation, action, maintenance) of the transtheoretical model. Preliminary support was provided for the predictive validity and utility of the PSOCQ and for the relevance of a stages of change model in addressing issues related to the self-management of chronic pain.1,19 Keefe and colleagues16 identified the stages of change in an arthritis population having persistent pain using a modified version of the URICA (University of Rhode Island Change Assessment). This instrument is well suited for complex problem behavior, because it yields scores for each stage of change for each individual instead of classifying individuals into a single stage. It is based on Prochaska’s transtheoretical model of change. According to Prochaska’s transtheoretical model, Maurischat and colleagues22 validated a questionnaire of a German version of the PSOCQ, the FQ-STAPM assessing stages of chronic pain management, in a mixed population of chronic pain patients. Item- and factor analysis resulted in 4 stages: precontemplation, preparation, action, and maintenance. No separate stage termination was identified. The results generally replicated the findings of Kerns and Habib18and also improved the discrimination between the action and maintenance stages. Taken together, we hypothesize that chronic back pain patients who report a commitment to a self-management approach (ie, patients on the action or maintenance stage) endorse less pain chronicity, fewer health care expenditures, less psychological symptom severity, and less pain-related disability. The goals of the present study were: (1) to classify chronic back pain patients into different motivational stages using the FQ-STAMP; (2) to determine whether there is a correlation between the stages of the FQSTAMP and the stages of chronicity according to the Mainz Pain Staging System; (3) to determine whether the stages of chronic pain management differ in terms of sociodemographic, pain-related, and psychometric variables; medicine-taking; and healthcare system expenses.

Methods Recruitment and Participant Characteristics After ethical committee (Charité Campus Mitte: 1514/ 2001, amendment 02.12.2003) and written informed consent, 206 patients with chronic back pain were evaluated. Chronic back pain was defined as pain that persists longer than 12 weeks. None of the patients had received a multimodal pain management including pain therapy, psychotherapy, and physiotherapy. All participants were volunteers who were recruited from the pain clinic of the Department of Anesthesiology and Intensive Care Medicine, Charité Campus Mitte, the Department of Physical Medicine, Charité Campus Mitte, and 2 outpatient pain clinics in Berlin (Drs. Newie and Hermanns) over a period from 2002 to 2004. Of the 206 patients, 168 (81%) patients returned their questionnaires and 163 patients filled in the questionnaire completely and were included in this observational study. Additionally, the participants were subjected to personal interviews. The pain therapist confirmed that the patients had chronic back pain.

Questionnaires German Questionnaire FQ-STAMP (Freiburg Questionnaire-Stages of Chronic Pain Management) Maurischat et al21 classified chronic pain patients including back pain patients, into 4 different motivational stages: precontemplation, preparation, action, and maintenance. The FQ-STAMP contains 17 items, 5 for the precontemplation, 4 for the preparation, 4 for the action, and 4 for the maintenance. Item composition of the Freiburg Questionnaire– Stages of Chronic Pain Management (FQ-STAPM) is as follows (translation of the German FF-STABS: Freiburger Fragebogen – Stadien der Bewältigung chronischer Schmerzen): 1. I’ve been working to learn skills in order to handle my pain, for more than one month. 2. I suspect that I have long-term pain problems, but there is nothing that I can really change. 3. Even if my pain didn’t go away, I’d be willing to change the way I’m dealing with it. 4. When my pain occurs, I stay calm and go about my usual everyday life. 5. A few weeks ago I started to develop strategies that are helping me to be in better control of my pain. 6. My pain is exclusively a medical problem, thus a matter for doctors to deal with. 7. Time has come for me to think seriously about a different approach towards my pain. 8. I’m 100% in control of my pain and its effect on my life. 9. For several months now, I have been taking suggestions from others and acting on them, regarding how I can better live with my pain.

ORIGINAL REPORT/Zenker et al 10. In spite of what the doctors say, I’m convinced that there must be a surgery or medication that would help to get rid of my pain. 11. Within the next months I’ll start to control my pain, before it ruins my life. 12. For several months now my pain has hardly influenced me. 13. For several weeks I’ve been learning different strategies that influence my pain. 14. The best solution for me is to find a physician, who can determine how I can get rid of my pain entirely. 15. In the near future I’m seriously intending to deal with my pain in a different way. 16. I’ve known for a long time, that I can control my pain. 17. I’m asking myself: “Why can’t simply somebody do something, so that my pain will go away?” Precontemplation ⫽ (2 ⫹ 6 ⫹ 10 ⫹ 14 ⫹ 17) Preparation ⫽ (3 ⫹ 7 ⫹ 11 ⫹ 15) Action ⫽ (1 ⫹ 5 ⫹ 9 ⫹ 13) Maintenance ⫽ (4 ⫹ 8 ⫹ 12 ⫹ 16) Participants rated the degree to which they agreed or disagreed with these items using a 5-point scale (1 ⫽ strongly disagree to 5 ⫽ strongly agree). Raw scores were transformed to a mean raw score for each stage. Patients were assigned to the following groups by using the FQSTAMP. The precontemplation stage represented patient perception of chronic pain as a purely medical problem that should receive some form of treatment, ie, the patient’s motivation is low. Preparation represented the beginning realization that coping skills might be of value in management of pain, but without any definitive commitment. The action stage represented a current commitment to acquire or master pain management skills. The maintenance stage represented perseverance in the application and continuing use of these skills, ie, the patient’s motivation is high. To assign the participants to the stages, the highest mean raw score for each stage of a patient was determined. In case of 2 equal mean raw scores, the mean raw score of the higher stage of motivation determined the stage of chronic pain management. In case of more than 2 equal mean raw scores, a classification into a specific stage was not possible.22 A classification of 155 patients out of 163 into 4 distinct motivational stages was possible. Therefore 8 patients who had 3 equal mean raw scores could not be classified and were excluded from the study.

German Mainz Pain Staging System (MPSS) The Mainz Pain Staging System is an interview-administered, multi-dimensional measure of chronic pain severity 10. The system suggests grading chronic pain in terms of 4 axes: time (persistence), spreading of pain site, medication use, and health care utilization. The whole scale consists of 10 items. The resulting score is used to

419 classify the pain problem to three stages of chronicity (I⫽ mild, II⫽ moderate, III⫽ severe chronic pain).7,27

German Pain Questionnaire (DSF) The German pain questionnaire (DSF) has been developed and validated by the Taskforce on “Standardization and Economy in Pain Management” of the German Chapter of the International Association for the Study of Pain (DGSS). The concept of the DSF is based on a bio (medical) – psycho – social pain model. The modular approach to pain assessment consists of: sociodemographic variables (eg, age, gender, body mass index, marital status, educational level and occupation); social factors (eg, retirement status, compensation and/or litigation status, disability for work); pain-related variables (eg, pain sites, temporal characteristics, duration, intensity); pain-associated symptoms (eg, social stress, sleep disorder, additional pain regions); previous pain treatment procedures (eg, number of consulted physicians, number of appointments, number of consulted specialization units, number of stays in hospital, and number of rehabilitation programs; case history); relieving and intensifying factors; comorbid conditions; pain-related disability (Pain Disability Index); affective and sensory qualities of pain (Pain Perception Scale); health-related quality of life (SF36).23 The Pain Disability Index (PDI) is a 7-item self-report instrument based on a 10-point scale that assesses perception of the specific impact of pain on disability that may preclude normal or desired performance of a wide range of functions, such as family and social activities, sex, work, life-support (sleeping, breathing, eating), and daily living activities.5 The Pain Perception Scale measures 2 dimensions of subjectively felt pain, the affective characterization (14 items) as well as modes of sensory characterization of pain (10 items) that allows multifaceted and standardized quantification of pain experience. Scale analyses demonstrate a below average, average, above average, and far above average of pain perception.9 The SF (short form)-36 is one of the most widely used health-related quality of life (HRQOL) instruments and has demonstrated high levels of reliability and validity in diverse patient populations. It has 36 items that measure 8 multi-item health concepts (ie, physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health) refer to a 4-week period. This instrument was developed to address the health-related concepts that are most influenced by disease states and their related treatments. The SF-36 can be scored to yield 2 orthogonal factor-based component summary scores for mental and physical health. The mental (MCS-36) and physical component summary (PCS-36) scores were derived from the 8 scales of the SF-36. The MCS-36 and PCS-36 are scored using a method that transforms the scores to a standardized scale (T-scores) with a norm of 50. Sample mean MCS-36 and PCS-36 scores above or below 50 can be interpreted as having better or worse HRQOL 30.

420

Chronic Back Pain Patients: Assessment With the FQ-STAMP

Table 1. Distribution of Chronic Back Pain Patients (%) Classified to the Three Stages of Chronicity (MPSS) on the Four Stages of Chronic Pain Management (FQ-STAMP) MPSS

PRECONTEMPLATION1

PREPARATION2

ACTION3

MAINTENANCE4

I n ⫽ 19 II n ⫽ 34 III n ⫽ 102

3 (6.4%) 10 (21.3%) 34 (72.3%)

– 10 (34.5%) 19 (65.5%)

3 (6.4%) 6 (12.8%) 38 (80.8%)

13 (40.6%) 8 (25.0%) 11 (34.4%)

P ⱕ.001

pz p1,2 0.670 p1,3 0.368 p1,4ⱕ0.001 p2,3 0.204 p2,4ⱕ0.001 p3,4ⱕ0.001

Abbreviations: MPSS, German Mainz Pain Staging System; FQ-STAMP, Freiburg Questionnaire-Stages of Chronic Pain Management; using ␹2 analysis (P) followed by post hoc analysis Mann-Whitney U test (pz).

Hospital Anxiety and Depression Scale (HADS) The Hospital Anxiety and Depression Scale (HADS) is an easy-to-use self-reporting questionnaire to assess levels of anxiety and depression. The HADS comprises statements that the patients rate based on their experience over the past week. The 14 statements are relevant to either generalized anxiety (7 statements) or “depression” (7 statements). Even-numbered questions relate to depression and odd-numbered questions relate to anxiety. Each question has 4 possible responses. Responses are scored on a scale from 3 to 0. The maximum score is therefore 21 for depression and 21 for anxiety. A score of 11 or higher indicates the probable presence of the mood disorder, with a score of 8 to 10 being just suggestive of the presence of the respective state. The 2 subscales, anxiety and depression, have been found to be independent measures. In its current form the HADS is now divided into 4 ranges: normal (0 –7), mild (8 –10), moderate (11–15), and severe (16 –21). Validation studies for the Hospital Anxiety and Depression Scale have been performed in various somatically compromised populations.33

Illness and Health Locus of Control Scale Schmitt et al29 distinguish 3 control beliefs: the patients’ behavior is regarded as most important for improvement during illness (internal locus of control); the own state of health is seen as dependent from other persons, who are engaged in the therapeutic process (powerful others locus of control), and the state of health is regarded as dependent from fate or chance influences (chance locus of control). Each dimension consists of 7 items. The questionnaire is in use for health and illness concepts (eg, patient compliance, treatment).

Statistical Analysis All data were analyzed by using the statistics program SPSS (statistical package for the social sciences) PC-version 10.0. The data were presented descriptively. All characteristics for ordinal and metrically not normally distributed variables were indicated as a median and a variation range; absolute and relative frequencies were used for nominal variables.

Data were exploratively analyzed and statistical measures such as median and interquartile range for ordinal variables as well as absolute and relative frequencies for nominal variables are presented. Because of the limited sample sizes and/or nonnormally distributed (continuous) variables, respectively, nonparametric tests were used. In the comparison of more than two (independent) groups of patients, the Kruskall-Walis test was applied. Post hoc comparisons of two groups each were carried out with the Mann-Whitney U test for independent samples. Nominal variables were analyzed with the help of the (exact) ␹2 test. Significance was assessed at the P ⬍ .05 level. The results have to be understood as explorative ones. Therefore, no multiple adjustments were carried out. The analyses were accomplished by using the statistics program SPSS (Version 11). The differences regarding the frequency distribution of the nominal variables were checked for significant results with the ␹2 test or at a too small case number with an exact test after Monte Carlo. P ⬍ .05 was regarded as significant.

Results Stages of Chronic Pain Management (FQ-STAPM) One hundred fifty-five chronic back pain patients could be classified in 4 distinct motivational stages. 47 patients (30.3%) were in the stage of precontemplation, 29 patients (18.7%) were in the stage of preparation, 47 patients (30.3%) were in the stage of action, and 32 patients (20.6%) were in the stage of maintenance. The highest mean raw score differed significantly from the other 3 stages by using the Kruskall-Walis test (data not shown).

Comparison of the Stages of Chronic Pain Management: Sociodemographic Variables The average age was 54 (19 –90) years, most participants were female (67%), and on average patients had suffered from pain for 7 (0.5–50) years. 28% of the participants reported a high school education or better. 76% of the patients were married or living with a partner, whereas 23% were living single. A series of chi-square analyses was conducted to determine whether there were significant differ-

ORIGINAL REPORT/Zenker et al

421

Table 2. Distribution of Chronic Back Pain Patients (%) Classified to Compensation Variables on the Four Stages of Chronic Pain Management (FQ-STAMP) COMPENSATION

VARIABLES

No seeking disability compensation Seeking disability compensation Application for disability compensation Full disability compensation Pension

PRECONTEMPLATION1

PREPARATION2

ACTION3

MAINTENANCE4

P

pz

6 (12.8%) 4 (8.5%) 7 (14.9%) 10 (21.3%) 20 (42.5%)

11 (39.4%) 2 (6.9%) 3 (10.3%) 9 (31.0%) 4 (13.8%)

8 (17.0%) 5 (10.6%) 10 (21.3%) 14 (29.8%) 10 (21.3%)

14 (43.8%) 1 (3.1%) – 7 (21.9%) 10 (31.3%)

.009

p1,2 0.007 p1,3 0.076 p1,4 0.064 p2,3 0.171 p2,4 0.558 p3,4 0.568

Abbreviation: FQ-STAMP, Freiburg Questionnaire-Stages of Chronic Pain Management; using ␹2 analysis (P) followed by post hoc analysis Mann-Whitney-U-test (pz).

ences among the 4 motivational stages on age, gender, body mass index, marital status, educational level, and profession. There were no significant differences among the different stages (data not shown).

Relationship Between the Stages of the FQ-STAMP and the Stages of Chronicity According to the MPSS Table 1 shows the distribution of 155 chronic back pain patients, classified in the 3 stages of chronicity (MPSS I, MPSS II, MPSS III), on the 4 stages of chronic pain management (FQ-STAMP). Patients of a lower level of chronicity according to the MPSS were classified significantly more frequently in the maintenance stage than in the precontemplation stage (p1/4 ⱕ 0.001), the preparation stage (p2/4 ⱕ 0.001), and the action stage (p3/4 ⱕ 0.001). The higher the level of chronicity, the significantly lower was the adoption of a self-management approach to chronic pain.

Comparison of the Stages of Chronic Pain Management: Compensation Variables Patients were receiving partial (16%) and full disability compensation (22%) related to their pain, 30% were retired, 8.6% were unemployed, and 33.7% were employed. The results of the chi-square analyses indicated that there were significant stage differences in compensation variables (P ⫽ .009). Using the post hoc analysis Mann-Whitney U, patients in the preparation stage sought significantly more disability compensation, applied significantly more for disability compensation, and received significantly more full disability compensation or old-age pension than patients in the precontemplation stage (Table 2; p1/2 ⫽ 0.007).

back pain patients grouped into the 4 stages of chronic pain management. The chi-square analysis indicated a significant correlation between the stages and the pain intensity (P ⫽ .005; P ⫽ .005). Using the post hoc analysis Mann-Whitney U test, the average and maximum intensity of pain in the precontemplation stage was significantly higher than in the maintenance stage (p1/4 ⫽ 0.002; p1/4 ⫽ 0.002) and the preparation stage (p1/2 ⫽ 0.002; p1/2 ⫽ 0.017). The maximum intensity of pain in the precontemplation stage was significantly higher than in the action stage (p1/3 ⫽ 0.015). There were no significant differences between the stages and pain duration (P ⫽ .403) respectively present pain intensity, using chi-square analysis. Patients in the precontemplation, preparation, and action stages suffered more from persistent pain compared to the patients in the maintenance stage. There were no significant differences between the stages of chronic pain management and social stress, sleep disorder, and additional pain regions. Patients in the maintenance stage, the action stage, the preparation stage could imagine influencing the pain significantly more than patients in the precontemplation stage (P ⫽ .006; p1/2 ⫽ 0.02; p1/3 ⫽ 0.003; p1/4 ⫽ 0.038 data not shown).

Comparison of the Stages of Chronic Pain Management: Pain-Related Variables One hundred sixteen (75%) patients suffered from low back pain, 6 (3%) patients suffered from thoracic back pain, and 33 (22%) patients suffered from cervical back pain. There were no significant differences between the 4 stages and the 3 different locations of back pain (data not shown). Fig 1 shows the average and maximum intensity of pain by using the numeric rating scale (NRS) in chronic

Figure 1. The average and maximum intensity of pain of 155 chronic back pain patients is documented with a numeric rating scale (NRS ranging from 0 to 10; 0 ⫽ no pain, 10 ⫽ most severe pain). Data represent medians ⫾ SEM grouped into the 4 stages of chronic pain management (FQ-STAMP), using chi-square analysis followed by post hoc analysis Mann-Whitney U test (p); *P ⬍ .05.

422

Chronic Back Pain Patients: Assessment With the FQ-STAMP

Figure 2. (A) The number of consulted physicians, (B) the number of appointments, (C) the number of consulted specialization units, (D) the number of stays in hospital, and (E) the number of rehabilitation programs of 155 chronic back pain patients are classified in the 4 stages of chronic pain management (FQ-STAMP). Data represent medians ⫾ SEM, using ␹2 analysis followed by post hoc analysis Mann-Whitney U test (p); *P ⬍ .05.

Comparison of the Stages of Chronic Pain Management: Healthcare System Expenses There were significant differences among the 4 stages of chronic pain management in the number of consulted physicians (P ⫽ .004), of appointments (P ⫽ .002), of consulted specialization units (P ⫽ .008), of

stays in hospital (P ⫽ .036), and of rehabilitation programs (P ⫽ .00). Patients in the maintenance stage consulted significantly fewer physicians compared to patients in the precontemplation stage (p1/4 ⫽ 0.015), in the preparation stage (p2/4 ⫽ 0.001), and in the action stage (p3/4 ⫽ 0.005; Fig 2A). Patients in the maintenance stage visited the physicians significantly less frequently than patients in the precontemplation

ORIGINAL REPORT/Zenker et al

423

Distribution of Chronic Back Pain Patients (%) Classified to Orthodox Medicine Treatment, Physiotherapy, Psychotherapy and Alternative Medicine Treatment on the Four Stages of Chronic Pain Management (FQ-STAMP)

Table 3.

VARIABLE Conventional medical treatment Yes No Physiotherapy Yes No Psychotherapy Yes No Alternative medicine treatment Yes No

PRECONTEMPLATION1

PREPARATION2

ACTION3

MAINTENANCE4

P .081

46 (97.9%) 1 (2.1%)

29 (100.0%)

45 (95.7%) 2 (4.3%)

28 (87.5%) 4 (12.5%)

44 (93.6%) 3 (6.4%)

26 (89.7%) 3 (10.3%)

41 (87.2%) 6 (12.8%)

25 (78.1%) 7 (21.9%)

12 (25.5%) 35 (74.5%)

7 (24.1%) 22 (75.9%)

17 (36.2%) 30 (63.8%)

10 (31.3%) 22 (68.7%)

18 (38.3%) 29 (61.7%)

7 (24.1%) 22 (75.9%)

18 (38.3%) 29 (61.7%)

10 (31.3%) 22 (68.7%)

.224

.615

.546

Abbreviation: FQ-STAMP, Freiburg Questionnaire-Stages of Chronic Pain Management; using ␹2 analysis (P).

stage (p1/4 ⫽ 0.001), in the preparation stage (p2/4 ⫽ 0.018), and in the action stage (p3/4 ⫽ 0.008; Fig 2B). Patients in the maintenance stage consulted significantly fewer different specialists than patients in the precontemplation (p1/4 ⫽ 0.005), the preparation (p2/4 ⫽ 0.006), and action (p3/4 ⫽ 0.003; Fig 2C) stages. Patients in the maintenance stage stayed significantly less frequently in the hospital compared to patients in the action stage (p3/4 ⫽ 0.006, Fig 2D). Patients in the maintenance stage joined significantly more rehabilitation programs than patients in the other stages (p1/4 ⫽ 0.007, p2/4 ⫽ 0.007, p3/4 ⫽ 0.001; Fig 2E). There were no significant differences between the 4 stages in conventional medical treatment, physiotherapy, psychotherapy, and alternative medicine treatment (Table 3).

Pain Treatment Comparison of the Stages of Chronic Pain Management: The Use of Peripheral Analgesics, Tricyclic Antidepressants, Antiepileptic Drugs, Muscle Relaxants, and Opioids Analyses of chi-square tests were performed to identify differences between the 4 stages of chronic pain management in the use of peripheral analgesics (nonsteroidal anti-inflammatory agents, Cox-2-specific-inhibitor, metamizol, acetaminophen), tricyclic antidepressants, antiepileptic drugs, and muscle relaxants. No significant differences were found. However, there was a significant difference in the use of opioids. Patients in the maintenance stage used significantly less opioids than patients in the precontemplation stage (p1/4 ⫽ 0.002) (Fig 3). There was no significant difference between the 4 stages of chronic pain management and the frequency of opioid withdrawals (data not shown).

Psychometric Variables Patients in the maintenance stage had a significantly lower level of disability related to pain than patients in the precontemplation, preparation, and action stages (p1/4ⱕ0.001; p2/4 ⫽ 0.01; p3/4 ⫽ 0.006, Table 4). The Hospital Anxiety and Depression Scale (HADS) detected the presence of depression in 48% of the patients and detected the presence of anxiety in 36% of the patients. There were significant differences between the 4 stages of chronic pain management in depression and anxiety (P ⫽ .001). Patients in the maintenance stage had a significantly lower level of anxiety and depression compared to patients in the precontemplation (p1/4 ⱕ 0.001; p1/4 ⱕ 0.001), preparation (p2/4 ⫽ 0.009; p2/4 ⫽ 0.003), and action (p3/4 ⫽ 0.002; p3/4 ⫽ 0.001) stages (Table 4). The health-related quality (HRQOL) of life was decreased on average in all patients classified in the 4 stages of chronic pain management. Sample mean MCS-36 and PCS-36 scores were below 50. There were significant differences among the 4 stages in HRQOL

Figure 3. Data represent the distribution (%) of 155 chronic back pain patients using opioids on the 4 stages of chronic pain management (FQ-STAMP); using chi-square analysis followed by post hoc analysis Mann-Whitney U test (p); *P ⬍ .05.

424

Chronic Back Pain Patients: Assessment With the FQ-STAMP

Table 4. Distribution of Chronic Back Pain Patients (%) Classified to Psychometric Tests on the Four Stages of Chronic Pain Management (FQ-STAMP) PSYCHOMETRIC

TESTS

PRECONTEMPLATION1

PREPARATION2

ACTION3

MAINTENANCE4

Pain disability index*

46% (29–54%)

36% (28–42%)

39% (25–50%)

18% (5–36%)

HADS† Normal Mild depression Moderate, severe depression

6 (12.8%) 11 (23.4%) 30 (63.8%)

6 (20.7%) 7 (24.1%) 16 (55.2%)

7 (15.9%) 11 (31.8%) 23 (52.3%)

13 (41.9%) 12 (38.7%)] 6 (19.4%)

HADS† Normal Mild anxiety Moderate, severe anxiety

9 (19.1%) 17 (36.2%) 21 (44.7%)

5 (17.3%) 11 (37.9%) 13 (44.8%)

9 (20.5%) 17 (38.6%) 18 (40.9%)

18 (58.1%) 9 (29.0%) 4 (12.9%)

pz

ⱕ.001

p1,2 0.019 p1,3 0.059 p1,4 ⱕ0.001 p2,3 0.531 p2,4 0.010 p3,4 0.006 p1,2 0.337 p1,3 0.501 p1,4 ⱕ0.001 p2,3 0.748 p2,4 0.009 p3,4 0.002 p1,2 0.871 p1,3 0.789 p1,4 ⱕ0.001 p2,3 0.697 p2,4 0.003 p3,4 0.001 p1,2 0.267 p1,3 0.148 p1,4 ⱕ0.001 p2,3 0.723 p2,4 0.002 p3,4 0.008 p1,2 0.762 p1,3 0.522 p1,4 0.012 p2,3 0.435 p2,4 0.006 p3,4 0.022 p1,2 0.328 p1,3 0.043 p1,4 0.003 p2,3 0.440 p2,4 0.051 p2,4 0.051

.001

ⱕ.001

HRQOL‡ PCS

25.3 (18.8–29.6)

27.4 (22.6–32.2)

29.2 (23.9–35.3)

39.6 (28.5–47.6)

HRQOL‡ MCS

42.0 (32.0–51.6)

38.8 (34.4–50.1)

43.2 (37.4–53.6)

50.8 (43.2–58.5)

IHLCS§ Internal locus of control powerful others locus of control chance locus of control

P

.001

.025

ⱕ.001 1 (2.8%)

1 (5.3%)

2 (6.7%)

10 (41.7%)

21 (58.3%)

13 (68.4%)

23 (76.6%)

9 (37.5%)

14 (38.9%)

4 (26.3%)

5 (16.7%)

5 (20.8%)

*Data represent medians ⫾ SEM (average impact of pain on disability: 25–75%; above average impact of pain on disability: 75–90% and far above average impact of pain on disability: ⬎90%). †Data represent % of chronic back pain patients. HADS, Hospital Anxiety and Depression Scale. ‡Data represent medians (T-score) ⫾ SEM. HRQOL, health related quality; MCS/PCS, mental and physical component summary scores. §Data represent % of chronic back pain patients. IHLCS, Illness and health locus of control scale. FQ-STAMP, Freiburg Questionnaire-Stages of Chronic Pain Management; using ␹2 analysis (P) followed by post hoc analysis Mann-Whitney-U-test (pz).

based on mental and physical components (P ⫽ .001; P ⫽ 0.025). Patients in the maintenance stage had a significantly higher quality of life according to physical health compared to patients in the precontemplation, preparation, and action stages (p1/4 ⫽ 0.001, p2/4 ⫽ 0.002, p3/4 ⫽ 0.008). Patients in the maintenance stage had a significantly higher quality of life according to mental health compared to patients in the precontemplation stage (p1/4 ⫽ 0.012), the preparation stage (p2/4 ⫽ 0.006) and the action stage (p3/4 ⫽ 0.022; Table 4). Using the chi-square-test and the post hoc Mann-Whitney U test, we could reveal that patients in the maintenance stage significantly regarded their own behavior as most important for their improvement during illness com-

pared to patients in the precontemplation stage. Patients in the stage of precontemplation and action stages significantly regarded their state of health as dependent on fate or chance compared to the patients in the maintenance stage (P ⫽ .001, p1/4 ⫽ 0.003, p3/4 ⫽ 0.043; Table 4).

Discussion The results from the present study show that most patients could be classified into 1 specific motivational stage of a German version of the transtheoretical model, the Freiburg Questionnaire–Stages of Chronic Pain Management among chronic back pain patients. The FQSTAMP describes the willingness of behavior change for

ORIGINAL REPORT/Zenker et al pain management as a process characterized by 4 stages: precontemplation, preparation, action, and maintenance. According to the transtheoretical model, these motivational stages were identified in a sample of arthritis patients,16 in a sample of fibromyalgic patients,6 and in a heterogeneous sample of chronic pain patients as well.21 Keller and colleagues17 supported the applicability of the transtheoretical model for postural behavior contributing to the prevention of back pain and back pain chronicity. With the application of the FQ-STAMP to the readiness of treatment among chronic back pain patients, a treatment might be assigned according to the patient’s motivational preparedness in order to improve outcomes of pain management.21 Despite the demonstrated efficacy of cognitive-behavioral therapy as a part of the multimodal treatment of chronic back pain patients, it is apparent that patients may vary in the degree to which they are ready to adopt a self-management approach to pain.32,4 Patients who are resistant to selfmanagement approaches are less likely to be successful in a multimodal treatment.20 Therefore, growing interest is in the patient’s motivation and self-management stage.21 In the present sample of chronic back pain patients, 30% of the patients were in the precontemplation stage, 19% in the preparation stage, 30% in the action stage, and 21% in the maintenance stage. Habib, Morrissey, and Helmes12 showed a similar assessment to the stages among chronic pain patients, mainly back pain patients. Maurischat and colleagues21 classified chronic pain patients (80% back pain patients) into 13% precontemplation stage, 50% preparation stage, 22% action stage, and 12% maintenance stage. This result demonstrates that back patients are a heterogeneous group and challenges its treatment. Additionally, the data from the present study provide preliminary support for the utility and relevance of a stages-of-change model in addressing pain chronicity, pain intensity, healthcare system expenses, medicine taking, and psychometric variables related to the self-management of chronic pain. The data demonstrate that there is a significant relationship between motivation and pain chronicity. Patients with a lower level of pain chronicity were classified significantly more frequently in the maintenance stage than in a stage of less motivated patients. The severity of chronic pain depended on pain persistence, spreading of pain site, medication use, and health care utilization.7 This is a novel finding in chronic back pain patients. Heger and colleagues14 demonstrated that the state of chronification of psychomatic pain patients determined motivation for therapy. Predicting successful treatment, Pfingsten and colleagues25 showed that individual perceptions and experiences were more important than physical capabilities in back pain patients. Surprisingly, our data show that patients in stage III of the pain chronicity are found equally among the lesser and higher motivated patients. Pfingsten and colleagues27 found no difference in effectiveness of treatment between patients who were graded as severe pain

425 patients (stage III) and the other stages. In literature32,4,20 motivation is considered to be important for successful multimodal treatment in chronic pain patient. Hence, the FQ-STAMP might be a useful tool to identify patients with severe chronic pain for successful treatment. Our data didn’t provide any significant differences among the motivational stages on age, gender, body mass index, marital status, educational level, and profession. According to literature, these results are controversial. For example, Kerns and Rosenberg19 showed significantly more pain patients with a lower educational level in the precontemplation stage and showed significant differences on gender as well. Habib, Morrissey, and Helmes12 did not confirm these results. As the samples of patients are too heterogeneous and too small, further research should focus on a potential association of the motivational stages with sociodemographic factors. Consistent with previous work,21,19 we show that the average and maximum intensity of pain of less motivated patients is significantly higher than of patients in the maintenance stage. Patients in the precontemplation, preparation, and action stages suffer more from persistent pain compared to the patients in the maintenance stage. These results suggest that the less motivated patients might lack pain-coping strategies compared to the patients in the maintenance stage.21 Pain intensity might be a sign for the high pressure underlying the patients. According to the transtheoretical model, patients in the action stage could imagine that they could influence the pain significantly more than could patients in the precontemplation stage. Patients in the action stage appear to be working on pain-coping skills in contrast to lesser-motivated patients. Interestingly, we couldn’t show a significant difference between the action stage and the precontemplation/preparation stage. All participants of our study were recruited from pain clinics. Maurischat and colleagues22 recruited chronic pain patients via different facilities (eg, orthopedic clinic, rehabilition units, pain clinic). Therefore, the composition of the participants might be not comparable between the 2 studies. According to Maurischat and colleagues,21 there was a significant increase in healthcare system expenses by lesser-motivated patients. These patients consulted significantly more physicians, stayed more frequently in hospital, and joined more rehabilitation programs than patients in the other stages. Patients in the lower stages represent their perception of chronic pain as a purely medical problem that should receive some form of treatment. The own situation is seen as mainly dependent on health care utilization.15,31 These results are consistent with our data revealed by the classification of the patients to the pain chronicity stages. Maurischat and colleagues21demonstrated that patients in the precontemplation stage took medicine more frequently than patients in the maintenance stage. Our data is consistent with this finding. Moreover, we could show that patients in the maintenance stage used significantly less opioids than patients in the precontem-

426

Chronic Back Pain Patients: Assessment With the FQ-STAMP

plation stage. No significant differences were found in the use of peripheral analgesics, tricyclic antidepressants, antiepileptic drugs, or muscle relaxants. Interestingly, only 21% of the patients in stage I of pain chronicity used opioids compared to 87% of the patients in stage III of pain chronicity. Pain-related inactivity, difficulties in coping with pain, and feelings of helplessness and hopelessness of the less motivated patients may be due to increased medicine taking, eg, opioids. Finally, our results revealed significant differences between the motivational stages of chronic pain management on psychometric variables. The patients in the maintenance stage had a significantly lower PDI, a significantly lower HADS, a significantly lower level of affective pain perception scale, a significantly higher quality of life, and they significantly regarded their own behavior as most important for the improvement during illness compared to less-motivated patients. Generally, the psychometric data are consistent with the characteristics of the stage model (FQ-STAMP) based on the transtheoretical model. Maurischat and colleagues21 demonstrated a stage-dependent correlation between depression, anxiety, and control beliefs (locus of control) as well. Keefe and colleagues16 showed high levels of psychological and physical disability in the preparation stage. Our results reflect that the high psychosocial burden expressed by the patients and the prevalence of depressive and anxiety disorders emphasize the importance of effective diagnostic strategies to recognize mental disorders, and specialized psychological treatment. This treatment might provide psychological support and effective interventions for patients with chronic back pain.13

However, we couldn‘t demonstrate a significant difference between the patients in the action stage and the precontemplation/preparation stage. The transtheoretical model is a dynamic model. Patients in the action stage develop strategies to control their pain. Failure of the treatment in the action stage will increase their level of psychological and physical disability. This result is confirmed by the clinical experience in the pain therapy. One limitation of the present study concerns the recruitment procedure that may have led to a selective sample of patients. For example, patients who were not interested in the study may have not returned their questionnaire. Despite the fact that the study had 81% feedback and is considered representative, this might partly explain the variety of different results among the studies using the transtheoretical model. The study is a crosssectional study. Therefore, the study is limited on providing longitudinal data. Taken together, our results confirm previous findings.21,20 These results support the relevance of the FQSTAMP in addressing the association with pain chronicity, health care utilization, and pain-related and psychometric variables among chronic back pain patients. Patients who start a program at least partly convinced that managing pain is their responsibility benefit far more than patients whose notions of pain management remain focused on medical management.2 The interplay of motivation and disability in treatment programs might predict the outcome of pain management and might require distinguished communication skills to adapt to the patient needs. Future research should specifically address this question.3,8,10,24,26,30

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