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Patient expectations about success of treatment and reported relief from low back pain
Journal of Psychosomatic Research, Vol. 24, pp. 297-301. Pergamon Press Ltd. 1980. Printed in Great Britain.
PATIENT EXPECTATIONS AND REPORTED MICHAEL
0022.3999/80/1201-0297$02.00/O
ABOUT SUCCESS OF TREATMENT
RELIEF FROM LOW BACK PAIN THOMAS* (Received
and DAVID LYTnEt
14 February
1980)
Abstract-Expectations of success from medical treatment for back pain seen at a hospital orthopaedic clinic. The degree of subjective relief provided treatments were compared. Moderator effects of self-concept, depression were studied. Patient ratings of reduced pain and amount of general relief differentially correlated with self-concept, depression and demographic patient ratings of general relief after treatment are complex and not simply
was measured in 95 patients by several different medical and demographic variables provided by treatment were variables. Results indicate a measure of pain reduction.
PSYCHOSOMATIC research investigates the involvement of psychological, social, economic, vocational, as well as many other conditions, and the relationship between these variables and the physical status of individuals. There is considerable literature which documents the interfacing between physical and psychological variables [l-5]. In particular, understanding of chronic low back pain presents difficulties. Clinically, evidence is often inconclusive as to the aetiology of the patient’s chronic complaints of pain. Furthermore, there is as yet no specific empirical treatment that is uniformly effective with pain of nonspecific aetiology. Some studies have documented that certain patient personality descriptions appear closely associated with complaints of low back pain. In at least one study [6] combinations of psychological and demographic variables were able to provide additional information in predicting which patients would receive a specific medical diagnosis and which would receive a nonspecific diagnosis. However, at present no single psychological or physical variable reliably predicts prognosis with cases where the chronic back pain is of inconclusive aetiology. The present study attempted to investigate psychological, medical, and demographic variables, and their relationship to patient expectations of success of treatment. It was hoped to find an explanation which would provide better understanding of subjective evaluations of relief from pain and general satisfaction with medical treatment.
METHOD Subjects Subjects consisted of 95 patients, 57 males and 38 females attending an orthopaedic clinic in a community hospital. The patients’ mean age was 37 yr (S.D. 11 yr) and their mean years of education was 11 yr (S.D. 2.8 yr). The patients were referred to the clinic principally from general practitioners. Procedure Patients were first interviewed to obtain a full medical history, then given a physical examination, and finally were asked to fill out a psychological and demographic questionnaire. The questionnaire included an estimation by the patient of the expected degree of relief from symptoms, on a scale from one (no help at all) to seven (completely successful). A standard checklist of symptoms was filled out during the physical examination by the orthopaedic surgeon (see Table 1). Three different physicians filled out the checklist for a group of seven patients. The reliability using a Pearson product moment correlation was r = 0.81. *Psychological TOrthopaedic
Service Centre, University of Manitoba, Winnipeg, Canada R3T 2N2. Surgery Section, St. Boniface Hospital, Winnipeg, Canada R2H 2A6. 297
298
MICHAEL R. THOMASand DAVID LYTTLE TABLE 1.-BACK
PROBLEMCHECKLIST
Score each item 0 or 1 I.
Clinical signs 1. Lumbar
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
scoliosis Limited range of back movements Cannot walk on tip-toes Cannot walk on heels Absent ankle jerk Weakness of foot dorsiflexion Straight leg raising 60” or less Wasting of calf 1 cm or more Diminished leg sensation to cold Absence of pinprick sensation in areas of leg Peri-anal anaesthesia Limited hip extension Local tenderness in lumbar spine Total
II. Radiological 1. 2. 3. 4.
~
signs
Spondylolisthesis Disc space infection Vertebral osteomelitis Ankylosing spondylitis Total Sum total
~
The questionnaire consisted of a series of 25 background questions, the Tennessee Self Concept Scale, a short form of the Minnesota Multi-Phasic Personality Inventory (the Mini-Mult) and the Quick I.Q. Test. Next the orthopaedic surgeon, without access to the psychological data, using the medical examination and the radiological evidence formulated a diagnosis and treatment plan for each patient. In cases with confirmed specific diagnosis, such as infection or tumour, the appropriate specific treatment was instituted. In cases with nonspecific diagnosis, a form of symptomatic treatment was selected by consultation between physician and patient, based on patient idiosyncrasies and preferences, convenience and time considerations. All 95 patients were called for a follow-up visit after approximately 3 months. Sixty-six patients were seen for the requested follow-up examination, and 29 failed to respond. Their physical status was again assessed by the orthopaedic surgeon and the patients then evaluated the treatment programme they had received by rating how successful they felt the treatment programme had been on a scale from one (provided no relief) to seven (been completely successful).
RESULTS
A step-wise multiple regression dealt with the major question of how does patient expectation of successful treatment for back pain correspond to demographic, medical, and psychological variables, including a final patient evaluation of treatment received. The initial patient ratings of the expected success of treatment were subtracted from the final patient ratings of relief provided by treatment. This provided a difference score which was the dependent variable against which all other information was correlated. The first finding was that the patients as a group had high expectations for treatment efficiency. Most patients on a seven point scale (seven being the most expected success) scored between 4 and 7 with a mean of 5.7.
Patient
expectations
about success of treatment
and reported
relief from low back pain
299
In comparison, on the seven point scale measuring relief provided by treatment, patients tended to score bi-modally at either extreme with the mean being 3.79. The difference score for all patients independent of the type of medical treatment showed a significant negative difference (P < 0.01) between expectation of success of treatment and relief attained after treatment, the mean being - 1.9. The stepwise multiple regression demonstrated that there were three factors significantly correlated with difference scores. Patients who reported the most dissatisfaction with any form of medical treatment of chronic back pain were (1) patients whose immediate family had never had back troubles; (2) patients who had never been admitted to a hospital for a serious accident or operation; (3) and patients who classified their religious affiliation as Protestant. The use of difference scores was based on the assumption that ratings of expectancy of success of treatment and relief of symptoms after treatment were unidimensional. This assumption was not supported by the analysis of the data. This points to the statistical difficulties of using difference scores in general, especially when using multidimensional scales [7]. In view of this finding another step-wise multiple regression was performed using only patient evaluations of relief provided by treatment as the dependent variable. This analysis showed that five variables were significantly correlated with the amount of rated subjective relief obtained after treatment. Patients expressed the most relief from symptoms when the following conditions were met: (1) few prior hospital admissions; (2) having a close relative who had a history of low back pain; (3) the back pain the patient experienced was the result of lifting; (4) the back pain first occurred in a work related setting; (5) and the patient was not working at the time of assessment. Next we come to findings involving the medical data (see Table 2). Comparisons were made between seven medical treatments. Assignment to the various treatments and programs after initial medical diagnosis was relatively random for those cases with unknown aetiology. These comparisons showed that the greatest subjective relief from symptoms was reported after a rest and exercise programme at home (M = 4.7) and least relief from symptoms after receiving medication (M = 2.6). This difference was significant at the (P < 0.05) level. A comparison was also made between patients who in the initial physical examination had at least four or more verifiable clinical features and patients who had only one or less verifiable clinical features. Both groups, overall, expected greater success of treatment than was reported by ratings of relief of symptoms after treatment. However, those patients TABLE
Z.--PATIENT
RATING
OF
EFFECTIVENESS*
Rest and exercise program Physiotherapy Spinal injections Braces Surgery Acupuncture Medication
MEDICAL
Mean ratings
Treatment 1. 2. 3. 4. 5. 6. 7.
OF
at home
*The higher the number the more effective of scores between 1 and 7.
M = M = M = M= M= M = M =
4.1 4.3 3.8 3.5 3.4 3.3 2.6
thz treatment
TREATMENTS
Number of patients 15 6 11 6 17 4 7 was rated,
range
300
MICHAEL R. THOMAS and DAVID LYTTLE
who were initially diagnosed with more clinical features, rated relief after treatment as being significantly (P < 0.05) more satisfactory than those diagnosed as having fewer clinical symptoms. Perhaps more importantly was the finding that patient ratings (when averaged) reported less relief of symptoms after treatment than their initial ratings of expected success prior to treatment. Yet these same patients as a group reported a reduction in pain after completion of treatment. The analysis used for preplanned comparisons of the psychological data was t-tests for related samples. First, patients were compared along the psychological dimensions of self-concept and depression. High self-concept patients when compared to low self-concept patients subjectively rated their treatment for back pain as providing greater relief of symptoms. Also the high self-concept patients scored significantly less pathological than low self-concept patients on a number of MMPI scales (see Table 3). TABLE WHICH SCORED
3.-MMPI
SCALES
LOW SELFCONCEPT* MORE
PATHOLOGICAL
HIGH SELF-CONCEPT
ON
PATIENTS THAN
PATIENTS
Significance
Scale
(PI L F Hs D HY Pd Pa Pt SC Ma
< < < < < < < < < <
*Tennessee
0.05 0.005 0.006 0.0001 0.0001 0.03 0.0001 0.0001 0.0001 0.008
Self-Concept
Scale.
Highly depressed patients (as determined by the D scale of the MMPI short form) were more frequently found to have an easily verifiable medical diagnosis (P < 0.001). Other characteristics of the high depression group were that the group was significantly (P < 0.01) comprised of more women than men, and they were taking significantly (P< 0.02) more medication than less depressed patients. DISCUSSION
The initial findings in this study were interpreted as indicating that patients who had expectations based on little relevant health experiences tend to set personal goals for recovery which frequently will not be met by current medical practices for back pain. This interpretation seems consistent with the findings that some prior hospital admissions and having a relative with back trouble both seem to be positive factors for recovery. They may provide a basis for realistic expectations for treatment. Perhaps the most important implication of the study, however, is that relief of symptoms from back pain was more significantly correlated with demographic information than with the medical treatment the patients received. Another important
Patient
expectations
about success of treatment
and reported
relief from low back pain
301
finding is that perceived ‘relief’ after treatment was not related to the type of clinical signs recorded by the orthopaedic surgeon in the pretreatment medical examination. The combination of these findings would seem to emphasize that the type of medical treatment itself has less influence than demographic or psychological factors in the determination of patients’ assessment of relief from back pain. A conclusion which seems clear is the importance of past medical and family experiences on patient expectations of success of treatments for back pain. Less clear is the relationship between psychological variables and patients’ perceptions of successful medical treatment for back pain. High self-concept patients reported more relief from symptoms of back pain and appeared better psychologically adjusted (as measured by less pathological scores on a number of MMPI scales) than low self-concept patients. However, the psychological data still do not make understandable the finding that what patients rated as ‘relief’ after treatment was something other than a simple reduction of pain [S]. Yet in medical terms, reduction of pain is often regarded as successful treatment for back pain. This finding has very important implications regarding evaluation of medical treatment programmes, since much of the effort of a physician may appear to the patient to be wasted unless time is taken at the outset of treatment to explain reasonable attainable goals. What patients may be looking for regarding successful treatment will require further investigation of psychological concepts such as expectancy, depression, and self-concept.
REFERENCES 1. CANNON W. B. Bodily Changes in Pain, Hunger, Fear and Rage. Appleton, New York (1920). 2. DUNBAR H. F. PsychosomaticDiagnosis. Hoeber-Harper, New York (1943). 3. ALEXANDER F. PsychosomaticMedicine. Norton, New York (1950). 4. MILLER N. E. Psychosomatic effects of specific types of training. Ann. N. Y. Acad, Sci. 159, 1025
(1969). 5. LIPOWSKI Z. J., LIPSIT~ D. R. and WHYBROW P. C. Psychosomatic Medicine: Current Trends and C[inica[Appkation. Oxford University Press, New York (1977). 6. THOMAS M. R. and LYTTLE D. Development
of diagnostic
checklist
for low back
pain patients.
J. C/in. Psychol. 32,80 (1976). 7. MUELLERP., EDWARDS D. W. and YAR~IS R. M. Stressful life events and psychiatric symptomatology: change or undesirability. J. Hlth Sot. Behav. 18,307 (1977). 8. LEAVI~T F., GARRON D. C. and BIETIAUSKASL. A. Stressing life events and the experience of low back pain. J. Psychosom. Res. 23,49 (1979).
PATIENT EXPECTATIONS AND REPORTED MICHAEL
0022.3999/80/1201-0297$02.00/O
ABOUT SUCCESS OF TREATMENT
RELIEF FROM LOW BACK PAIN THOMAS* (Received
and DAVID LYTnEt
14 February
1980)
Abstract-Expectations of success from medical treatment for back pain seen at a hospital orthopaedic clinic. The degree of subjective relief provided treatments were compared. Moderator effects of self-concept, depression were studied. Patient ratings of reduced pain and amount of general relief differentially correlated with self-concept, depression and demographic patient ratings of general relief after treatment are complex and not simply
was measured in 95 patients by several different medical and demographic variables provided by treatment were variables. Results indicate a measure of pain reduction.
PSYCHOSOMATIC research investigates the involvement of psychological, social, economic, vocational, as well as many other conditions, and the relationship between these variables and the physical status of individuals. There is considerable literature which documents the interfacing between physical and psychological variables [l-5]. In particular, understanding of chronic low back pain presents difficulties. Clinically, evidence is often inconclusive as to the aetiology of the patient’s chronic complaints of pain. Furthermore, there is as yet no specific empirical treatment that is uniformly effective with pain of nonspecific aetiology. Some studies have documented that certain patient personality descriptions appear closely associated with complaints of low back pain. In at least one study [6] combinations of psychological and demographic variables were able to provide additional information in predicting which patients would receive a specific medical diagnosis and which would receive a nonspecific diagnosis. However, at present no single psychological or physical variable reliably predicts prognosis with cases where the chronic back pain is of inconclusive aetiology. The present study attempted to investigate psychological, medical, and demographic variables, and their relationship to patient expectations of success of treatment. It was hoped to find an explanation which would provide better understanding of subjective evaluations of relief from pain and general satisfaction with medical treatment.
METHOD Subjects Subjects consisted of 95 patients, 57 males and 38 females attending an orthopaedic clinic in a community hospital. The patients’ mean age was 37 yr (S.D. 11 yr) and their mean years of education was 11 yr (S.D. 2.8 yr). The patients were referred to the clinic principally from general practitioners. Procedure Patients were first interviewed to obtain a full medical history, then given a physical examination, and finally were asked to fill out a psychological and demographic questionnaire. The questionnaire included an estimation by the patient of the expected degree of relief from symptoms, on a scale from one (no help at all) to seven (completely successful). A standard checklist of symptoms was filled out during the physical examination by the orthopaedic surgeon (see Table 1). Three different physicians filled out the checklist for a group of seven patients. The reliability using a Pearson product moment correlation was r = 0.81. *Psychological TOrthopaedic
Service Centre, University of Manitoba, Winnipeg, Canada R3T 2N2. Surgery Section, St. Boniface Hospital, Winnipeg, Canada R2H 2A6. 297
298
MICHAEL R. THOMASand DAVID LYTTLE TABLE 1.-BACK
PROBLEMCHECKLIST
Score each item 0 or 1 I.
Clinical signs 1. Lumbar
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
scoliosis Limited range of back movements Cannot walk on tip-toes Cannot walk on heels Absent ankle jerk Weakness of foot dorsiflexion Straight leg raising 60” or less Wasting of calf 1 cm or more Diminished leg sensation to cold Absence of pinprick sensation in areas of leg Peri-anal anaesthesia Limited hip extension Local tenderness in lumbar spine Total
II. Radiological 1. 2. 3. 4.
~
signs
Spondylolisthesis Disc space infection Vertebral osteomelitis Ankylosing spondylitis Total Sum total
~
The questionnaire consisted of a series of 25 background questions, the Tennessee Self Concept Scale, a short form of the Minnesota Multi-Phasic Personality Inventory (the Mini-Mult) and the Quick I.Q. Test. Next the orthopaedic surgeon, without access to the psychological data, using the medical examination and the radiological evidence formulated a diagnosis and treatment plan for each patient. In cases with confirmed specific diagnosis, such as infection or tumour, the appropriate specific treatment was instituted. In cases with nonspecific diagnosis, a form of symptomatic treatment was selected by consultation between physician and patient, based on patient idiosyncrasies and preferences, convenience and time considerations. All 95 patients were called for a follow-up visit after approximately 3 months. Sixty-six patients were seen for the requested follow-up examination, and 29 failed to respond. Their physical status was again assessed by the orthopaedic surgeon and the patients then evaluated the treatment programme they had received by rating how successful they felt the treatment programme had been on a scale from one (provided no relief) to seven (been completely successful).
RESULTS
A step-wise multiple regression dealt with the major question of how does patient expectation of successful treatment for back pain correspond to demographic, medical, and psychological variables, including a final patient evaluation of treatment received. The initial patient ratings of the expected success of treatment were subtracted from the final patient ratings of relief provided by treatment. This provided a difference score which was the dependent variable against which all other information was correlated. The first finding was that the patients as a group had high expectations for treatment efficiency. Most patients on a seven point scale (seven being the most expected success) scored between 4 and 7 with a mean of 5.7.
Patient
expectations
about success of treatment
and reported
relief from low back pain
299
In comparison, on the seven point scale measuring relief provided by treatment, patients tended to score bi-modally at either extreme with the mean being 3.79. The difference score for all patients independent of the type of medical treatment showed a significant negative difference (P < 0.01) between expectation of success of treatment and relief attained after treatment, the mean being - 1.9. The stepwise multiple regression demonstrated that there were three factors significantly correlated with difference scores. Patients who reported the most dissatisfaction with any form of medical treatment of chronic back pain were (1) patients whose immediate family had never had back troubles; (2) patients who had never been admitted to a hospital for a serious accident or operation; (3) and patients who classified their religious affiliation as Protestant. The use of difference scores was based on the assumption that ratings of expectancy of success of treatment and relief of symptoms after treatment were unidimensional. This assumption was not supported by the analysis of the data. This points to the statistical difficulties of using difference scores in general, especially when using multidimensional scales [7]. In view of this finding another step-wise multiple regression was performed using only patient evaluations of relief provided by treatment as the dependent variable. This analysis showed that five variables were significantly correlated with the amount of rated subjective relief obtained after treatment. Patients expressed the most relief from symptoms when the following conditions were met: (1) few prior hospital admissions; (2) having a close relative who had a history of low back pain; (3) the back pain the patient experienced was the result of lifting; (4) the back pain first occurred in a work related setting; (5) and the patient was not working at the time of assessment. Next we come to findings involving the medical data (see Table 2). Comparisons were made between seven medical treatments. Assignment to the various treatments and programs after initial medical diagnosis was relatively random for those cases with unknown aetiology. These comparisons showed that the greatest subjective relief from symptoms was reported after a rest and exercise programme at home (M = 4.7) and least relief from symptoms after receiving medication (M = 2.6). This difference was significant at the (P < 0.05) level. A comparison was also made between patients who in the initial physical examination had at least four or more verifiable clinical features and patients who had only one or less verifiable clinical features. Both groups, overall, expected greater success of treatment than was reported by ratings of relief of symptoms after treatment. However, those patients TABLE
Z.--PATIENT
RATING
OF
EFFECTIVENESS*
Rest and exercise program Physiotherapy Spinal injections Braces Surgery Acupuncture Medication
MEDICAL
Mean ratings
Treatment 1. 2. 3. 4. 5. 6. 7.
OF
at home
*The higher the number the more effective of scores between 1 and 7.
M = M = M = M= M= M = M =
4.1 4.3 3.8 3.5 3.4 3.3 2.6
thz treatment
TREATMENTS
Number of patients 15 6 11 6 17 4 7 was rated,
range
300
MICHAEL R. THOMAS and DAVID LYTTLE
who were initially diagnosed with more clinical features, rated relief after treatment as being significantly (P < 0.05) more satisfactory than those diagnosed as having fewer clinical symptoms. Perhaps more importantly was the finding that patient ratings (when averaged) reported less relief of symptoms after treatment than their initial ratings of expected success prior to treatment. Yet these same patients as a group reported a reduction in pain after completion of treatment. The analysis used for preplanned comparisons of the psychological data was t-tests for related samples. First, patients were compared along the psychological dimensions of self-concept and depression. High self-concept patients when compared to low self-concept patients subjectively rated their treatment for back pain as providing greater relief of symptoms. Also the high self-concept patients scored significantly less pathological than low self-concept patients on a number of MMPI scales (see Table 3). TABLE WHICH SCORED
3.-MMPI
SCALES
LOW SELFCONCEPT* MORE
PATHOLOGICAL
HIGH SELF-CONCEPT
ON
PATIENTS THAN
PATIENTS
Significance
Scale
(PI L F Hs D HY Pd Pa Pt SC Ma
< < < < < < < < < <
*Tennessee
0.05 0.005 0.006 0.0001 0.0001 0.03 0.0001 0.0001 0.0001 0.008
Self-Concept
Scale.
Highly depressed patients (as determined by the D scale of the MMPI short form) were more frequently found to have an easily verifiable medical diagnosis (P < 0.001). Other characteristics of the high depression group were that the group was significantly (P < 0.01) comprised of more women than men, and they were taking significantly (P< 0.02) more medication than less depressed patients. DISCUSSION
The initial findings in this study were interpreted as indicating that patients who had expectations based on little relevant health experiences tend to set personal goals for recovery which frequently will not be met by current medical practices for back pain. This interpretation seems consistent with the findings that some prior hospital admissions and having a relative with back trouble both seem to be positive factors for recovery. They may provide a basis for realistic expectations for treatment. Perhaps the most important implication of the study, however, is that relief of symptoms from back pain was more significantly correlated with demographic information than with the medical treatment the patients received. Another important
Patient
expectations
about success of treatment
and reported
relief from low back pain
301
finding is that perceived ‘relief’ after treatment was not related to the type of clinical signs recorded by the orthopaedic surgeon in the pretreatment medical examination. The combination of these findings would seem to emphasize that the type of medical treatment itself has less influence than demographic or psychological factors in the determination of patients’ assessment of relief from back pain. A conclusion which seems clear is the importance of past medical and family experiences on patient expectations of success of treatments for back pain. Less clear is the relationship between psychological variables and patients’ perceptions of successful medical treatment for back pain. High self-concept patients reported more relief from symptoms of back pain and appeared better psychologically adjusted (as measured by less pathological scores on a number of MMPI scales) than low self-concept patients. However, the psychological data still do not make understandable the finding that what patients rated as ‘relief’ after treatment was something other than a simple reduction of pain [S]. Yet in medical terms, reduction of pain is often regarded as successful treatment for back pain. This finding has very important implications regarding evaluation of medical treatment programmes, since much of the effort of a physician may appear to the patient to be wasted unless time is taken at the outset of treatment to explain reasonable attainable goals. What patients may be looking for regarding successful treatment will require further investigation of psychological concepts such as expectancy, depression, and self-concept.
REFERENCES 1. CANNON W. B. Bodily Changes in Pain, Hunger, Fear and Rage. Appleton, New York (1920). 2. DUNBAR H. F. PsychosomaticDiagnosis. Hoeber-Harper, New York (1943). 3. ALEXANDER F. PsychosomaticMedicine. Norton, New York (1950). 4. MILLER N. E. Psychosomatic effects of specific types of training. Ann. N. Y. Acad, Sci. 159, 1025
(1969). 5. LIPOWSKI Z. J., LIPSIT~ D. R. and WHYBROW P. C. Psychosomatic Medicine: Current Trends and C[inica[Appkation. Oxford University Press, New York (1977). 6. THOMAS M. R. and LYTTLE D. Development
of diagnostic
checklist
for low back
pain patients.
J. C/in. Psychol. 32,80 (1976). 7. MUELLERP., EDWARDS D. W. and YAR~IS R. M. Stressful life events and psychiatric symptomatology: change or undesirability. J. Hlth Sot. Behav. 18,307 (1977). 8. LEAVI~T F., GARRON D. C. and BIETIAUSKASL. A. Stressing life events and the experience of low back pain. J. Psychosom. Res. 23,49 (1979).