- Email: [email protected]
The pain ward follow-up analyses
Pain, 3 (19776 277-280 @ EIsevier/North-Holland
Biomedical
Press
THE PAIN WARD FOLLOW-UP ANALYSES
RONALD J. IGNELZI *, RICHARD and GRETCHEN TIMMERMANS Neurosurgical Section, Califi 92161 (U.S.A.) (Accepted
November
A. STERNBACH
Veterans A&=rinistation
**
Hospital, San Diego,
29th, 1976)
SUMMARY
Two-year and 3-year follow-up analyses show that those who did not receive surgery for pain relief did as well as those who did receive such surgery during their stay, both groups showing consistently lower pain levels and analgesic intake than on admission, while activity levels progressively increased. The surgical patient<:, were more likely to be readmitted for their pain problem than were the others, whereas the others were more likely to be readmitted for other medical problems. -
--
We initially reported on the in-hospit& progress of 54 patients, in a multidisciplinary treatment program [a]. We here present the ~~~~01~~~~resdts on this group, all of whom were discharged more than 3 years prior to this writing, From Fig. 1 it can be seen that at 3 years post-dis cant reductions from admission levels in patients’ pain sic intake, and increases in levels of activity, for th follow-up. The pain estimates zze on a O-100 s&e; number of hours per day in work-line activities (no sic intake is expressed in dosage units calccallate owing the method of Fordyr,e morphine strength of an effective dose a are sigzifieant~ly different on ~~~~~Wo~~ et aL [I 3. Admission and 3-y all 3 vaizbles for the total group, which &o-wed a decre~e in pain estkaate Neurosurgery (11 ZA), Veterans ’ To wnom reprint requests shouid. be addressed: Administration Hospital, 3350 La Jolla Village Drive, San Diego, Calif. 92161. ** Now Director, Pain Treatment Center, Scripps Clinic Medical Institutions, Scripps. Clinic Medical Institutions, I.0666 North Torrey Pines Road, La Jolla, Calif. 92037, ‘U.S.A.
278
TOTAL
~
A. PAIN ESTIMATES ,¢:z:
~
70
SURGERY NONSURGERY
~_ 6o co 50 N
~
40 0
40 II 29 FIRST WE IN HOSPITAL
40 II 29 40 II 29 LAST WK 6+MONTH IN HOSPITAL FOLLOWUP
32 I0 22 3+YEAR FOLLOWUP
B. ACTIVITY LEVELS I0 or) 0
6 4
o
39 II
25
59
Ii
28
35 !1 24
32 I0 22
45 12 33
36 IO 26
C. ANALGESIC INTAKE fJ')
p..-
.4
-
(.D fj~
0
°'
(')
46 i2 34
46 12 34
Fig. ', Pr-!low-up data on patients discharged 3 years or longer. Mean and standard errors shown. Sample sizes shown beneath histograms. A: patients' pair estimates. B" activity le~ c~s. C: analgesic intake.
(one-tailed t-test = 2.240, df = 69, P < 0.025), a highly significant increase in activity levels (t = 6.521, df = 69, P < 0.0005), and a very significant decrease
in analgesic intake (t = 3.476, df = 80, P < 0.(}005). The 3 measures for the surgery patients are also significantly different from admission to 3 years later; i.e., the pain estimate decreased (one-tailed t-test = [.764, df = 19, P <
0.05); activity levels increased (t = 5.795, df = 19, P < 0.0005); and analgesic intake decreased (t = 2.847, df = 20, P < 0.005). T w o o f the 3 measures are significantly improved for t h e n'on-surgery patients: activity levels increased {t = 4.499, df = 48, P < 0.0095) and analgesic intake decreased (t = 2°944, df = 58, P < 9.005). There are no differences between the surgic ~ ~ d non-surgical groups on follow-up at 3 years. A m o r e accurate estimate o f the effectiveness of the pain ward a p p r o a c h
279
60 50 2
40
z 30 i5? 0
37 142 FIRST WK IN HOSP
3t 142 LAST WK IN HOSP
II 43 6 MOS
B.ACTiVlTYLEVELS
16 32 I YR
6 I7 I l/2 YR
Ii 25 2eYR
_
f
43
I7 29
6
16
II
25
50
IS 39
7
18
iI
2s
ll
-I-
39 2
7
5 OI
5 3 0
35 I40
35
140
II
C.ANALGESiC INTAKE
36 130
36 I31
I7
Fig. 2. Foflow-up data an alt pain ward patients at admksion, discharge, alnd at 6 month Mervals thereafter, giving means and standard prrcxs of pain estimates, activity Ievels, and analgesic intake. Sample sizes shown beneath histograms.
can be ob”Mned from examining the data from a 1 er sample at 6-month intends, as shown in Fig. 2. These data show the results on dB patients with whom follow-up was possible at the interval shown. Differences between SWgicd and non-surgical patients are not significantIy different at any point. For the non-surgical group, pain estimates are not significantly foww than admissionlevels 2 years later, but activity levels are very significantly @eater -tailed t-test; t = 7.03, df = 163, P < O.O005), and analgesic intake very ficantly less (t = 2.73, df = 153: P < 0.095). For surgical packientsthe years after admiSsioXf (t = 2.I.0, (2%= 45, decrease in pain is significmt P < 0.025), the increase in activity is highly significmt (t = 7.59, eJf‘L=44, P < O.OOOS),and decrease in analgesic irhke is highly significant @ = 2.89, df = 45, P .< 0.005). Despite small sa~~ple sizes at the later follow-up periods, it appears that the treatment progmrn is effective. Thwe is 2 pmpsslw
280 TABLE I FOLLOW-UP DATA ON PAIN PATIENTS
Surgery (N = 37) Non-surgery (N = 142)
Returned to work or regular activity
Returned hospital visits * pain
other
13 (35%) 38 (27%)
10 (27%) 9 (6%)
2 (5%) 19 (13%)
Deceased
1 (4%) 7 (5%)
* X2 = 6.89, p < 0.01, two-tailed test.
decrease in pain and usage of analgesics, and increases in activity for both the patients who received surgery for pahL relief during their stay, and those who did not. There are no significant differences between the ÷~wo groups over the 2-year period. An incidental finding of some interest emerged in checking the records of ;hese patients, as shown in Table I. It would seem that patients who received •~urgery for pain relief were much more likely to be readmitted to the hospital for problems related to their pain complaint than were the non-surgical patients. On the other hand, the latter were more likely to be readmitted for some other medical problem. CONCLUSIONS
Ti~e pain w ~ d prov:ides a multi-modality setting for the evaluation and treatment of patients with non-malignant intractable pain. Non-surgical treatment includes physical therapy, relaxation training, operant conditioning, ~ o u p therapy, regulation of ~,algesics, bioIeedback training, transcu~aneous electrical neurosi;imulation, ~md vocational lehabilitation. Follow-up data suggest that pain levels and analgesic intake remain consistently lower than on admission, whi~e activity levels progressively increase. No significant differences exist between those who received surgery for pain relief and those who ~d not, except that the surgical cases were more likely to be readmitted for their p~An problem while the others were more likely to be readmitted for other medical problems. REFERENCES 1. Fordyce, W.E., Fowler, R.S., Jr., Lehmann, J.F., DeLateur, R.J., Sand, P.L. and Trieschma~n, R.B., Operant conditioning in the treatment of chronic pain, Arch. Phys. reed. Rehab., 54 (1973) 399--408. 2. Greenhoot~ J.H. end Sternbach, R.A., Conjoint treatment of chronic pain. In: J.J. Bonica (Ed.), Advances in Neurology, VoI. 4, International Symposium on Pain, Raven Pres:~, New York, 1974, pp. 595--~(}4.
Biomedical
Press
THE PAIN WARD FOLLOW-UP ANALYSES
RONALD J. IGNELZI *, RICHARD and GRETCHEN TIMMERMANS Neurosurgical Section, Califi 92161 (U.S.A.) (Accepted
November
A. STERNBACH
Veterans A&=rinistation
**
Hospital, San Diego,
29th, 1976)
SUMMARY
Two-year and 3-year follow-up analyses show that those who did not receive surgery for pain relief did as well as those who did receive such surgery during their stay, both groups showing consistently lower pain levels and analgesic intake than on admission, while activity levels progressively increased. The surgical patient<:, were more likely to be readmitted for their pain problem than were the others, whereas the others were more likely to be readmitted for other medical problems. -
--
We initially reported on the in-hospit& progress of 54 patients, in a multidisciplinary treatment program [a]. We here present the ~~~~01~~~~resdts on this group, all of whom were discharged more than 3 years prior to this writing, From Fig. 1 it can be seen that at 3 years post-dis cant reductions from admission levels in patients’ pain sic intake, and increases in levels of activity, for th follow-up. The pain estimates zze on a O-100 s&e; number of hours per day in work-line activities (no sic intake is expressed in dosage units calccallate owing the method of Fordyr,e morphine strength of an effective dose a are sigzifieant~ly different on ~~~~~Wo~~ et aL [I 3. Admission and 3-y all 3 vaizbles for the total group, which &o-wed a decre~e in pain estkaate Neurosurgery (11 ZA), Veterans ’ To wnom reprint requests shouid. be addressed: Administration Hospital, 3350 La Jolla Village Drive, San Diego, Calif. 92161. ** Now Director, Pain Treatment Center, Scripps Clinic Medical Institutions, Scripps. Clinic Medical Institutions, I.0666 North Torrey Pines Road, La Jolla, Calif. 92037, ‘U.S.A.
278
TOTAL
~
A. PAIN ESTIMATES ,¢:z:
~
70
SURGERY NONSURGERY
~_ 6o co 50 N
~
40 0
40 II 29 FIRST WE IN HOSPITAL
40 II 29 40 II 29 LAST WK 6+MONTH IN HOSPITAL FOLLOWUP
32 I0 22 3+YEAR FOLLOWUP
B. ACTIVITY LEVELS I0 or) 0
6 4
o
39 II
25
59
Ii
28
35 !1 24
32 I0 22
45 12 33
36 IO 26
C. ANALGESIC INTAKE fJ')
p..-
.4
-
(.D fj~
0
°'
(')
46 i2 34
46 12 34
Fig. ', Pr-!low-up data on patients discharged 3 years or longer. Mean and standard errors shown. Sample sizes shown beneath histograms. A: patients' pair estimates. B" activity le~ c~s. C: analgesic intake.
(one-tailed t-test = 2.240, df = 69, P < 0.025), a highly significant increase in activity levels (t = 6.521, df = 69, P < 0.0005), and a very significant decrease
in analgesic intake (t = 3.476, df = 80, P < 0.(}005). The 3 measures for the surgery patients are also significantly different from admission to 3 years later; i.e., the pain estimate decreased (one-tailed t-test = [.764, df = 19, P <
0.05); activity levels increased (t = 5.795, df = 19, P < 0.0005); and analgesic intake decreased (t = 2.847, df = 20, P < 0.005). T w o o f the 3 measures are significantly improved for t h e n'on-surgery patients: activity levels increased {t = 4.499, df = 48, P < 0.0095) and analgesic intake decreased (t = 2°944, df = 58, P < 9.005). There are no differences between the surgic ~ ~ d non-surgical groups on follow-up at 3 years. A m o r e accurate estimate o f the effectiveness of the pain ward a p p r o a c h
279
60 50 2
40
z 30 i5? 0
37 142 FIRST WK IN HOSP
3t 142 LAST WK IN HOSP
II 43 6 MOS
B.ACTiVlTYLEVELS
16 32 I YR
6 I7 I l/2 YR
Ii 25 2eYR
_
f
43
I7 29
6
16
II
25
50
IS 39
7
18
iI
2s
ll
-I-
39 2
7
5 OI
5 3 0
35 I40
35
140
II
C.ANALGESiC INTAKE
36 130
36 I31
I7
Fig. 2. Foflow-up data an alt pain ward patients at admksion, discharge, alnd at 6 month Mervals thereafter, giving means and standard prrcxs of pain estimates, activity Ievels, and analgesic intake. Sample sizes shown beneath histograms.
can be ob”Mned from examining the data from a 1 er sample at 6-month intends, as shown in Fig. 2. These data show the results on dB patients with whom follow-up was possible at the interval shown. Differences between SWgicd and non-surgical patients are not significantIy different at any point. For the non-surgical group, pain estimates are not significantly foww than admissionlevels 2 years later, but activity levels are very significantly @eater -tailed t-test; t = 7.03, df = 163, P < O.O005), and analgesic intake very ficantly less (t = 2.73, df = 153: P < 0.095). For surgical packientsthe years after admiSsioXf (t = 2.I.0, (2%= 45, decrease in pain is significmt P < 0.025), the increase in activity is highly significmt (t = 7.59, eJf‘L=44, P < O.OOOS),and decrease in analgesic irhke is highly significant @ = 2.89, df = 45, P .< 0.005). Despite small sa~~ple sizes at the later follow-up periods, it appears that the treatment progmrn is effective. Thwe is 2 pmpsslw
280 TABLE I FOLLOW-UP DATA ON PAIN PATIENTS
Surgery (N = 37) Non-surgery (N = 142)
Returned to work or regular activity
Returned hospital visits * pain
other
13 (35%) 38 (27%)
10 (27%) 9 (6%)
2 (5%) 19 (13%)
Deceased
1 (4%) 7 (5%)
* X2 = 6.89, p < 0.01, two-tailed test.
decrease in pain and usage of analgesics, and increases in activity for both the patients who received surgery for pahL relief during their stay, and those who did not. There are no significant differences between the ÷~wo groups over the 2-year period. An incidental finding of some interest emerged in checking the records of ;hese patients, as shown in Table I. It would seem that patients who received •~urgery for pain relief were much more likely to be readmitted to the hospital for problems related to their pain complaint than were the non-surgical patients. On the other hand, the latter were more likely to be readmitted for some other medical problem. CONCLUSIONS
Ti~e pain w ~ d prov:ides a multi-modality setting for the evaluation and treatment of patients with non-malignant intractable pain. Non-surgical treatment includes physical therapy, relaxation training, operant conditioning, ~ o u p therapy, regulation of ~,algesics, bioIeedback training, transcu~aneous electrical neurosi;imulation, ~md vocational lehabilitation. Follow-up data suggest that pain levels and analgesic intake remain consistently lower than on admission, whi~e activity levels progressively increase. No significant differences exist between those who received surgery for pain relief and those who ~d not, except that the surgical cases were more likely to be readmitted for their p~An problem while the others were more likely to be readmitted for other medical problems. REFERENCES 1. Fordyce, W.E., Fowler, R.S., Jr., Lehmann, J.F., DeLateur, R.J., Sand, P.L. and Trieschma~n, R.B., Operant conditioning in the treatment of chronic pain, Arch. Phys. reed. Rehab., 54 (1973) 399--408. 2. Greenhoot~ J.H. end Sternbach, R.A., Conjoint treatment of chronic pain. In: J.J. Bonica (Ed.), Advances in Neurology, VoI. 4, International Symposium on Pain, Raven Pres:~, New York, 1974, pp. 595--~(}4.