- Email: [email protected]
The role of prior pain experience and expectations on postoperative pain
34
Vol. 7 No. 1 January 1992
Journal of Pain and SymptomManagement
le of Prior Pain The Expectations on Post0 Paul N. H. Walmsley, MBChB, Dorothy Y. Brockopp, PhD, and Gene W. Brockopp, PhD D$artm& of Anesthesiology(P.N.H. W., G. W.P.), College of Nursing (D.Y.B.), and Department of Psychiaty (G. W.P.), University of Kentucky, Lexington, Kentucky
Abstract The pesmt study was designed to examine previous pain experiences as they relate to expectations of postoperative pain. In the study, 101 patients aged 55-87 (47 men, 54 women) participated in a structured inter&v that examined 13 factors thought to be associated with presurgical expectations of postsurgical pain. These factors relating to prior @in experience were identified&m the literature as well as the experience of The two variables clinicians in the areas of anesthesiology, nursing and psycholoa. that emelated sign@cantly (multiple r = 0.51) with pain expected postoperatively were: a single item from the general attitude questionnaire about pain (pain is to be expected after surgery even with medicine) and the total of the global ratings of past pain experience. A follow-up study will examine these variables in relation to actual pain experimce. J Pain Symptom Manage 1992;7;34-37 Key Words Pain expectation:, cognition, expectation, pain, o&r adults
htroductbn A belief in the multidimensional nature of the pain experience has fostered considerable research into the various psychological factors associated with pain. The pain of surgery or childbirth has been examined in relation to a patient’s anxiety,‘-” neuroticism,‘**” extroversion,‘s*‘4 coping styles,15 and locus of control .6V’6-1*Seven studies supported a positive relationship between anxiety and postoperative pain’* whereas another found extroversion to be associated with increased postoperative pain. ” Address reprint requesls lo: Dorothy Y. Brockopp, PhD, Collegeof Nursing, University of Kentucky, 801 Rose Street, Lexington, KY 40536-0084. Acceptedfm publication:June 12, 1991. (B Ir.“. ....*aLCr Pain Relief Committee, 1992 Published by Elsevier, New York, New York
A psychological factor that has received little attention in the literature is the expectation of pain that patients have in relation to a specific, presumably painful event. One study showed a small but significant correlation between the expected and actual pain of 118 patients undergoing laparoscopic surgery for sterilization.*l An examination of 2 1 surgical patients showed a significant difference between patients’ expectations prior to surgery and pain scores following surgery, with a majority of patients underestimating their pain.* According to cognitive-expectancy theory, individuals tend to anticipate the degree to which they can influence a particular outcome.‘g Given the example of postoperative pain, individuals’ expectations of pain following surgery could influence both their motivation to attempt to find pain relief and the nature of the pain 08858924/92/$5.00
Vol. 7 No. 1 jammy
I992
Priw Pain, Expectations, and Postoperatiue Pain
experience itself. Inaccurate estimates of exgected pain might be base on prior experience veresrather than the reality of the situation. timates of pain could cause patients to become increasingly anxious and tense thereby exacerbating the pain experience. Expectations are thought to develop in selation to prior experience with pain, observation of others’ pain experience, and the information that is conveyed about the pain experience.” The purpose of this study was to examine to what extent prior experience and general attitudes toward pain are associated with the development of expectations of pain. The question was the following: “What factors are associated with the individual’s expectation of postsurgical pain?” Data will be used to develop a tool to examine preoperative pain expectations. An overall goal of this line of research is to identify patients needs relative to pain management prior to surgery.
35
Table I Structured Interview Expectation of Pain Postssurgically 1. Thinking about this operation, show me on this scale bow much pain you expect to have. (VAS 1-10 cm) Presurgical Pain 1. Thinking of your pain right now, show me on this scale what your pain is like? (VAS l-10 cm) Attitudes about Pain Disagree Agree 1. I can handle most pain 1 2 3 4 5 2. Doctors take care of 1 2 3 4 5 pain well 3. My pain will be relieved 1 2 3 4 5 4. Nurses take care of 1 2 3 4 5 pain well 5. If I know what pain to expect I can 1 2 3 4 5 handle it 6. Pain is to be expected after surgery even 1 2 3 4 5 with medicine
Pain History
In the study, 181 patients scheduled for elective surgery (47 men and 54 women between the ages of 55 and 87) were enrolled in the study. Cardiac patients were excluded due ts a concern regarding possible increase in anxiety in response to the interview. All patients over 55 yr of age undergoing elective surgery within a 3-mo period were asked to participate. No subjects were medicated for pain at the time of interview. Five patients refused. Older adults were chosen as the population of interest because of the confusion regarding the management of pain within this group and the need to better understand their needs.22q23
Measures A structured interview was developed to estimate the degree of pain expected postsurgically and to examine the following factors thought to correlate with this expectation: presurgical pain, attitudes about pain, and pain history (see Table 1). A 10 cm visual analogue scale (VAS) with “no pain” at one end and “pain as bad as it could be” at the other end was used to measure items directly related to the pain experience. Items examining attitudes toward pain were measured
(specific) 1. Thinking of your (specific past surgeries) show me on this scale what your pain was like after surgery. (VAS l-10 cm) (global) 2. Thinking about all of your surgeries, how would you rate your pain? (VAS l-10 cm) (These two questions were repeated in relation to trauma, chronic pain, childbirth, and other pain). VAS, visual analogue scale.
using a 5-point Likert scale with “Disagree” at one end, “Agree” at the other end.
The structured interview was conducted by a trained research assistant 24 hr prior to surgery. Each item was read to subjects who marked their response on a VAS for items related to pain, and circled a number on a Likert scale for items related to attitudes.
edts Using stepwise multiple regression, the two variables that correlated significantly (multiple r = 0.51, 4; = 12.33, p
36
Walnts@et al.
global surgical pain, global trauma pain, global childbirth pain, chronic pain, and other pain). The total of the global pain ratings of past pain exp&nceS was the single strongest partial correlate of expected pain (simple r 21 0.34). Presurgical pain, five of the six attitudes about pain, and pain related to specific surgeries were not correlated with patients’ expectations of postsurgical pain.
Expectations of pain may influence the pain experience. For example, in comparing the needs for analgesia among men wounded in battle with a matched group of civilians undergoing surgery Beecher ’ found that 32% of the wounded men requested narcotics as opposed to 83% of the civilian group. It was felt rhat the expectations and meaning given to the different events affected the response to pain. Factors that account for patients’ expectations of pain are largely unknown. The results of this study suggest that a portion of that expectation (13% of the variance) may be accounted for by asking patients about their prior pain history. Patients’ response to the item “pain is to be expected after surgery even with medicine” (12% of the variance) was also associated with their expectation of pain. Together, responses to questions regarding prior pain history and attitude toward pain accounted for 25% of the variance in relation to pain expectation. Although one might expect pain from prior surgeries to correlate with expectation of postoperative pain, only the total of global pain scores, i.e., all surgeries, trauma, etc., was related. Gathering information regarding patients’ prior experience with pain could assist clinicians in providing them with appropriate information about the probable level of discomfort to be expected and the pain management strategies that can be used. Understanding the patients’ beliefs about the effectiveness of pain medication following surgery could also assist the clinician to make the patient aware of effective pain man-
agement strategies. This study was based on the assumption that the expectation of an event is an important factor in mediating how an individual responds to that event. Expectations regarding postsurgical pain may be modified if clinicians are able to collect relevant data. According to this study,
Journal of Pain and SymptomManagement
expectations that can include both overestimates and underestimates of postsurgical pain may be the result of prior experiences and attitude toward the effectiveness of pain medica-
tion.
The investigators acknowledge the Sanders Brown Center on Aging, University of Kentucky for funding this study and also the capable assistance of the research assistant Carol Guerdan.
eferenees 1. Beecher HK. Pain in men wounded Ann Surg 1946;123:96.
in battle.
2. Carr, CJ. Postoperative pain: patiezus expectations and experiences. J Adv Nurs 1990;15:89-100. 3. Chapman CR, Cox GB. Anxiety, pain and depression surrounding elective surgery: a multivariate comparison of abdominal surgery patients with kidney donors and recipients. J Psychosom Res 1977;2 1: 7-19. 4. Johnson JE, Rice VH, Ruller SS, Endress P. Sensory information, instruction in a coping strategy and recovery from surgery. Res Nurs HeaM 1978;1:417. 5. Bruegel MA. Relationship of preoperative anxiety to the perception of postoperative pain. Nurs Res 1971;20:2631. 6. Wise TN, Hall WA, Wong 0. The relationship of cognitive styles and affective states to postoperative analgesic utilization. J Psychosom Res 1978;22:513518. 7. Taenzer M. Influence of psychological factors on postoperative pain, mood and analgesic requirements. Pain 1986;24:331-342. 8. Parbrook CD, Steel DF, Dabrymple
DG. Factors
predisposing to postoperative pain and pulmonary complications: a study of male patients undergoing elective surgery.
Br J Anaesth 1973:45:21-33.
9. Ray C, Fitzgibbon G. Stress arousal and coping with surgery. Psycho1 Med 1981;11:741-746. 10. Scott LE. Glum GA. Preoperative predictors of postoperative pain. Pain 1983;15:283-293. 11. Martinez-Urrutia A. Anxiety and pain in surgical patients. J Consult Clin Psycho1 1975;43:437-442. 12. Boyle P. Parbrook GD. The interrelation of per=. sonality and postoperative factors. Br J Anaesth 1977;49:259-264. 13. Eysenck S. Personality and pain assessment childbirth of married and unmarried mothers. Mental Sci 1961;107:417-430.
in J
Vol. 7 No. 1 Januaq
1992
Prior Pain, Expectations, and Postoperatiue Pain
37
14. Bond MR. Glynn JP, Thomas IX. The relationship between pain and personality in patients receiving pentazocine (Fortral) after surgery. J Psychosom Res 1976;20:369-381.
19. S, Carber J. A cognitive-expectancy tbeapy for helplessnes depression. In: ory Carber J. Seligman M, eds. an helplessness. New York: Academic Press, 1980: 173- 196.
15. Andrews JM. Recovery from surgery, with and without preparatory instruction for three coping styles. J Personal Sot Psycho1 1970;15:223-226.
20. Bandura A. Social learning theory. Cliffs, NJ: Prentice Hall, 1977.
16. Auerback SM, Kendall PC, Cutler I-IF, Levitt R. Anxiety, locus of control, type of preparatory information and adjustment to dental surgery. J Consult Clin Psycho1 1976;44:809-818. 17. Clum CA, Scott L, Burnside J. Information and locus of control as factors in the outcome of surgery. Psycho1 Reports 1979;45:867-873. 18. Johnson JE, Qabbs JM, Levantbal II. Psycbosocial factors in the welfare of surgical patients. Nurs Res 1979; 19: 18-29.
Englewood
21. Wallace LM. Surgical patients’ expectations of pain and discomfort: does accuracy of expectations minimize post-surgical pain and distress? Pain 1985; 22:363-373. 22. Sear J, Nand C, Moore R. Studies on morphine disposition: Plasma concentrations of morphine and its metabolites in anesthetized middle-aged and elderly surgical patients. J Clin Anesth 1989;1:164-169. 23. Witte M. Pain control. 15:32-37.
J Cerontol
Nurs 1989;
Vol. 7 No. 1 January 1992
Journal of Pain and SymptomManagement
le of Prior Pain The Expectations on Post0 Paul N. H. Walmsley, MBChB, Dorothy Y. Brockopp, PhD, and Gene W. Brockopp, PhD D$artm& of Anesthesiology(P.N.H. W., G. W.P.), College of Nursing (D.Y.B.), and Department of Psychiaty (G. W.P.), University of Kentucky, Lexington, Kentucky
Abstract The pesmt study was designed to examine previous pain experiences as they relate to expectations of postoperative pain. In the study, 101 patients aged 55-87 (47 men, 54 women) participated in a structured inter&v that examined 13 factors thought to be associated with presurgical expectations of postsurgical pain. These factors relating to prior @in experience were identified&m the literature as well as the experience of The two variables clinicians in the areas of anesthesiology, nursing and psycholoa. that emelated sign@cantly (multiple r = 0.51) with pain expected postoperatively were: a single item from the general attitude questionnaire about pain (pain is to be expected after surgery even with medicine) and the total of the global ratings of past pain experience. A follow-up study will examine these variables in relation to actual pain experimce. J Pain Symptom Manage 1992;7;34-37 Key Words Pain expectation:, cognition, expectation, pain, o&r adults
htroductbn A belief in the multidimensional nature of the pain experience has fostered considerable research into the various psychological factors associated with pain. The pain of surgery or childbirth has been examined in relation to a patient’s anxiety,‘-” neuroticism,‘**” extroversion,‘s*‘4 coping styles,15 and locus of control .6V’6-1*Seven studies supported a positive relationship between anxiety and postoperative pain’* whereas another found extroversion to be associated with increased postoperative pain. ” Address reprint requesls lo: Dorothy Y. Brockopp, PhD, Collegeof Nursing, University of Kentucky, 801 Rose Street, Lexington, KY 40536-0084. Acceptedfm publication:June 12, 1991. (B Ir.“. ....*aLCr Pain Relief Committee, 1992 Published by Elsevier, New York, New York
A psychological factor that has received little attention in the literature is the expectation of pain that patients have in relation to a specific, presumably painful event. One study showed a small but significant correlation between the expected and actual pain of 118 patients undergoing laparoscopic surgery for sterilization.*l An examination of 2 1 surgical patients showed a significant difference between patients’ expectations prior to surgery and pain scores following surgery, with a majority of patients underestimating their pain.* According to cognitive-expectancy theory, individuals tend to anticipate the degree to which they can influence a particular outcome.‘g Given the example of postoperative pain, individuals’ expectations of pain following surgery could influence both their motivation to attempt to find pain relief and the nature of the pain 08858924/92/$5.00
Vol. 7 No. 1 jammy
I992
Priw Pain, Expectations, and Postoperatiue Pain
experience itself. Inaccurate estimates of exgected pain might be base on prior experience veresrather than the reality of the situation. timates of pain could cause patients to become increasingly anxious and tense thereby exacerbating the pain experience. Expectations are thought to develop in selation to prior experience with pain, observation of others’ pain experience, and the information that is conveyed about the pain experience.” The purpose of this study was to examine to what extent prior experience and general attitudes toward pain are associated with the development of expectations of pain. The question was the following: “What factors are associated with the individual’s expectation of postsurgical pain?” Data will be used to develop a tool to examine preoperative pain expectations. An overall goal of this line of research is to identify patients needs relative to pain management prior to surgery.
35
Table I Structured Interview Expectation of Pain Postssurgically 1. Thinking about this operation, show me on this scale bow much pain you expect to have. (VAS 1-10 cm) Presurgical Pain 1. Thinking of your pain right now, show me on this scale what your pain is like? (VAS l-10 cm) Attitudes about Pain Disagree Agree 1. I can handle most pain 1 2 3 4 5 2. Doctors take care of 1 2 3 4 5 pain well 3. My pain will be relieved 1 2 3 4 5 4. Nurses take care of 1 2 3 4 5 pain well 5. If I know what pain to expect I can 1 2 3 4 5 handle it 6. Pain is to be expected after surgery even 1 2 3 4 5 with medicine
Pain History
In the study, 181 patients scheduled for elective surgery (47 men and 54 women between the ages of 55 and 87) were enrolled in the study. Cardiac patients were excluded due ts a concern regarding possible increase in anxiety in response to the interview. All patients over 55 yr of age undergoing elective surgery within a 3-mo period were asked to participate. No subjects were medicated for pain at the time of interview. Five patients refused. Older adults were chosen as the population of interest because of the confusion regarding the management of pain within this group and the need to better understand their needs.22q23
Measures A structured interview was developed to estimate the degree of pain expected postsurgically and to examine the following factors thought to correlate with this expectation: presurgical pain, attitudes about pain, and pain history (see Table 1). A 10 cm visual analogue scale (VAS) with “no pain” at one end and “pain as bad as it could be” at the other end was used to measure items directly related to the pain experience. Items examining attitudes toward pain were measured
(specific) 1. Thinking of your (specific past surgeries) show me on this scale what your pain was like after surgery. (VAS l-10 cm) (global) 2. Thinking about all of your surgeries, how would you rate your pain? (VAS l-10 cm) (These two questions were repeated in relation to trauma, chronic pain, childbirth, and other pain). VAS, visual analogue scale.
using a 5-point Likert scale with “Disagree” at one end, “Agree” at the other end.
The structured interview was conducted by a trained research assistant 24 hr prior to surgery. Each item was read to subjects who marked their response on a VAS for items related to pain, and circled a number on a Likert scale for items related to attitudes.
edts Using stepwise multiple regression, the two variables that correlated significantly (multiple r = 0.51, 4; = 12.33, p
36
Walnts@et al.
global surgical pain, global trauma pain, global childbirth pain, chronic pain, and other pain). The total of the global pain ratings of past pain exp&nceS was the single strongest partial correlate of expected pain (simple r 21 0.34). Presurgical pain, five of the six attitudes about pain, and pain related to specific surgeries were not correlated with patients’ expectations of postsurgical pain.
Expectations of pain may influence the pain experience. For example, in comparing the needs for analgesia among men wounded in battle with a matched group of civilians undergoing surgery Beecher ’ found that 32% of the wounded men requested narcotics as opposed to 83% of the civilian group. It was felt rhat the expectations and meaning given to the different events affected the response to pain. Factors that account for patients’ expectations of pain are largely unknown. The results of this study suggest that a portion of that expectation (13% of the variance) may be accounted for by asking patients about their prior pain history. Patients’ response to the item “pain is to be expected after surgery even with medicine” (12% of the variance) was also associated with their expectation of pain. Together, responses to questions regarding prior pain history and attitude toward pain accounted for 25% of the variance in relation to pain expectation. Although one might expect pain from prior surgeries to correlate with expectation of postoperative pain, only the total of global pain scores, i.e., all surgeries, trauma, etc., was related. Gathering information regarding patients’ prior experience with pain could assist clinicians in providing them with appropriate information about the probable level of discomfort to be expected and the pain management strategies that can be used. Understanding the patients’ beliefs about the effectiveness of pain medication following surgery could also assist the clinician to make the patient aware of effective pain man-
agement strategies. This study was based on the assumption that the expectation of an event is an important factor in mediating how an individual responds to that event. Expectations regarding postsurgical pain may be modified if clinicians are able to collect relevant data. According to this study,
Journal of Pain and SymptomManagement
expectations that can include both overestimates and underestimates of postsurgical pain may be the result of prior experiences and attitude toward the effectiveness of pain medica-
tion.
The investigators acknowledge the Sanders Brown Center on Aging, University of Kentucky for funding this study and also the capable assistance of the research assistant Carol Guerdan.
eferenees 1. Beecher HK. Pain in men wounded Ann Surg 1946;123:96.
in battle.
2. Carr, CJ. Postoperative pain: patiezus expectations and experiences. J Adv Nurs 1990;15:89-100. 3. Chapman CR, Cox GB. Anxiety, pain and depression surrounding elective surgery: a multivariate comparison of abdominal surgery patients with kidney donors and recipients. J Psychosom Res 1977;2 1: 7-19. 4. Johnson JE, Rice VH, Ruller SS, Endress P. Sensory information, instruction in a coping strategy and recovery from surgery. Res Nurs HeaM 1978;1:417. 5. Bruegel MA. Relationship of preoperative anxiety to the perception of postoperative pain. Nurs Res 1971;20:2631. 6. Wise TN, Hall WA, Wong 0. The relationship of cognitive styles and affective states to postoperative analgesic utilization. J Psychosom Res 1978;22:513518. 7. Taenzer M. Influence of psychological factors on postoperative pain, mood and analgesic requirements. Pain 1986;24:331-342. 8. Parbrook CD, Steel DF, Dabrymple
DG. Factors
predisposing to postoperative pain and pulmonary complications: a study of male patients undergoing elective surgery.
Br J Anaesth 1973:45:21-33.
9. Ray C, Fitzgibbon G. Stress arousal and coping with surgery. Psycho1 Med 1981;11:741-746. 10. Scott LE. Glum GA. Preoperative predictors of postoperative pain. Pain 1983;15:283-293. 11. Martinez-Urrutia A. Anxiety and pain in surgical patients. J Consult Clin Psycho1 1975;43:437-442. 12. Boyle P. Parbrook GD. The interrelation of per=. sonality and postoperative factors. Br J Anaesth 1977;49:259-264. 13. Eysenck S. Personality and pain assessment childbirth of married and unmarried mothers. Mental Sci 1961;107:417-430.
in J
Vol. 7 No. 1 Januaq
1992
Prior Pain, Expectations, and Postoperatiue Pain
37
14. Bond MR. Glynn JP, Thomas IX. The relationship between pain and personality in patients receiving pentazocine (Fortral) after surgery. J Psychosom Res 1976;20:369-381.
19. S, Carber J. A cognitive-expectancy tbeapy for helplessnes depression. In: ory Carber J. Seligman M, eds. an helplessness. New York: Academic Press, 1980: 173- 196.
15. Andrews JM. Recovery from surgery, with and without preparatory instruction for three coping styles. J Personal Sot Psycho1 1970;15:223-226.
20. Bandura A. Social learning theory. Cliffs, NJ: Prentice Hall, 1977.
16. Auerback SM, Kendall PC, Cutler I-IF, Levitt R. Anxiety, locus of control, type of preparatory information and adjustment to dental surgery. J Consult Clin Psycho1 1976;44:809-818. 17. Clum CA, Scott L, Burnside J. Information and locus of control as factors in the outcome of surgery. Psycho1 Reports 1979;45:867-873. 18. Johnson JE, Qabbs JM, Levantbal II. Psycbosocial factors in the welfare of surgical patients. Nurs Res 1979; 19: 18-29.
Englewood
21. Wallace LM. Surgical patients’ expectations of pain and discomfort: does accuracy of expectations minimize post-surgical pain and distress? Pain 1985; 22:363-373. 22. Sear J, Nand C, Moore R. Studies on morphine disposition: Plasma concentrations of morphine and its metabolites in anesthetized middle-aged and elderly surgical patients. J Clin Anesth 1989;1:164-169. 23. Witte M. Pain control. 15:32-37.
J Cerontol
Nurs 1989;