Symptom burden in patients undergoing autologous stem-cell transplantation.

Patients who undergo autologous peripheral blood stem cell (PBSC) transplantation experience multiple symptoms that adversely affect quality of life. We assessed symptoms during the acute phase of autologous PBSC transplantation to determine the severity of individual symptoms and to determine overall symptom profiles in 100 patients with multiple myeloma or non-Hodgkin's lymphoma. Study subjects completed the blood and marrow transplantation module of the M. D. Anderson Symptom Inventory before hospitalization, during conditioning, on day of transplantation, at nadir (the time of lowest white blood cell count) and on day 30 post-transplantation. Additional symptom, quality-of-life and medical status measures were collected. Symptom means were mild at baseline, intensified during conditioning, peaked at nadir and decreased by day 30. At nadir, the most severe symptoms for the entire patient sample were lack of appetite, fatigue, weakness, feeling sick, disturbed sleep, nausea and diarrhea. Cancer diagnosis was a significant predictor of changes in symptoms over time. The patterns of fatigue, pain, sleep disturbance and lack of appetite were significantly different for patients with multiple myeloma as compared with patients with non-Hodgkin's lymphoma.

Minority cancer patients and their providers: pain management attitudes and practice.

BACKGROUND: The goals of the current studies were: 1) to determine the pain treatment needs of socioeconomically disadvantaged African-American and Hispanic patients with recurrent or metastatic cancer and 2) to assess the attitudes of health care professionals who treat them. METHODS: In the first study 108 African-American and Hispanic patients with metastatic or recurrent cancer and pain completed a survey about their pain intensity, pain interference, and attitudes toward analgesic medications. Physicians also rated their patients' pain and the adequacy of the patients' current analgesic prescriptions was assessed. In the second study 55 physicians and nurses who treat these patients completed a questionnaire regarding cancer pain and its management in their practice settings. RESULTS: Approximately 28% of the Hispanic and 31% of the African-American patients received analgesics of insufficient strength to manage their pain. Although the majority of patients received appropriate analgesics, 65% reported severe pain. Physicians underestimated pain severity for 64% of the Hispanic and 74% of the African-American patients. Physicians were more likely to underestimate the pain severity of female patients than male patients. Inadequate pain assessment, patient reluctance to report pain, and lack of staff time were perceived as barriers to pain management. CONCLUSIONS: Although the data suggest recent improvements in analgesic prescribing practices for African-American and Hispanic cancer patients, the majority of patients reported high levels of pain and limited pain relief from analgesic medications. Inadequate pain assessment remains a major barrier to optimal cancer pain treatment.

Guidelines for program evaluation in chronic non-malignant pain management.

The current article offers guidelines to systematically evaluate programs which treat chronic non-malignant pain syndrome patients. The guidelines represent a basic program evaluation strategy and include specific recommendations and choices on measurement-assessment tools based upon available research literature and common clinical practice. They are based on evaluation by objectives, which include the program's ability to reduce the misuse of medications, increase physical function, increase productive activity at home, work and socially, improve overall mood, reduce subjective pain intensity, reduce the use of healthcare, when applicable, achieve equitable case settlement, and minimize pain treatment program cost without compromising quality of care. The method and timing of assessing each of these objectives are delineated with an emphasis on using reliable, valid measures which can be applied effectively within a clinical setting. The guidelines also advocate patient and staff satisfaction assessment, thus offering a fully integrated program evaluation system which can measure effectiveness and allow ongoing improvement in care.

Work-related upper-extremity disorders and work disability: clinical and psychosocial presentation.

Work-related upper-extremity disorders (WRUEDs) are an increasingly common cause of work-related symptoms and disability. Although most upper-extremity disorders are acute and self-limited, a small percentage of workers with symptoms go on to permanent disability and account for the majority of costs associated with these conditions. Little is known, however, about this progression from symptoms to disability and how it might be prevented. In this study, we evaluate the demographic, vocational, medical, and psychosocial characteristics of patients with WRUEDs and examine several hypotheses regarding the differences between working and work-disabled patients. One hundred twenty-four consecutive patients were evaluated in a clinic specializing in occupational upper-extremity disorders. Patients currently working (n = 55) and work-disabled patients (n = 59) were similar with regard to age, gender, and reported job demands. The work-disabled group reported less time on the job, more surgeries, a higher frequency of acute antecedent trauma, and more commonly had "indeterminate" musculoskeletal diagnoses. They also reported higher pain levels, more anger with their employer, and a greater psychological response or reactivity to pain. These findings, though cross-sectional in nature, suggest that, in addition to medical management, more aggressive approaches to pain control, prevention of unnecessary surgery, directed efforts to improve patients' abilities to manage residual pain and distress, and attention to employer-employee conflicts may be important in preventing the development of prolonged work disability in this population.

Clinical practice guidelines for chronic non-malignant pain syndrome patients.

The current paper provides specific guidelines for treating chronic non-malignant pain syndrome patients. The guidelines were developed from an extensive review of existing literature on practice guidelines, the research literature, and common clinical practice across major pain treatment facilities in the USA. They are intended for application to all chronic pain syndrome patients (other than cancer pain) regardless of specific site or etiology of pain. They advocate goal directed treatment to reduce medication misuse and invasive medical procedures, maximize and maintain physical activity, return to productive activity, increase the patient's ability to manage pain, reduce subjective pain intensity, reduce or eliminate the use of healthcare services for primary pain complaint, provide useful information for case settlement, and minimize treatment cost without sacrificing quality. The guidelines recommend interdisciplinary integrated evaluation and treatment on a time limit basis with a focus on conservative medical, psychological behavioral, physical, and vocational interventions based upon the patient's needs. There is emphasis on increasing the patient's level of function and ability to manage pain and related problems. Outpatient care is strongly recommended, with specific upper limits regarding treatment intensity and the use of trigger point injections and nerve blocks delineated. The guidelines also recommend that the long term use of opioid or sedative-hypnotic medications, surgery, implantable spinal devices, or brain stimulation techniques be avoided with chronic pain syndrome patients. These guidelines are intended to serve as a starting point to effectively extend and complement those released by the Agency for Health Care Policy and Research for other types of pain problems such as cancer and acute low back pain.

Survey of opioid use in chronic nonmalignant pain patients.

BACKGROUND AND OBJECTIVES: Opioids have been accepted as appropriate treatment for acute and cancer pain, but remain controversial for use with chronic nonmalignant pain. Clinicians are concerned about efficacy, tolerance, addiction, and unwanted side effects. METHODS: The aim of this study was to survey chronic pain patients who were taking opioids for their pain, to determine the incidence of these adverse conditions. Two hundred seventeen patients who were being treated for their pain at two different pain centers completed a medication questionnaire. The most common diagnosis was low back pain. One hundred twelve patients reported taking oral opioids for their pain. RESULTS: Of the patients who reported taking opioids for their chronic pain, 83% felt that the opioids were moderately beneficial in relieving their pain; 25% felt that the opioid had not lost its ability to relieve the pain over time; 35% reported that they did not need to increase their medication; 36% expressed no fear of addiction or dependence; and 56% reported having no unwanted side effects. CONCLUSIONS: The results suggest that chronic nonmalignant pain patients taking opioids for their pain reported some tolerance, fear of addiction, and side effects when taking opioids. However, despite these concerns, some of these patients felt that opioid therapy was very beneficial. Further investigations are needed to determine which patient characteristics predict benefit from opioid therapy for nonmalignant pain.

Pain behavior of rheumatoid arthritis patients enrolled in experimental drug trials.

OBJECTIVE: This study examined the sensitivity of a behavioral observation method for the assessment of arthritis pain as an outcome measure in clinical drug trials. METHODS: The subjects were 33 rheumatoid arthritis patients who were receiving either an active experimental drug or a placebo. Disease activity measures, self-reports of pain, and pain behavior observations were completed for each subject prior to drug initiation, 6 weeks after drug initiation, and 12 weeks after drug initiation. RESULTS: Significant reductions in measures of disease activity and self-report of pain were found for the subjects who received an active drug, relative to those who received the placebo. The pain behavior scores produced by both groups of subjects remained relatively stable during the study. CONCLUSION: The lack of change in pain behavior suggests that arthritis pain behavior may lack sensitivity to short-term changes accompanying drug therapy.

Observation of pain behavior in rheumatoid arthritis patients during physical examination. Relationship to disease activity and psychological variables.

This study examined the reliability and validity of a behavioral observation method for the assessment of arthritis pain in a clinical practice setting. Trained observers measured the occurrence of seven pain behaviors in a group of 61 rheumatoid arthritis patients undergoing physical examinations. These observations were compared with videotaped observations of the patients in a laboratory setting. Significant differences were found between the pain behavior frequencies observed during the examinations and those observed during videotaped sessions. Total pain behavior scores obtained in both settings were significantly correlated with patients' self-reports of pain and with disease activity measures. Pain behavior observed during the exams was significantly associated with patients' self-reports of anxiety and depression.

Psychologic preparation for cardiac catheterization.

Cardiac catheterization is an invasive medical procedure that is anxiety arousing for most patients. Four psychologic preparatory strategies designed to reduce anxiety and enhance adaptation were compared with an attention placebo control intervention. Sixty adult patients scheduled for cardiac catheterization were randomly assigned to one of five groups: sensory-procedural information, modeling, cognitive-behavioral coping skills, modeling plus coping skills, or attention placebo control. Subjects' reactions to cardiac catheterization were assessed by using self-report, behavioral, and physiologic measures. Results indicated that subjects in the modeling and modeling plus coping skills groups were rated as less anxious and better adjusted during the catheterization than control subjects. Compared with controls, subjects in the two modeling groups also reported less subjective anxiety and greater perceived coping ability during the catheterization. All subjects who received a preparatory treatment demonstrated lower levels of autonomic arousal both during and after the test than did control subjects. The results support the efficacy of preparatory strategies that include a patient model.

Stress induces alteration of esophageal pressures in healthy volunteers and non-cardiac chest pain patients.

The present study was designed to explore the relationship between psychological stress and esophageal motility disorders. Nineteen non-cardiac chest pain patients (10 with the nutcracker esophagus and nine with normal baseline manometry) and 20 healthy control subjects were administered two acute stressors: intermittent bursts of white noise and difficult cognitive problems. The results indicated that the esophageal contraction amplitudes and levels of anxiety-related behaviors of non-cardiac chest pain patients and control subjects were significantly greater during the stressors than during baseline periods. All patients demonstrated significantly greater (P less than 0.01) increases in contraction amplitude and anxiety-related behavior during cognitive problems than during the noise stressor. The nutcracker esophagus patients showed a greater increase in contraction amplitude during the problems (23.50 +/- 9.42 mm Hg, X +/- SE) than control subjects (P less than 0.01), while the amplitude changes of chest pain patients with normal baseline manometry were not significantly greater than that of control subjects (9.00 +/- 1.91 mm Hg). The present results identified an increase in contraction amplitude as the primary esophageal response to stress. The possible interaction of esophageal contraction abnormalities, psychological stress, and the perception of chest pain is discussed.

Effects of psychological therapy on pain behavior of rheumatoid arthritis patients. Treatment outcome and six-month followup.

A randomized clinical trial was performed to evaluate a psychological treatment intervention and a social support program, compared with a control program in which no adjunct treatment was rendered, and their effects upon pain behavior, affect, and disease activity of 53 patients with rheumatoid arthritis. The psychological intervention produced significant reductions in patients' pain behavior and disease activity at posttreatment. Significant reductions were also observed in trait anxiety at posttreatment and 6-month followup. Relaxation training may have been the most important component of the psychological intervention. The social support program produced a significant reduction in trait anxiety only at posttreatment. This is the first well-controlled study to demonstrate reduced pain behavior, disease activity, and trait anxiety following psychological treatment.

The assessment of pain in rheumatoid arthritis: disease differentiation and temporal stability of a behavioral observation method.

An observation method for the assessment of pain behaviors in patients with rheumatoid arthritis (RA) has been developed. We investigated the extent to which the frequencies of pain behaviors differentiated patients with RA and patients with chronic low back pain from depressed and nondepressed, pain free, control subjects. The reliability of the pain behavior frequencies of patients with RA across 2 observation sessions also was determined. Total pain behavior scores clearly differentiated patients with RA and low back pain from depressed and nondepressed, pain free, control subjects. Pain behavior observed in patients with RA showed a high degree of stability over time. The results of our study suggest that the behavioral observation method will prove useful in the assessment of RA pain in clinical and research settings.

The assessment of pain in rheumatoid arthritis. Validity of a behavioral observation method.

It is difficult to objectively measure pain in rheumatoid arthritis (RA). A behavioral observation method for the assessment of RA pain has been developed. In this study, videotapes were made of 53 RA patients while they performed standardized maneuvers. Trained raters viewed the videotapes and recorded the frequencies of 7 pain behaviors. Clinical and laboratory measures of rheumatoid disease activity also were recorded for each patient. Rheumatology fellows viewed 20 randomly chosen video recordings of the patients and made global estimates of the intensity and unpleasantness of pain. Significant positive correlations were found between total pain behavior scores and measures of disease activity. The fellows' estimates of the intensity and unpleasantness of the patients' pain also were significantly and positively correlated with the total pain behavior scores. The behavioral observation method may be useful in the assessment of RA pain and may be included as an objective outcome measure in clinical trials with RA patients.

Psychological comparison of patients with nutcracker esophagus and irritable bowel syndrome.

UNLABELLED: Recent evidence suggests that psychological factors may affect esophageal as well as intestinal motility. To study this further, we compared the psychological profiles of 20 irritable bowel patients and 20 patients with recurrent noncardiac chest pain associated with high-amplitude peristaltic contractions in the distal esophagus, the "nutcracker esophagus." Three control groups with 20 patients each also were evaluated. The Millon Behavioral Health Inventory was administered to all subjects. This is a 150-item self-report instrument developed to assess psychological impact of medical illnesses in nonpsychiatric populations. The nutcracker and irritable bowel patients differed significantly (P less than 0.05) from controls on scales of gastrointestinal susceptibility and somatic anxiety, suggesting that these patients react to psychological stress with an increase in symptom frequency and severity. They also tend to be hypochondriacal and seek early medical care. Irritable bowel patients, however, have a more generalized disorder, as they also scored significantly higher (P less than 0.05) than the other groups on three general measures of depression and anxiety. CONCLUSION: as previously observed in the irritable bowel syndrome, emotional factors may modulate pain perception in the nutcracker esophagus. Simple psychometric instruments like the Millon Behavioral Health Inventory may be useful in identifying these patients who may benefit from psychotropic drugs or behavior modification.

Psychological approaches to the management of arthritis pain.

The present review examines the literature regarding the efficacy of cognitive-behavioral and other self-control interventions in helping arthritis patients reduce their pain and functional disabilities. The evidence indicates that self-control interventions have produced significant and positive changes in the pain and functional disabilities of patients with rheumatoid arthritis and arthritis secondary to hemophilia. However, the literature suffers from deficiencies with regard to the use of small subject samples; inadequate control procedures and follow-up assessments; failure to demonstrate that positive outcomes are related to changes in subjects' covert experiences or control of physiological variables; and reliance upon self-report measures of outcome. The review is followed by a description of a multidisciplinary study of the efficacy of a biofeedback-assisted, cognitive-behavioral group therapy program for rheumatoid arthritis patients that features several methodological improvements relative to previous investigations. The preliminary outcome data show that the cognitive-behavioral intervention is associated with reductions in pain behavior and self-reports of pain and disability. It is concluded that, although the self-control interventions have shown promising results, psychologists must demonstrate positive and reliable outcomes among large numbers of arthritis patients over extended periods of time if the interventions are to be viewed as credible by rheumatologists.

Psychological preparation for invasive medical and dental procedures.

Psychological preparation for invasive medical and dental procedures has been based on the rationale that high levels of preprocedural fear are detrimental to patients' subsequent adaptation. After a brief survey of the theoretical and empirical evidence pertaining to this rationale, the major psychological approaches designed to alleviate preprocedural concern and enhance recovery are discussed. Outcome studies that have employed informative, psychotherapeutic, modeling, behavioral, cognitive-behavioral, and/or hypnotic techniques are summarized and evaluated. Although the research suggests that each of these approaches can be effective, such serious methodological problems as heterogeneity of sample characteristics, limited range of outcome measures, and lack of manipulation checks prevent definitive conclusions. Legal-ethical concerns and the issue of cost effectiveness are also considered. Suggestions are made for future research and theory development.