Multimethod assessment of treatment process in chronic low back pain: comparison of reported pain-related anxiety with directly measured physical capacity.

Although cognitive behavioural treatments (CBT) have proven efficacy in improving symptom management, pain-related distress, physical performance and return to work. few studies have examined the relationship between changes in behavioural process variables during treatment and improvement in outcome variables following treatment. We designed a multimethod assessment strategy to test the relative contribution of changes in physical capacity and pain-related anxiety to treatment outcome variables. Low back pain patients (n = 59) were treated with an intensive programme of physical exercise and CBT. Comparisons from pre- to post-treatment showed significant improvement in pain severity, interference, affective distress, activity level, and depression. Improvements in pain-related anxiety were associated with improvements in all outcome variables except interference. Of three physical capacity composite scores, improvement in only one (lumbar extension and flexion capacity) was associated with improvements in all outcome variables except interference. Further analyses demonstrated that the relationship between changes in pain-related anxiety and treatment outcome were independent of changes in physical capacity performance. Changes during treatment in pain-related anxiety may be more important than changes during treatment in physical capacity when predicting the effect of treatment on behavioural outcome measures. These results are discussed in the context of how to improve assessment of the chronic pain patient and improve the effectiveness of multidisciplinary CBT.

The assessment of anxiety and fear in persons with chronic pain: a comparison of instruments.

Instruments used to study anxiety and fear responses related to chronic pain vary along two dimensions. They differ in terms of the stimuli or situations that evoke anxiety responses and the types of anxiety responses included (i.e. cognitive, motoric, and physiological). This study examined relations of variables from the Pain Anxiety Symptoms Scale (PASS), the Fear-Avoidance Beliefs Questionnaire (FABQ), the Fear of Pain Questionnaire (FPQ), and the trait version of the Spielberger State-Trait Anxiety Inventory (STAI) with variables related to pain severity, perceived disability, and pain behavior. Subjects were 45 consecutive referrals to a university pain clinic who completed these measures during their evaluation. Results suggested that anxiety responses directly related to the patient's particular pain sensations are more relevant to the understanding of chronic pain than are more general tendencies to respond anxiously or fear more varied pain stimuli. Regression analyses showed that empirically selected subsets of the anxiety variables predict from 16 to 54% of the variance in pain severity, disability and pain behavior. Also, assessment of multiple anxiety response types appears useful for understanding pain behavior and disability. Further study of fear and anxiety responses of persons with pain is likely to benefit from careful selection of measures dependent on the stimulus and response dimensions assessed.

Does anxiety affect coping with chronic pain?

OBJECTIVE: To evaluate whether symptoms of emotional distress related to pain affect patients' use of pain coping strategies. Relations between anxiety responses, as assessed by the Pain Anxiety Symptoms Scale, and coping strategies, as assessed by the Coping Strategies Questionnaire, were examined. DESIGN: Cross-sectional, retrospective, correlational. SETTING: A multidisciplinary pain management clinic in a university hospital. PARTICIPANTS: One hundred sixty-five patients (49.7% female) with chronic pain complaints. The most frequent complaint was low back pain (73%). Average age was 45.3 years (SD = 13.8). MAIN OUTCOME MEASURES: Pain coping strategy scores and ratings of ability to control and decrease pain. RESULTS: Generally, cognitive anxiety was associated with less overall coping with pain, whereas physiological anxiety was associated with a greater coping with pain. Escape and avoidance anxiety responses were associated with greater use of overt pain behaviors for coping. Regression analyses indicated that anxiety symptoms combined across cognitive, motoric, and physiological response types accounted for significant variance in seven of eight coping strategy scores. These analyses also revealed significant unique relations of separate anxiety modalities with coping variables. Relations between anxiety scores and the Catastrophizing subscale of the CSQ were much greater than the relations of anxiety scores with other coping variables, suggesting that catastrophizing may be better conceptualized as a distress response rather than a coping strategy. CONCLUSIONS: These results show that different types of anxiety symptoms have differing relations with pain coping responses. Cognitive anxiety symptoms may interfere with coping, whereas physiological anxiety symptoms may enhance coping. Possible mechanisms and implications are discussed.

Prediction of pain in patients with chronic low back pain: effects of inaccurate prediction and pain-related anxiety.

This study investigated predictions of pain intensity, reports of pain and anxiety, frequency of pain-related anxiety symptoms, and range of motion, in 43 patients exposed to pain during a physical examination. All patients had primary complaints of low back pain. The pain stimuli used for this study included back and/or leg pain produced by repeatedly raising the extended leg of the patient to the point of pain tolerance. Generally, findings demonstrated that (a) predictions of pain were a function of discrepancies between previous predictions and experiences of pain, (b) patients reporting greater pain-related anxiety showed a tendency to overpredict new pain events, but corrected their predictions readily, (c) patients reporting less pain-related anxiety displayed a persistent tendency to underpredict pain, and (d) higher predictions of pain, independent of pain reports, related to less range of motion during a procedure that involved painful movement. Discussion focuses on differences between these results and those of previous studies and the implications of inaccurate prediction for continued pain and disability.

Enhancing the cognitive outcomes of low birth weight, premature infants: for whom is the intervention most effective?

The Infant Health and Development Program is a national collaborative study to test the efficacy of combining early child development and family support services with pediatric follow-up to reduce the incidence of health and developmental problems among low birth weight, preterm infants in eight medical school sites. Its efficacy in enhancing intellectual outcomes at age 3 in more and less environmentally vulnerable, low birth weight, preterm children, as defined by maternal education (high school completion or less vs some college) and race (black vs white/other), is explored. Children whose mothers had a high school education or less benefited from the intervention. This was true for both the black and white samples. Children whose mothers had attended college did not exhibit significant enhancement in IQ scores at 3 years. Birth weight affected the response to treatment for one of the four subgroups: Among white mothers with some college, the lighter (less than 2000 g) low birth weight, preterm children were less influenced by the intervention than were the corresponding heavier children. Implications for targeting certain subgroups of low birth weight, preterm children for services are considered.

Pain disability index: construct and discriminant validity.

The Pain Disability Index (PDI) was developed as a self-report measure of general and domain-specific, pain-related disability. This study's purpose was twofold: (1) to assess construct validity of the scale relative to other measures of pain-related disability and psychologic distress and (2) to assess the strength of the PDI, independent of pain intensity, in accounting for behavioral and psychologic aspects of disability. Results indicated stronger correlations for PDI factor 1 (discretionary activities) than factor 2 (obligatory activities), with factor scores significantly related to both psychologic distress and behavioral measures of disability. Partial correlation controlling for pain intensity demonstrated PDI factor 1 was significantly related to depression, employment status, and medication usage. The finding supports the usefulness of the PDI in providing important information on functional disability beyond what is provided by a simple measure of pain intensity.

Health care use among young children in day care. Results in a randomized trial of early intervention.

Exposure of young children to group day-care settings increases the risk of illness and may result in higher use of medical care. These observations raise concerns that the use of such settings for early intervention programs for low-birth-weight infants may increase the already high burden of medical care costs incurred by these children and their families. To address the question of medical care use associated with center-based care, we examined the hospital-based and ambulatory care reported for participants of the Infant Health and Development Program. This project is a multisite randomized trial of an early intervention program for preterm low-birth-weight infants with an intervention including 2 years of center-based care. The Intervention group did not differ in hospital-based care and averaged only two more physicians' visits over the 3-year observation period than the comparison group. We conclude that early intervention programs involving high-quality group care are not accompanied by substantial increases in health care use.

Identification of intrauterine growth retardation among low birth weight preterm infants.

This study describes an attempt to define intrauterine growth retardation low birth weight preterm infants by comparing reference standards for intrauterine growth in weight, length, and head circumference on their variability across ethnic groups and cities, and on their specificity in independently classifying infants as short, thin, or having small heads. The sample consisted of 985 inborn preterm low birth weight infants enrolled at eight participating sites in a randomized clinical trial using uniform sampling criteria. When gestational age was used as the reference standard, striking differences were found by ethnicity and site in the prevalence of low weight infants at birth. These differences, as well as the potentially false overlap of classification, were attenuated when the use of gestational age as a reference standard was used only for birth length, while length itself was used (as an alternative to gestational age) as the reference standard for birth weight, and weight was used as the reference standard for head circumference. These results raise questions about the use of gestational age as the primary or only reference standard in assessing weight and head circumference at bith.

Physical and psychological effects of aerobic exercise in delinquent adolescent males.

Aerobic exercise has been associated with improved psychological status and physical fitness in adults, but its effects in adolescents have been less clear. This study evaluated the effects of aerobic exercise on the self-concept, depression level, and physical fitness of juvenile delinquents. Ninety-eight incarcerated youths who volunteered to participate were assigned in a blind fashion to one of two exercise programs lasting three months. Sixty-nine completed all phases of the study and are the subjects of this report. One exercise program (32 subjects) emphasized aerobic exercise; the other (37 subjects), limited exertion. Before and after participating, each subject underwent measurement of self-concept, mood, and physical fitness. While the aerobic and comparison groups were initially similar, the data demonstrated an association between participation in the aerobic exercise program and improved self-concept, mood, and fitness. Improvement in psychological variables was not dependent on improved physical fitness and was not related to preintervention measures.

Physical and psychological effects of aerobic exercise in boys with learning disabilities.

Aerobic exercise has been associated with improvements in psychological status and physical fitness in adults, but its effects on children are less clear. The purpose of this study was to evaluate the effects of an aerobic exercise program on the self-concept, academic achievement, motor proficiency, and cardiovascular fitness of boys with learning disabilities. Fifty-four boys were randomly assigned to one of two exercise programs lasting 20 weeks. One program emphasized aerobic exercise and the other consisted of similar but less vigorous activities. The self-concept, academic achievement, motor proficiency, and physical fitness of each subject was assessed before and after the exercise programs. The results from group comparisons demonstrated an association between the aerobic exercise program and improvement of self-concept and physical fitness. No effect on academic achievement or motor proficiency could be attributed to the aerobic exercise program.

Use of physical and neurologic observations in assessment of gestational age in low birth weight infants.

The relative validities of three clinical assessment methods for estimating gestational age in newborn low birth weight infants were evaluated with reference to estimates based on the date of the mother's last menstrual period. For 1246 infants in eight diverse institutions, estimates based on physical criteria correlated more strongly with dates estimates, yielded estimates more similar on average to dates estimates, and yielded higher proportions of correct classifications of prematurity and small for gestational age than did estimates based on neurologic criteria or neurologic and physical criteria combined. These results support the use of physical criteria rather than neurologic or combined criteria for the clinical assessment of gestational age in low birth weight infants. In a subsample of 511 black and white infants, there were no ethnic differences in mean error of estimate for any of the three methods.

Growth and intellectual development.

Data from the National Health Examination Survey (cycles II and III) provided a representative sample of 13,887 US youths (6 to 17 years of age) with which to examine the relationship between height (normalized for age and sex) and measures of intellectual development (Wechsler Intelligence Scale for Children) and academic achievement (Wide Range Achievement Test). Additionally, 2,177 subjects were studied first in cycle II and 2 to 5 years later in cycle III, forming a well-selected longitudinal study group in which to examine any association between linear growth and change in IQ scores. Wechsler Intelligence Scale for Children and Wide Range Achievement Test scores were significantly correlated with height in both cycle II and cycle III. However, no significant association between change in relative height and change in IQ scores could be detected in the longitudinal group. These data suggest that therapies designed to increase height are unlikely to alter measures of intellectual development or academic achievement.

Single parents, extended households, and the control of adolescents.

This paper uses a representative national sample of adolescents to study the interrelationships among family structure, patterns of family decision making, and deviant behavior among adolescents. Mother-only households are shown to be associated with particular patterns of family decision making and adolescent deviance, even when family income and parental education are controlled. In contrast to adolescents in households with 2 natural parents, youth in mother-only households are perceived as more likely to make decisions without direct parental input and more likely to exhibit deviant behavior. The presence of an additional adult in a mother-only household, especially for males, is associated with increased parental control and a reduction in various forms of adolescent deviance. Finally, patterns of family decision making and family structure both make independent contributions to adolescent deviance, and the impact of family structure on deviance of adolescent males is hardly affected by controlling for patterns of family decision making.

The effects of pubertal timing on body image, school behavior, and deviance.

Variation in the timing of pubertal maturation may result in behavioral differences among early, mid-, and late maturers. Using data from the National Health Examination Survey, a national probability sample of children and youth aged 12-17, we investigated the relationships between maturational timing and body image, school behavior, and deviance. In terms of body image, the early maturing boys were the group most satisfied with height and weight. The early maturing girls were most dissatisfied with weight, with 69% wishing to be thinner. This great dissatisfaction with weight reported by early maturing girls is probably not an affect of early maturation, but a concomitant of maturation in general. The majority of girls became dissatisfied with their weight as they matured, and females from the higher social groups were more likely to want to be thinner than females from lower groups. Thus, a normal developmental process is being viewed negatively by females and positively by males. Male early maturers more often had deviant behavior, but there were no consistent findings for girls. There was no effect of maturational timing on teacher reports of school absence, adjustment, popularity, need for discipline, or grade repetition.

Sexual maturation, social class, and the desire to be thin among adolescent females.

Veblen's 1899 hypothesis that associated a female desire for thinness with the higher social classes was tested with data from a representative national sample of adolescents, 12 to 17 years of age, in the National Health Examination Survey. Controlling for the actual level of fatness, adolescent females in higher social classes wanted to be thinner more often than those in lower classes. The greater female desire for thinness was not the product of health information nor of sex differences in the level of fatness. The thinner the female, the greater the impact of social class on the desire for thinness. During puberty, adolescent females negatively evaluated the body fat associated with normal sexual development.

Educational correlates of early and late sexual maturation in adolescence.

From the National Health Examination Survey data, 4,735 Caucasian males and females, 12 to 17 years, were classified by age and stage of sexual maturation (Tanner). Early and late maturers were each compared to all other youth of comparable age and sex, in eight education-related categories: youth and parental aspirations and expectations concerning the level of education which would be achieved by the student, teacher reports of intellectual ability and academic achievement, and test scores (WISC and WRAT). Except at age 12, late maturing boys received significantly lower ratings than mid maturers in all these areas, and early maturing males received higher ratings. For females, no differences persisted across age groups. In advising male adolescents, physicians should be alert to the possibility that school functioning may be linked to maturational processes.