Presurgical Psychological Screening in Chronic Pain Syndromes

A Guide for the Behavioral Health Practitioner

Andrew R. Block

• Publisher: Psychology Press
• Year: 2014
• eBook ISBN: 9781317778721
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Pain is an unfortunate daily experience for many individuals. Chronic pain -- lasting six or more months -- is suffered by approximately 30% of the population in the United States. These individuals wake up, function during the day and go to sleep, trying to keep pain at a minimum while, at the same time, maintaining some quality of life. They may make frequent visits to the doctor and the pharmacy. When they find relief, it is usually short-lived and comes at a cost such as dependence on narcotic medications or complete limitation of activity. Pain often becomes the central point of their existence.

This practice guide describes an approach to psychological evaluation of the chronic pain patient who is being considered for surgery. A large body of research is accumulating which demonstrates that the outcome of surgical procedures aimed at chronic pain relief can be strongly influenced by psychological and emotional factors. This approach, termed "presurgical psychological screening" (PPS) uses interview and testing techniques to identify emotional, behavioral, and psychosocial difficulties which have been demonstrated to negatively impact surgical outcome. Studies show that even patients with clearly identifiable pathophysiology may respond poorly to surgery, due to issues such as pain sensitivity, medication dependence, rewards for pain behavior and personality style. Thus, some insurance carriers, rehabilitation nurses and state worker's compensation systems are encouraging, or even requiring, presurgical psychological screening in cases of surgery designed to relieve chronic pain.

The first to present a comprehensive, unified approach to PPS in chronic pain syndromes, this text is designed to provide the behavioral health practitioner, as well as the trainee, with all the tools and information necessary to conduct PPS evaluations. It identifies a multitude of risk factors for poor surgical outcome and reviews research associated with each risk factor. Hands-on techniques for eliciting information from the patient about risk factors is also detailed. Toward this end, the practice guide also contains a number of forms and session outlines which can be directly utilized, or which can be altered to fit readers' needs. Models for weighing and combining surgical outcome risk factors are also provided. Thus, practitioners are able to reach valid and reliable predictions of surgical results. Finally, the text provides outlines of psychological interventions which can facilitate surgical outcome as well as surgical treatment alternatives. Upon completion of this practice guide, readers should be able to begin providing PPS evaluations which are scientifically valid, clinically sound, and which result in significant overall improvement in the treatment of chronic pain syndromes.

Chapter 1

Introduction and Overview

Presurgical Psychological Screening in Chronic Pain Syndromes

Pain is an unfortunate daily experience for many individuals. Chronic pain, lasting 6 or more months, is suffered by approximately 30% of the U.S. population (Bonica, 1990). These individuals wake up, function during the day, and go to sleep trying to keep pain at a minimum while, at the same time, maintaining some quality of life. They may be frequent visitors to the doctor and the pharmacy. When they find relief it is usually short-lived and comes at a cost, such as dependence on narcotic medications or complete limitation of activity. Pain often becomes the central point of their existence.

All pain is disturbing, irritating, and distracting, but when it is experienced on a constant basis, these noxious characteristics can become intolerable. Individuals who experience chronic pain can become increasingly physically disabled and emotionally distraught. Depression, and even suicidal thoughts, may arise. Marriages may disintegrate and jobs may be lost. The suffering individual is, therefore, willing to spend tremendous amounts of time and energy in order to eliminate or reduce the experience of chronic pain.

The general pattern of pain treatment takes a fairly predictable course. Usually, when pain is first experienced, initial diagnostic and intervention efforts are minimal, and may be limited to medication, rest, and reassurance. Most often this is sufficient, and the pain may pass in a few days or weeks. If the pain persists, more expensive diagnostic tests, such as magnetic resonance imaging (MRI), computerized axial tomography (CAT) scans, and the like, may be used. Correspondingly more intense and expensive treatments, such as injections, chiropractic, and physical therapy, may be taken. However, after many months and treatments, some patients still feel little or no relief. There may then come a point where the patient may think: “If only someone could cut out the source of the pain I would be happy.” Thus, the groundwork is laid for considering surgery as a solution to the pain.

Chronic pain can be experienced in almost every organ system of the body. It is associated with a huge range of physical diagnoses (Merskey & Bogduk, 1994). In many of these conditions, invasive treatment may be a plausible approach to removing the physical source of the pain, or at least reducing its impact on the patient. Thus, surgery may offer the possibility of reduced suffering, improved independence and quality of life, and a return to greater functional ability.

Research suggests, however, that surgery for chronic pain relief requires a great deal of circumspection. Chronic pain is not simply a result of an untreated physical condition. Rather, psychological factors also play a large role in chronic pain. Patients may have long-standing psychological problems, predating the pain, that can influence their pain perception and the ability to handle the chronic pain condition. Also, psychological and interpersonal difficulties may be experienced in response to the pain, worsening its impact. Thus, chronic pain can be viewed as a syndrome in which physical and psychological factors interact to affect the outcome of any intervention. Surgical success or failure may be determined by this complex interplay.

Failure of surgery for relief of chronic pain can have serious consequences. Often, failed surgery may produce iatrogenic effects, such as the development of scar tissue, nerve damage, or weakening of physical structures. Further, the patient may be more functionally disabled or require more narcotic medication than prior to surgery. Sometimes the initial surgery may only represent the beginning of a long trail of expensive, invasive interventions, providing little or no pain relief. Thus, the failure of surgery can place extreme burdens on the patient, the medical community, and the insurer who pays for treatments.

This practice guide describes an approach to psychological evaluation of the chronic pain patient who is being considered for surgery. This approach, termed presurgical psychological screening (PPS), uses interview and testing techniques to identify emotional, behavioral, and psychosocial difficulties that have been demonstrated to negatively impact surgical outcome. This PPS approach emphasizes the importance of examining such psychological factors in the context of both the patient’s specific physical condition, as well as the proposed surgery. Thus, the interaction of medical and psychological factors is explicitly considered in each case.

The PPS approach described in this volume has two goals. First, the patient is given a surgical prognosis; good, fair, or poor pain relief is expected as a result of surgery. Thus, PPS can serve to sharpen the surgeon’s diagnostic accuracy, screening out those patients who are likely to respond poorly to surgery. Second, a set of treatment plans is developed to augment surgical outcome or as pain control alternatives to surgery. Thus, PPS may facilitate the surgery in producing greater pain relief and may reduce treatment time and cost. Further, in cases where invasive treatment is not advisable, PPS can provide techniques for pain control and improvement in function, which are both less costly than surgery and do not run the risk of iatrogenic difficulties.

The bulk of this practice guide is spent examining PPS for chronic back and neck pain patients. By far, the majority of PPS research has been performed on these populations. Carefully examining PPS for spine surgery allows it to stand as a more general model for PPS. Psychological factors observed in chronic back pain are also found frequently in other pain syndromes. In the final chapter of this volume, psychological factors are examined in two additional pain syndromes that are frequently treated with surgical intervention: chronic idiopathic pelvic pain (CPP) and temporomandibular joint dysfunction (TMD). The final chapter builds on the findings in these pain syndromes to develop such a general PPS model, which can be used in screening surgical candidates who have a wide range of chronic pain syndromes.

Chronic Back Pain

Back pain is one of the most vexing problems in health care today. It affects approximately 70% of all individuals in the United States at some time during their lives (Fordyce, Brockway, & Spengler, 1986) and is the second most frequent cause of visits to physicians (Cypress, 1983). Back pain is the leading cause of disability and lost production in the United States (Loeser, Bigos, Fordyce, & Violinn, 1990). The direct and indirect costs of low back pain alone are estimated to exceed $50 billion per year in the United States (Frymoyer, 1991). Yet, the most effective course of treatment for an episode of back pain is often to perform no medical or surgical intervention. In fact, most of those affected can recover with just 2 to 3 days of bed rest and anti-inflammatory medication (Deyo, Diehl, & Rosenthan 1986).

Not all back pain sufferers recover so easily. In the desperate search for relief, some patients go on to a wide variety of treatments. This small number of patients both incur tremendous medical expenses and experience protracted frustration. By way of illustration, S. Leavitt, Johnson, and Beyer (1971) found that 25% of patients with job-related low back injuries are responsible for 87% of total treatment costs. Similarly, Spitzer (1987) found that 7.4% of all industrial back claims were responsible for 86% of total costs. It is most likely in response to such recalcitrant patients that a number of specialized interventions have developed or flourished, including chiropractic, biofeedback, acupuncture, and work hardening, among others. Although all of these treatments may provide relief, some patients continue to suffer. These are often individuals who are eventually considered for spine surgery.

According to Spitzer (1987), only about 1 % of back pain sufferers require surgery. Yet this still represents a huge number of patients. A recent survey by Taylor, Deyo, Cherkin, and Kreuter (1994) indicates that 279,000 operations for low back pain were performed in the United States during 1990, with the number of surgeries continuing to climb. The largest proportion of these surgeries were for herniated discs. About 16% involved spinal fusions. For these surgical patients, the only solution has been to remove or repair the offending body part—the putative “pain generator.”

Unfortunately, spine surgery often does not have the desired effect. For example, Dzioba and Doxey (1984), in examining the outcome of 116 occupationally injured lumbar surgery patients, found that 43% had poor results and 50% had good to excellent results. Weber (1983), in a randomized study of 126 back pain patients, found no major differences between conservatively treated and operated patients. Turner et al. (1992), reviewing published research on spinal fusion surgery outcome, found that satisfactory clinical outcome is obtained in 65% to 75% of patients, depending on the type of fusion performed. Similarly, a literature review on lumbar discec-tomy (Hoffman, Wheeler, & Deyo, 1993) found a mean “success rate” of 67%. Thus, even with the development of highly sophisticated diagnostic procedures, and with constant improvements in surgical techniques, the cure for many cases of back pain remains elusive.

The uneven results of spine surgery may be explained by any number of factors. Perhaps adequate diagnostic tests are not always performed, or improper surgical techniques are used (S. Walker & Cousins, 1994). It may be the case that some surgeons are simply better technicians than others. However, there is a large body of research suggesting that the variability in spine surgery outcome may at least be partially explained on the basis of psychological factors. Emotional condition, personality, environmental factors and reinforcers, it would appear, exert strong influences on pain perception and response.

Psychological Influences on Spine Surgery Outcome

The earliest investigations relating psychology and spine surgery outcome were conducted by one of the most respected orthopedic surgeons in the United States, Leon Wiltse (Wiltse & Rocchio, 1975). The original study examined a relatively simple surgical procedure, chemonucleolysis, a technique that involves chemical ablation of a ruptured disc nucleus. This study assessed psychological status using the Minnesota Multiphasic Personality Inventory (MMPI). These researchers found that “symptomatic success” of chemonucleolysis was obtained in 90% patients having low scores on the MMPI hypochondriasis (HS) and hysteria (Hy) scales, compared to a 10% chance of success in patients with high scores on those two scales. As in most presurgical screening research, all patients in this study had identified physical pathology to account, at least partially, for their complaints. Wiltse concluded that “a given patient’s response to pain is very much a psychological phenomenon … (even) if the patient has objective findings which justify surgery, arrangements should be made for psychological counseling before and after surgery” (p. 482). He further stated that “If the patient has unfavorable findings by psychological testing … and few objective findings, the surgeon should be very slow to resort to surgical treatment, since the symptoms are not likely to be relieved.” Thus, for Wiltse, spine treatment success was a matter of assessing and appropriately treating both the physical and psychological problems experienced by the patient.

A more recent example of presurgical psychological screening is that of Spengler, Ouelette, Battie, and Zeh (1990). This study carefully assessed medical and some psychological factors in patients undergoing elective lumbar discectomy. All patients were examined for neurological signs and other physical signs, and they received diagnostic tests such as lumbar myelography or CT scans. In addition, all patients were administered the MMPI. Clinical outcome was measured in terms of pain relief, improvement in functioning, and reduced use of narcotics. Results showed that clinical outcome was much more strongly predicted by psychological than by medical factors, although the most powerful predictive model combined bo...

Table of contents

• Cover
• Half Title
• Dedication
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Preface
• Chapter 1 Introduction and Overview
• Chapter 2 Pain Theories
• Chapter 3 Obtaining Medical Information
• Chapter 4 Interviewing the Spine Surgery Candidate
• Chapter 5 Psychometric Testing of Spine Surgery Candidates: Personality and Cognition
• Chapter 6 PPS Decision Making: Determining Prognosis and Planning Treatment
• Chapter 7 PPS Reporting
• Chapter 8 General Applications of PPS in Chronic Pain Syndromes
• References
• Author Index
• Subject Index