Effects of Coping on Pain Perception and Life Quality in Chronic Low Back Pain. Robert Metzger, MS, APRN, FNP-BC. Texas Woman s University

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1 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 1 Effects of Coping on Pain Perception and Life Quality in Chronic Low Back Pain Robert Metzger, MS, APRN, FNP-BC Texas Woman s University

2 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 2 Abstract Low back pain is one of the most common diagnoses in the United States (Chou & Shekelle, 2010). Chronic low back pain (CLBP) has been studied from several aspects and can lead to disabling conditions both physically and mentally. These disabling conditions can also cause an increase in patients perceptions of pain as well as a change in their quality of life (Bentsen, Hanestad, Rustoen, & Wahl, 2008). According to Chou and Shekelle (2010), low back pain is responsible for 2% of office visits and ranks fifth as reasons patients present to a physician. It is estimated, that approximately 50 to 100 billion dollars are spent by Americans every year on low back pain (Whitfill et al., 2010). Cognitive processes have been effective in influencing treatment outcomes for patients with CLBP even suggesting a more significant importance than physical adjustments (Woby, Roach, Urmston, & Watson, 2008). Per Busch (2005), coping which is a cognitive psychology concept, whether adaptive or maladaptive, is influential in comprehending pain continuance. Demonstrated adaptive factors, including coping which is more optimistic and self-assuring, result in a better prognosis for the patients. The question then arises in patients with CLBP does the application of coping measures reduce a patients pain perception and improve their quality of life The object of this study is to provide interventions which will serve to educate patients with CLBP to apply adaptive coping mechanisms into their daily lives. The primary objectives achieved by use of these methods is to notice a reduction in the use of pain medication, an improvement on pain scores, and an increase in daily activity levels. With these results, patients would be able to demonstrate a decreased pain perception and improved quality of life.

3 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 3 Effects of Coping on Pain Perception and Life Quality in Chronic Low Back Pain Statement of the Problem Low back pain is one of the most common diagnoses in the United States (Chou & Shekelle, 2010). According to Woby et al., (2005), back pain has a point prevalence of between 12% and 35% and a lifetime prevalence ranging from 49% to 80% (p. 37). Despite the acuity of most cases, some patients will proceed to develop chronic low back pain (CLBP) with a trend of 40% of patients with continued pain at six months, and 33% with up to two years of pain from initial treatment (Lewis et al., 2005). Chronic back pain has been studied from several aspects and can lead to disabling conditions both physically and mentally. These disabling conditions can also cause an increase in patients perceptions of pain as well as a change in their quality of life (Bentsen, Hanestad, Rustoen, & Wahl, 2008). A variety of treatments for CLBP exist which include acupuncture, massage, physiotherapy, or chiropractic adjustments. In addition, mind-body techniques such as breath therapy, tai chi, yoga, and Rolfings, have been explored (Mehling, Hamel, Acree, Byl, & Hecht, 2005). Cognitive processes have been effective in influencing treatment outcomes for patients with CLBP even suggesting a more significant importance than physical adjustments (Woby, Roach, Urmston, & Watson, 2008). Per Busch (2005), coping which is a cognitive psychology concept, whether adaptive or maladaptive, is influential in comprehending pain continuance. Justification According to Chou and Shekelle (2010), low back pain is responsible for 2% of office visits and ranks fifth as reasons patients present to a physician. The majority of patients with low back pain will see improvements in their condition while others will progress into CLBP. The expenses for CLBP are disproportional in relation to the costs for acute low back treatments.

4 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 4 It is estimated, that approximately 50 to 100 billion dollars are spent by Americans every year on low back pain (Whitfill et al., 2010). Even the cost for medication treatment in these patients is anywhere between five to ten thousand dollars per patient. Patients who live with CLBP must learn to manage their symptoms and adapt their lives. While some patients learn how to affectively perform these tasks to function normally, others can find this adjustment difficult which can then lead to the development of psychosocial consequences (Woby, Watson, Roach, & Urmston, 2005). It has been documented that community-dwelling elderly patients living with chronic pain have increased morbidities including depression, disability, and decreased quality of life (Morone & Greco, 2007). A lower quality of life is also common for those with CLBP. Bentsen, Hanestad, Rustoen, and Wahl (2008) state the goal of treatment is to optimize patients quality of life in terms of less pain and better functioning (p. 2062). According to Woby et al. (2005), coping strategies employed by an individual with CLBP could be one factor that partly influences how well they adjust to their symptoms (p. 37). Changes in physical activity, influenced from the employment of coping mechanisms by patients, can have a role in the development of chronic pain (Van der Hulst, Vollenbroek-Hutten, Schreurs, Rietman, & Hermens, 2010). The use of maladaptive coping measures, such as fear avoidance and catastrophizing, may lead to lower treatment outcomes (Chou & Shekelle, 2010). In addition, Gustavsson, Denison, and von Koch (2010) show a relationship between an increase in the disabling pain associated with neck pain related to maladaptive psychosocial factors. They continue to demonstrate adaptive factors, including coping which is more optimistic and self-assuring, resulting in a better prognosis for the patients. Therefore, it would seem that development of effective coping strategies can improve how patients learn to adjust to their

5 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 5 symptoms. The question then arises in patients with CLBP does the application of coping measures reduce a patients pain perception and improve their quality of life. Nursing practice, especially for those in advanced practice settings, can impact how patients cope with CLBP. Nurse practitioners (NPs) commonly treat low back pain in primary care settings. In addition, some NPs even work within specialties such as neurosurgery, orthopedic spine, or physical medicine and rehabilitation where low back pain can compose a significant amount of their workload. Raak, Wikblad, Raak, Carisson, and Wahren (2002) suggested by addressing pain with an understanding of influencing factors, nurses can provide a more comprehensive, effective treatment plan for their patients. Objectives Based on the issues addressed above, the following objectives for this proposed study include: Identify the development of psychosocial consequences which lead to CLBP. Identify morbidities (i.e. depression, disability, and decreased quality of life) associated with CLBP. Utilize the coping strategies questionnaire (CSQ) to investigate maladaptive versus adaptive coping mechanisms. Develop an educational resource to help patients identify techniques to increase adaptive coping mechanisms, thereby decreasing maladaptive strategies and the incidence and prevalence of CLBP. Assess the relationship between the application of adaptive coping mechanisms in patients with CLBP as it relates to their pain perception and quality of life. With

6 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 6 utilization of adaptive coping mechanisms, it is proposed that patients will have the following outcomes: Patients will have a decrease in pain rating using the visual analog scale (VAS) from the beginning to the end of the study. Patients will have a decrease in either the frequency or the dosage of their pain medications, which may include non-steroidal anti-inflammatories (NSAIDs), narcotics, neuropathic agents, and muscle relaxants. Patients will see an increase in their activity level from the start of the program to the end of the study. Examples of this would include developing an exercise program or returning to a work status. Methodology Study Design This study will be conducted at the outpatient orthopedic spine clinic of Parkland Health and Hospital Systems located in Dallas, Texas. Implementation of this study depends upon both prospectus and Institutional Review Board (IRB) approval. The proposed time frame for this study will cover a six month period beginning in June 2011 through November The study will be designed utilizing a non-randomized, non-controlled before-after trial. Recruitment Any patient who attends this clinic for treatment of CLBP will be evaluated for inclusion in the study. Van der Hulst, Vollenbroek-Hutten, and IJzerman (2005) and Wessels et al., (2006) define CLBP as low back pain with duration of greater than three months. CLBP also is localized physically from below the scapular region to above the buttocks. Patients may or may

7 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 7 not have symptoms which radiate into their lower extremities, also called lumbar radiculopathy. Recruitment of a convenience sample, approximately 60 patients, from the patient population will be based on the following inclusion criteria: male or female patients between the ages of 18 and 80 years old and patients with a diagnosis of CLBP. Exclusion criteria for participation include any patient with acute LBP and any post-surgical patients with CLBP. However, differentiation of post-surgical versus non-operative patients with CLBP could be considered during this study or future studies. All patients must provide informed consent in order to participate. Participants must be willing to take two written examinations. In addition, they must keep daily personal logs regarding their use of pain medication, personal activity level, and identification of use of coping mechanisms. Intervention In order to evaluate how patients are truly coping with their pain, this study is designed to be prospective over a six month period. Once IRB approval has been obtained, the selection process will occur for participants. Upon selection into the study, a participant will sign informed consent forms and begin interventions. The first intervention will consist of the patient performing the coping strategies questionnaire (CSQ) which takes them approximately five minutes to perform. This questionnaire will evaluate their understanding of coping and how they rank themselves in relation to coping. In addition, their medication lists, which will include dosages and frequency of dosing, will be obtained and recorded. Patients will also be educated on the proper use of a visual analog scale and provide their initial pain score. The primary investigator (PI), the nurse practitioner, will perform these tasks with the patient. However, the PI will also utilize a

8 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 8 medical assistant (MA) to perform some of the procedures. The MA will be instructed by the PI on the proper education of patients in regards to the examination instructions and VAS scoring. Overall, the initial consultation will take approximately minutes to perform. Handouts will be developed to provide to the patients to educate them in regards to adaptive coping mechanisms, such as distraction and endurance, and to assist them with avoiding maladaptive techniques, such as catastrophizing and fear avoidance. The PI will spend time with the patients at this initial consultation to go over the handout and to instruct patient on the various coping techniques. Patients will be encouraged to ask any questions and to provide return demonstration to assure understanding of the material. The purpose of this education will be to provide encouragement for the participant, to minimize resistance to follow up visitation, and to assure appropriate response efficacy. Patients will also be instructed to keep a daily personal log during this study of their medication dosage and frequency, their daily average VAS pain rating, their physical activity level, and any coping mechanisms, whether adaptive or maladaptive, they felt were performed. They will be provided with a booklet at their initial consultation with the requested data to submit and ample paper for their logs. A questionnaire will be developed to be included in their log books addressing their activity levels. Daily logs should take no more than approximately five minutes of the patient s time to complete. In addition to the logs the patients perform, weekly telephone calls will be conducted by the PI and MA. The patients logs will be reviewed with them. Their weekly information will be assessed and documented in files for each participant. These files will be reviewed at the end of each month by the PI and the assistant. Telephone calls will also be used for any follow-up

9 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 9 questioning or counseling that needs to be performed with the participants. A telephone number will also be provided to the participants at initiation of their study, which they can call at anytime during business hours, for questions or concerns. Patients will be asked to attend two follow up visits. The first visit will be in three months to review their comprehension and understanding of the coping skills. The second visit will be in six months, which will be at the conclusion of the study. At their six month visit, the participants will be asked to perform the CSQ again. Evaluation and Outcome Measures The outcomes desired from this project are to notice a reduction in patients VAS pain ratings, an increase in their activity levels, and a reduction in the frequency and dose of medications used for pain control. This is to be achieved by educating patients in the use of adaptive coping mechanisms. Upon completion of this study, the results of the patients CSQ scores, from both initial and final visits, will be reviewed by a consulted statistician. If unable to obtain a statistician, then a statistical software program may be utilized to evaluate the scores. Using the scores from these two questionnaires, a paired-sample t-test will be performed to compare the same prospective group before and after intervention. Patients will hopefully have statistically significant improvement in scores on the coping scale after study interventions. An alternative test could be an ANOVA exam to compare the various variables identified on the questionnaire. In addition to studying the results of the pre and post study tests, review of the patients logs will indicate if they have truly noticed any changes in their pain. Decreased ratings on the

10 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 10 VAS will indicate an improvement in pain perception. Changes in the dose and frequency of medication are anticipated with adaptive coping. This study is not expecting patients to resolve all pain medication usage but to find a reduction in its use. As well, it is proposed patients will lead more productive, active lifestyles by employing adaptive coping techniques. Based on all of these measures, patients will hopefully have the desired outcomes of decreased pain perception and an improvement in their quality of life. Budget The budget is based on the enrollment of 60 participants in this study. The budget is divided into direct costs which are mandatory for the study to be performed. Included in direct costs are the hours of work by the PI, estimated to be ten hours per week of the six month study, a total of 24 weeks. In addition, the MA will be compensated for a total of five hours per week for the same duration of time. The estimated times provided include the amount of time spent by the providers to call the patients, record their information, and review the provided documentation. Fees associated with obtaining IRB, statistical software, and facility costs are approximated. Indirect costs which cover the estimated basic office supplies are listed as well. All projected expenses are provided in Table 1 (See Appendix A). Summary Chronic low back pain has been demonstrated to be a prevalent and costly diagnosis within the United States (Chou & Shekelle, 2010; Woby et al., 2005). Despite a variety of treatment options, greater outcomes have been associated with changes in cognitive processes. Several studies showed how patients utilizing strategies, such as catastrophizing and fear avoidance, had an increase in their symptoms with their back pain becoming chronic and

11 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 11 disabling (Karsdorp & Vlaeyen, 2009; Pincus et al., 2002; Raak et al., 2002; Van der Hulst et al., 2010; Woby et al., 2005). The majority of research on coping with CLBP has focused on these negative coping mechanisms with limited studies analyzing positive coping strategies. A few studies illustrated the application of endurance and adaptive coping mechanisms providing increased physical activity thereby minimizing disabling features of CLBP (Karsdorp & Vlaeyen, 2009; Van der Hulst et al., 2010). Despite these changes, many of these patients still experienced high levels of pain perception. However, they were able to successfully distract themselves from pain. In conclusion, by evaluating patients with CLBP and employing adaptive coping strategies into their daily life, it is hypothesized that a decrease in pain ratings and perception, along with improvement in quality of life, will occur. Further by reducing their pain perception, patients may be able to reduce the frequency and/or dosage of their current medication regimens. Activity levels are expected to increase as a measure of their improved quality of life. Therefore, if these results are confirmed by this study, recommendations for the use of adaptive coping mechanisms for the treatment of CLBP could be employed.

12 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 12 References Bentsen, S., Hanestad, B., Rustoen, T., & Wahl, A. (2008). Quality of life in chronic low back pain patients treated with instrumented fusion. Journal of Clinical Nursing, 17, doi: /j x Busch, H. (2005). Appraisal and coping processes among chronic low back pain patients. Scandinavian Journal of Caring Science, 19, Chou, R., & Shekelle, P. (2010). Will this patient develop persistent disabling low back pain? Journal of the American Medical Association, 303(13), doi: / jama Gustavsson, C., Denison, E., & Von Koch, L. (2010). Self-management of persistent neck pain: A randomized controlled trial of a multi-component group intervention in primary health care. European Journal of Pain, 14, 630.e1-630.e11. doi: /j.ejpain Karsdorp, P., & Vlaeyen, J. (2009). Chronic pain: Avoidance or endurance? European Journal of Pain, 13, doi: /j.ejpain Lewis, J., Hewitt, J., Billington, L., Cole, S., Byng, J., & Karayiannis, S., (2005). A randomized clinical trial comparing two physiotherapy interventions for chronic low back pain. Spine, 30(7),

13 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 13 Mehling, W., Hamel, K., Acree, M., Byl, N., & Hecht, F. (2005). Randomized, controlled trial of breath therapy for patients with chronic low-back pain. Alternative Therapies, 11(4), Morone, N., & Greco, C. (2007). Mind-body interventions for chronic pain in older adults: A structured review. Pain Medicine, 8(4), doi: /j x Pincus, T., Burton, A., Vogel, S., & Field, A. (2002). A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine, 27(5), E109-E120. Raak, R., Wikblad, K., Raak, A., Carisson, M., & Wahren, L. (2002). Catastrophizing and health-related quality of life: A six year follow up of patients with chronic low back pain. Rehabilitation Nursing, 27(3), Van der Hulst, M., Vollenbroek-Hutten, M., & IJzerman, M. (2005). A systematic review of sociodemographic, physical, and psychological predictors of multidisciplinary rehabilitation or back school treatment outcome in patients with chronic low back pain. Spine, 30(7), Van der Hulst, M., Vollenbroek-Hutten, M., Schreurs, K., Rietman, J., & Hermens, H. (2010). Relationships between coping strategies and lumbar muscle activity in subjects with chronic low back pain. European Journal of Pain, 14, doi: / j.ejpain Wessels, T., Van Tulder, M., Sigl, T., Ewert, T., Limm, H., & Stucki, G. (2006). What predicts outcome in non-operative treatments of chronic low back pain? A systematic review. European Spine Journal, 15, doi: /s Whitfill, T., Haggard, R., Bierner, S., Pransky, G., Hassett, R., & Gatchel, R. (2010). Early

14 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 14 intervention options for acute low back pain patients: A randomized clinical trial with one-year follow-up outcomes. Journal of Occupational Rehabilitation, 20, doi: /s Woby, S., Roach, N., Urmston, M., & Watson, P. (2008). Outcome following a physiotherapistled intervention for chronic low back pain: The important role of cognitive processes. Physiotherapy, 94, doi: /j.physio Woby, S., Watson, P., Roach, N., & Urmston, M. (2005). Coping strategy use: Does it predict adjustment to chronic back pain after controlling for catastrophic thinking and selfefficacy for pain control. Journal of Rehabilitative Medicine, 37, doi: /

15 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 15 Appendix A Table 1 Project Budget With Indirect and Direct Costs Item Amount/ Frequency Cost per item Total Direct Costs: Nurse Practitioner PI) $60.00 / hr (10h/wk for 24 wks) $60.00 $14, Medical Assistant $12.50 / hr (5 h/wk for 24 wks) $12.50 $1, Facility Use Fee Once $1, $1, IRB Fee Once $ $ Statistician (or Statistical software) Once $ $ Indirect Costs: Copy Paper 2 cases of 10 reams (500 sheets/ream) $37.99 $75.98 Ink/Toner 2 cartridges $ $ Folders: Manila w/ 2 fasteners 2 boxes (50/box) $32.99 $65.98 Folders: 3 Prong Personal Portfolios 60 folders $0.49 $29.40 Clipboards 2 packages (2 / pack) $2.99 $5.98 Pens 3 boxes (12 / box) $1.29 $3.87

16 EFFECTS OF COPING ON PAIN PERCEPTION AND LIFE 16 Highlighters 1 box (12 / box) $7.99 $7.99 Legal Pads 1 package (12 / pack) $7.29 $7.29 Filing Cabinet 1 - lockable 2-door cabinet $54.99 $54.99 Postage Stamps 1 rolls (100 / roll) $44.00 $44.00 Envelopes 1 box (500 / box) $8.29 $8.29 GRAND TOTAL: $18,403.77

Effectiveness and safety of nonpharmacological and nonsurgical treatments for chronic pain conditions

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