Anne M. Boonstra, MD, PhD 1, Michiel F. Reneman, PhD 2,3, Roy E. Stewart, PhD 3 and Henrica R. Schiphorst Preuper, MD 2,3

Transcription

1 J Rehabil Med 2011; 43: ORIGINAL REPORT Do male and female patients with hroni musuloskeletal pain differ in their pre-treatment expetations of rehabilitation outome? Anne M. Boonstra, MD, PhD 1, Mihiel F. Reneman, PhD 2,3, Roy E. Stewart, PhD 3 and Henria R. Shiphorst Preuper, MD 2,3 From the 1 Revalidatie Friesland Center for Rehabilitation, Beetsterzwaag, 2 Center for Rehabilitation and 3 Graduate Shool for Health Researh SHARE, University Medial Center Groningen, University of Groningen, Groningen, The Netherlands Purpose: To analyse differenes between males and females in expetations about rehabilitation outome. Methods: Design: ross-setional study. Setting: a general rehabilitation entre. Patients: n = 616, mean age 44 years, with hroni musuloskeletal pain, referred for multidisiplinary pain rehabilitation. All eligible patients in the period January 2005 to September 2009 were sent a questionnaire prior to or during the first two weeks of the treatment; the response was 630 out of 1105 (57%), of whom 14 patients did not give permission to use their data for researh purposes. Main outome measure: odds ratios. Results: Odds ratios for 21 items from a list of 25 expetations were not signifiant, odds ratios for 3 expetations were lower than 2 and odds ratio for 1 expetation was 4.0. Male patients were more likely than female patients to expet that the treatment would enable them to ope better with being a spouse and that the ause of their pain would be found. Female patients were more likely than male patients to expet that the treatment would enable them to better aept the fat that they ould no longer do what they were able to do in the past, and that they would have fewer problems with household ativities. Conlusion: There were no gender differenes in pre-treatment expetations for 21 of 25 possible expetations, small differenes for 3 expetations and a strong, linially important differene for 1 expetation: female patients were more likely than male patients to expet that they would have fewer problems with household ativities. Key words: expetation; musuloskeletal pain; rehabilitation; multidisiplinary treatment; gender. J Rehabil Med 2011; 43: Correspondene address: Anne M. Boonstra, Revalidatie Friesland, PO Box 2, NL-9244 ZN Beetsterzwaag, The Netherlands. a.m.boonstra@revalidatie-friesland.nl Submitted June 6, 2010; aepted September 20, 2010 Introdution Musuloskeletal disorders are highly prevalent in the general population. Chroni musuloskeletal pain (CMP) of moderate to severe intensity ours in 19% of adults in European ountries (1), with a higher prevalene in female than in male subjets (1 3). This differene in prevalene between men and women is largely unexplained. Several studies have reported gender differenes with respet to various pain-related items in patients with CMP (4, 5). For example, gender differenes have been reported in the effet of hroni pain on ytokine blood levels (6), ishaemi pain tolerane (7), the risk of developing hroni pain disorders (1, 3) and atastrophizing ognitions (8). Gender differenes have also been reported to have a major influene on the results of treatment of patients with CMP (7, 9 10), although others have found no gender differene in treatment outome (11). An important issue in the treatment of patients with CMP is that of pre-treatment expetations. Patients expetations are among the preditors of linial outome in hroni pain treatment (12 15). For example, Myers et al. (12) found that higher expetations for reovery were assoiated with greater funtional improvement. Goossens et al. (14) showed that patients who, prior to the treatment, believed that the treatment would help them to ope better with their pain, reported better pain oping and ontrol, less atastrophizing thoughts and a higher health-related quality of life. Most studies have foused on the degree to whih patients believe that rehabilitation will be benefiial ( To what extent do you expet that ). Very few studies have tried to determine what exatly a patient with hroni pain expets from rehabilitation. A review of patients expetations about treatment for bak pain was presented by Verbeek et al. (16), and onluded that patients expet an explanation for their pain, instrutions and advie on bak pain management, pain relief and sikness ertifiation. In the study by MCarthy & Oldham (17), patients rated a lear diagnosis and a favourable treatment outome as highly important. It is obvious that it is important for healthare providers to know what their patients expet from the treatment (16). It is likely that differenes in expetations between healthare providers and patients have an adverse influene on the outome (18). Nowadays, goal setting is usually expliitly set by therapists together with patients and beause of this ollaboration, patients pre-treatment expetation are likely to influene the ontent of the rehabilitation treatment. As far as we know, there has been no researh into gender differene in expetations 2011 The Authors. doi: / Journal Compilation 2011 Foundation of Rehabilitation Information. ISSN

2 66 A. M. Boonstra et al. about rehabilitation treatment. Differenes in pre-treatment expetations between male and female patients may explain gender differenes in the ontent as well as outome of rehabilitation treatment and are therefore an interesting topi for researh. Before studying whether differenes in pre-treatment expetations influene outomes among male and female patients with CMP, however, it is important to know whether suh differenes atually exist. The researh question in the present study was therefore whether male and female patients with CMP differ in their pre-treatment expetations about rehabilitation treatment. Methods Patients The study inluded patients with CMP admitted to the Revalidatie Friesland rehabilitation entre (the Netherlands). Revalidatie Friesland offers in-patient treatment at 1 department, and out-patient treatment at 5 rehabilitation departments of hospitals in towns in the north of the Netherlands. It offers multidisiplinary treatment for patients with pain-related disabilities with a wide range of omplexity. The area where it is situated, in the north of the Netherlands, is partly rural and partly industrialized, with medium-sized towns. Patients were referred to the rehabilitation departments by general pratitioners, neurologists or other physiians. The study population onsisted of patients who were partiipating in a projet to assess the outome of rehabilitation in patients with CMP at the Revalidatie Friesland rehabilitation entre. The present study inluded patients who started treatment between January 2005 and September Inlusion riteria were: age over 18 years, pain due to musuloskeletal problems, whih had been present for longer than 3 months, and being admitted for rehabilitation treatment. Exlusion riteria were inability to understand the questions in Duth, o-morbidity with severe negative onsequenes for physial funtioning and unwillingness to provide data for researh purposes. All eligible patients were sent a questionnaire prior to or during the first two weeks of the treatment. A total of 630 patients returned this questionnaire (response rate 57%). Fourteen patients did not give permission to use their data for researh purposes, therefore they were exluded. Thus, a total of 616 patients were inluded in the analysis. Treatment Intended treatments were based on ognitive-behavioural onepts (13, 19). The rehabilitation physiian saw all patients before the treatment started, to hek the (ontra)indiations for rehabilitation and to explain the aims and ontents of the treatment in general terms. If before or at the initial stage of the programme the rehabilitation physiian suspeted substantial psyhologial involvement in the pain syndrome, the patient was referred to the team psyhologist. The treatment always involved a physiatrist, a physiotherapist and an oupational therapist, and if psyhosoial fators were dominant, a soial worker and/or a psyhologist. The treatment foused on various goals, depending on the harateristis of the omplaints, ativity limitations, partiipation problems and psyhologial distress. The most ommonly used treatment modalities were teahing ergonomi priniples, graded ativity and behavioural therapy. In general, treatment foused on optimization of funtioning. Assessment A desription of the sample was made by assessing patients harateristis with a questionnaire inluding questions about the duration of the urrent pain period, eduation level, employment status and marital status. The physiian reorded the gender and the main pain loation: bak, nek or other loation. Pain and disability were assessed by means of the visual analogue sale (VAS) for pain and the Short Form 36 (SF-36). The VAS for pain onsists of mm lines, the left end labelled as no pain (0 mm) and the right end as very severe pain (100 mm). Patients were asked to draw a vertial mark on 3 of these lines; on the upper line for the urrent pain, on the seond line for the pain at its worst (highest pain level) during the previous week, and on the lower line for the pain at its best (lowest pain level) during the previous week. The SF-36 inludes 36 questions and measures 9 dimensions: physial funtioning, soial funtioning, physial role restrition, emotional role restrition, mental health, vitality, pain, general health and health hange (20). The sores range from 0 to 100 on eah dimension, and a lower sore means more disability. Expetations about rehabilitation outome were measured with a self-onstruted questionnaire. Patients were given a list of 25 possible treatment expetations (Table I) and the option of adding further expetations. The patients were asked to indiate their expetations about the treatment by tiking the items. The treatment expetations inluded in the questionnaire were based on the results of a onsensus study about treatment goals in pain rehabilitation (21). The expetation that the ause of the pain will be found was added beause of the results of the study by Verbeek et al. (16). Statistial analysis We alulated the odds of the respondent indiating that they expeted a partiular expetation to be fulfilled, the referene ategory being that the respondent had not indiated this expetation. Marital status, employment status and benefit were dihotomized: living alone vs married or living with a partner; not employed vs employed or selfemployed; reeiving no benefit vs reeiving a benefit (for example soial, sikness or unemployment benefit). Eduation level was trihotomized, with low meaning primary shool to lower voational eduation; intermediate meaning intermediate voational eduation, and high meaning pre-university eduation and higher, inluding university students. Differenes between male and female patients in harateristis, duration and loation of omplaints, VAS sores and SF-36 sores were tested. Depending on whether the variable was nominal or ordinal, and normally or not normally distributed, we used the Pearson χ 2, Student s t-test or Mann-Whitney U test. The likelihood that an expetation was indiated by a male or female respondent was tested using logisti regression. Gender was entered into the analysis, and the harateristis that differed signifiantly between male and female were entered as ovariates. Beause patient inlusion had extended over a period of 5 years, the year of inlusion was also entered into the analysis. The likelihoods were expressed as adjusted odds ratios. In aordane with Fleiss et al. (22), we onsidered 0.35 < odds ratio (OR) < 3.0 to be small and OR < 0.35 or > 3.0 to be strong and linially important. The 2-tailed signifiane level was set at p All data were analysed using SSPS, version Results Most patients were referred by the general pratitioner (46%), neurologist (13%) or (orthopaedi) surgeon (15%); the others by other physiians, among others the rheumatologist (5%). Charateristis of the inluded patients, duration and loation of pain omplaints, VAS sores and SF-36 sores are presented in Table II. The male and female respondents differed in some harateristis. More male than female patients had been referred for bak pain. There were no differenes between the two groups in the duration of urrent omplaints, pain intensity or funtioning. Charateristis of the non-responders were limited to gender and age. Thirty-three perent (33%) of the non-responders were male. The mean age of the male non-responders was 44 years (standard deviation (SD) 11 years), while that

3 Gender differenes in patients expetations about pain rehabilitation 67 Table I. Perentage of male and female patients with hroni musuloskeletal pain who indiated speifi expetations, and odds ratios of being male or female patient and indiating a speifi expetation (for o-variants in model, see text). Only odds ratios with p 0.05 are presented Male (n = 167) % Female (n = 449) % Odds ratio Gender Being able to engage in more ativities Having fewer problems with ativities you like Knowing better whih ativities you an do and whih ones to avoid Making better hoies as regards ativities to do and those to avoid Being better able to aept the fat that you have pain Being able (or better able) to aept the fat that you an no longer do what you were able to do in the past ( ) Moving more easily or better Having a better physial ondition Being able to a have job (or work longer hours) Coping better with your job Having fewer problems with household ativities ( ) Being better able to raise your hild(ren) Coping better with being a husband/wife ( ) Having fewer problems with leisure ativities or volunteer work Coping with problems at home and/or at work Having a better grip on the pain Having better ontrol over your life Having less pain Having no pain Being better able to ope with the pain Being better able to relax Being better able to sleep Being less gloomy and/or angry and/or anxious Using less painkillers Having the ause of the pain found ( ) Other 4 7 Table II. Charateristis of patients with hroni musuloskeletal pain, as well as loation and duration of pain omplaints, Short Form 36 (SF-36) sores and visual analogue sale pain sores of male and female patients Charateristis Male (n = 167) Female (n = 449) p-value a Age, years, mean (SD) 46 (10) 44 (13) < a Marital status: % married or living with partner b Eduation level: % Low Intermediate High Employed (% yes) Reeiving benefit (% yes) Pain omplaints, loation (%) Bak Nek Other Duration of urrent omplaints, years, median (quartiles)/mean (SD) 2 (1 5)/4.9 (6.4) 2 (1 6)/4.6 (5.9) Pain intensity, mm, median (quartiles)/mean (SD) At the moment 57 (35 72)/53 (24) 57 (36 73)/54 (23) Worst 78 (65 89)/74 (20) 78 (65 90)/75 (20) Best 35 (18 54)/38 (25) 36 (20 57)/39 (25) Funtioning; SF-36 sores, median in % (quartiles) Physial funtioning 45 (30 65) 45 (30 65) Soial funtioning 50 (38 75) 50 (38 75) Physial role 0 (0 25) 0 (0 25) Emotional role 33 (1 100) 67 (0 100) Mental health 64 (52 80) 68 (55 80) Vitality 45 (35 60) 40 (30 55) Pain 33 (22 45) 33 (22 45) General health 50 (35 65) 50 (35 65) Health hange 25 (0 50) 25 (25 50) a Students t-test. b Pearson χ 2. Mann-Whitney U test. No p-value is presented when p > SD: standard deviation b

4 68 A. M. Boonstra et al. of the female non-responders was 43 years (SD 14 years). The ages of the male and female responders and non-responders did not differ signifiantly. Table I shows the perentages of male and female patients who expeted to ahieve partiular goals at the start of their treatment. All patients indiated at least one expetation. Four perent of the male respondents and 7% of the female respondents had added a further expetation to the given list of expetations. Beause of the diversity of answers, these additional items were not taken into aount in the analysis. We found differenes between male and female patients with CMP for 4 of the 25 possible expetations. The adjusted odds ratios are given in Table I insofar as they reahed the signifiane level. Male patients were more likely than female respondents to expet the treatment to enable them to ope better with being a spouse and that the ause of the pain would be found. Female respondents were more likely to expet that the treatment would enable them to better aept the fat that they ould no longer do what they were able to do in the past, and that they would have fewer problems with household ativities. Only the differene in the expetation of having fewer problems with household ativities reahed the level of linial importane. There were no differenes between the 5 years of data olletion in terms of the perentages of expetations indiated by the patients. Disussion This study examined differenes in expetations about rehabilitation outome between male and female patients with CMP who were referred for rehabilitation. For most of the 25 items on a list of expetations presented to the respondents, differenes between male and female patients were not signifiant, but 4 differenes were signifiant. The only differene with a linially important OR was found for the item: having fewer problems with household ativities : women were more likely to expet this than men. Although roles in partnerships have been hanging over the last few deades, it is still the women who are most involved in housekeeping, thus household ativities are more important for women than for men. The finding that men are more likely to expet to be better able to ope with being a spouse may be explained by the fat that males beome more foused on ativities within the family after developing pain omplaints. Faing the hallenges of their hanged role as a husband and oping with this new role may therefore be important to them. At this point, plausible explanations for the other differenes are laking: male respondents were more likely to expet that the ause of the pain would be found, and female respondents were more likely to expet that treatment would better enable them to aept the fat that they ould no longer do what they were able to do in the past. One might question whether these differenes in expetations are of linial importane. Sine the literature offers no information on whether there is a relationship between types of expetation and treatment effet, the answer to this question is speulative. The results of our study support the relevane of further researh into the possible relationship between a patient s expetations, fulfilment of these expetations and satisfation with treatment, from the perspetive of gender differenes. Further studies will have to provide more knowledge about gender differenes, so that effetive treatment an be provided for both male and female patients. As far as we know, no other studies have foused on gender differenes in pre-treatment expetations. Some limitations of our study must be mentioned. Only 27% of our patients were male. Researh has shown that fewer men than women in the general population report musuloskeletal pain. For example, in the study by Piavet et al. (2) 61% of the women and 51% of the men in the general population reported musuloskeletal pain. This partly explains the gender differenes in referral rates. However, our study had a higher perentage of female subjets with hroni pain than found in the general population by Piavet et al. (2). We therefore annot rule out that seletion bias may have influened our results. In addition, the study was performed in the Netherlands, and ultural aspets probably influene expetations, so we have to be autious about generalizing our findings to non-native Duth residents and to other ountries. Another limitation of this study was the low response rate. However, responders and non-responders did not differ in the harateristis known for both (gender and age). Therefore, we estimate the linial relevane of this limitation to be small if any. The fourth limitation was that the reliability and validity of the questionnaire were not assessed, whih warrants further investigation. The ontent of the questionnaire was based on the results of a onsensus study about treatment goals in pain rehabilitation (21), whih were in turn derived from a Delphi proedure, involving a large panel of professionals. Sine treatment goals and expetations are presumably losely related, we assumed that the questionnaire ontained the main expetations a patient may have. This assumption is supported by the fat that expetations that were not inluded in the list of expetations presented to the patients were diverse and also supported by the small perentage of respondents who suggested further expetations. In onlusion, this study found no gender differenes in pretreatment expetations of rehabilitation for 21 out of a list of 25 possible expetations, small differenes for 3 expetations and a strong, linially important differene for 1 expetation. Male patients were more likely than female respondents to expet that the treatment would enable them to ope better with being a spouse and that the ause of the pain would be found. Female respondents were more likely than male respondents to expet that the treatment would better enable them to aept the fat that they ould no longer do what they were able to do in the past and that they would have fewer problems with household ativities. Only the latter expetation was a strong and linially important differene. Aknowledgements We ertify that no party having a diret interest in the results of the researh supporting this artile has or will onfer a benefit on us or on any organization with whih we are assoiated.

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