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This is to certify that the

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THE INFLUENCE OF A COGNITIVE-BEHAVIORAL TREATMENT
PROGRAM 0N CHRONIC PAIN PATIENTS

presented by

Maureen Walczyk

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THE INFLUENCE OF A COGNITIVE-BEHAVIORAL TREATMENT PROGRAM
ON CHRONIC PAIN PATIENTS

By

Maureen Walczyk

A THESIS
Submitted to Michigan State University

in partial fulﬁllment of the requirements
for the degree of

MASTERS OF SCIENCE

Department of Kineéiology

2002

ABSTRACT
THE INFLUENCE OF A COGNITIVE-BEHAVIORAL TREATMENT PROGRAM
ON CHRONIC PAIN PATIENTS
MaureeRNalczyk
The purpose of this study was to determine the effect ofra functional

restoration program on the performance of chronic pain patients on the Global
Severity Index (GSI) and somatization subscale (SOM) of the SCL-QO-R. The
study also sought to replicate subrgroups of chronic pain patients identiﬁed with
the SCL-QO-R in prior studies. Persons participating in an outpatient
interdisciplinary cognitive-behavioral functional restoration program were
administered the SCL-QO-R prior to and following a seven week program.
Retrospective analyses using non-parametric tests were conducted on 100
subjects to determine the inﬂuence of the treatment program on performance. A
two-step cluster analysis was used to determine the presence of subgroups
among the participants. The results showed that: 1) the treatment program was
effective in signiﬁcantly reducing the GSI score; 2) performance on six of nine
SCL—90-R scale scores showed a signiﬁcant improvement over time; 3) change
on the SOM score from pre to post treatment exceeded the change on all scales
except the DEP score; 4) change on the SOM score from pre to post-treatment
was signiﬁcantly greater than that of the PAR, PHO, and PSY scales; and 5) the
cluster analyses for the entire group, and for men and women separately, each
yielded three-cluster solutions, similar to those reported by Shutty an DeGood

(1987) and VVIlliams et al. (1995).

To my family
Dave, David, and Jordan,

for their love, understanding and support

To my parents
whose belief in hard work and
a solid education provided the foundation from

which I based my educational endeavors

ACKNOWLEDGMENTS

I would like to express my sincerest gratitude to the members of my
Guidance Committee, who greatly aided me in the preparation of this thesis. I
extend special thanks to Dr. John Haubenstricker, who guided me throughout
all stages of the work. His patience with my work and his dedication to
research and collegiate studies is truly beyond exception. To Dr. Anne
Soderman and Dr. Marty Ewing, who advised me on the proposal and ﬁnal
draft, your input was greatly appreciated. You found a way to take a good
paper and make it better than I could have ever imagined.

I would also like to thank Dr. Lisa Rapport, a professor at Wayne State
University, who so willingly gave of her time to provide me with invaluable
statistical assistance. Thank you to Dr. Maury Ellenberg, M.D., program
director for the Functional Recovery Program of Michigan, for showing me
you must treat the person, not the condition. Your dedication to the
advancement for treatment of chronic pain will continue to help patients for
years to come. Thank you to Dr. Diane Karle, program psychologist at the
Functional Recovery Program of Michigan, for all of your insight and
assistance with my research. I appreciate all you taught me about the
cognitive-emotional side of pain. I would also like to acknowledge the
cooperation of other staff members from the Functional Recovery Program of
Michigan for the assistance you gave me throughout this research project and
the ongoing assistance you give to the patients.

iv

TABLE OF CONTENTS
Page
LISTOFTABLES vii
LISTOF FIGURES viii

CHAPTER1
INTRODUCTION......... 1

Statement ofthe Problem 11
Hypotheses 11
Need for the Study 12
Scope of the Study 13
Limitation ofthe Study 13

Deﬁnition ofTerms .. 13

CHAPTER2
REVIEW OF LITERATURE 16

Physiological mechanisms of pain and the
Gate Control Theory of Pain .....16

Assessment and Treatment of Pain ....19
Implications for Health Care Workers .. 20
A Multidisciplinary Approach to Treatment 22
Subgroups of Chronic Pain Patients 27

Summary 29

Page
CHAPTERS

RESEARCH METHODS 31
Participants... .31
Instrumentation........ 32

Procedures 36

Testing Environment 37

Treatment Program 37

Treatment ofthe Data 41

CHAPTER4
RESULTS AND DISCUSSION 45

Results 45

Drscussron 62

CHAPTER 5
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

Summary 67
Conclusions ....69

Recommendations ....69

vi

LIST OF TABLES

The primary symptom dimensions of the SCL-QO-R and the

global rndrces

Admission criteria for the Functional Restoration Program ..

Descriptive statistics and Wilcoxon Signed-Ranks Tests for

SCL-SO-R Scores ..

Post Hoc Tests for SCL-90-R change scores relative

to change on SOM

Characteristics of patients in Cluster 1-3...

vii

Page

33

38

47

5O

59

LIST OF FIGURES

Page
1. Proﬁles of SCL-SO-R scales for the three-cluster solution .. 53
2. Proﬁles of SCL-90-R Scales for the three-cluster solution: Men ...... 56
3. Proﬁles of SCL-90-R Scales for the three-cluster solution: Women... 57

viii

CHAPTER I
INTRODUCTION

Pain is a sensation that is experienced by all living beings at one time or
another during their existence. Pain is a signal our body needs in order to
survive. People with sudden or persistent pain routinely utilize the health care
system. Professionals in the medical ﬁeld are sought after to determine the
cause of a patient’s pain and to alleviate the noxious sensations the individual is
experiencing.

Throughout history, pain has been viewed differently by various societies
and cultures. Religious and emotional inﬂuences were thought to be responsible
for the pain experiences of people. Headley (1991) provides examples of
previously held views and theories of pain from an historical perspective. Ancient
Egyptians believed that pain was inﬂicted upon them through spirits of the dead.
People in India attributed pain to represent unfulﬁlled desires. Ancient Greeks
were interested in the senses. Aristotle believed the heart to be the source of
sensation and reason. He thought the heart constituted the sensorium
commune. The Greeks believed that pain and pleasure were linked together,
and that they were passions of the soul that originated from the heart (Bonica,
1990). Later, the Greeks began to shift their focus to the brain as being the
center of the nervous system.

The Chinese population believed pain was the result of one’s “yin and

yang” being out of balance. The yin was considered to be the feminine,

negative/passive force and the yang was the masculine, positive/active force.
When the yin and the yang were in balance, it was believed that the vital energy,
the “chi” was able to circulate to all of the parts of the body through channels or
meridians. If the chi circulated in too great or too little quantity, the yin and the
yang would become out of balance and disease and pain would result (Bonica,

1 990).

As medicine progressed so too did people’s perspective of pain. Theories
of pain developed and changed as discoveries were made of the human
anatomy such as the circulation of blood and the discovery of the nervous
system. The theories people held inﬂuenced the treatment approach undertaken
by the care providers of that time. In order to start to understand pain, there
must ﬁrst be a clear definition if what pain is, and what are the various levels of
pain are.

In order to start to understand pain, there must ﬁrst be a clear deﬁnition of
what pain is, and what are the various levels of pain are. The lntemational
Association for the Study of Pain (IASP); (1986) deﬁnes pain as “an unpleasant
sensory and emotional experience associated with actual or potential tissue
damage, or described in terms of such damage.” The deﬁnition points out that
the experience of pain not only has sensory components, but emotional ones as
well. The treatment of pain continues to prove challenging because two people
with identical injuries may not experience the sensation of pain in the same
manner. Pain itself can be deﬁned on different levels based on the physiological

condition of the process and the length oftime that a person has been in pain.

Acute pain is deﬁned as a signal associated with tissue damage or
biological dysfunction. This pain will generally disappear once healing takes
place (Chapman & Turner, 1990; Headley, 1991). Chronic pain is commonly
deﬁned as pain that lasts longer than six months. Some believe pain should be
labeled chronic if it lasts longer than the expected healing time (Tollison, 1998;
King & Goddard, 1994; Lynch, Kelly & Vasudevan, 1992; Vlaeyen, 1991 ).
Headley (1991) reports, “patients with acute and chronic pain are differentiated
by the degree to which these psychological reactions to pain exist, the duration of
the psychological reaction, and the duration and extent of physiological
adaptation responses” (p. 579).

It is necessary to assess psychological factors when attempting to
evaluate a chronic pain problem. Mirabelli (1985) states that the pain experience
is so complex that one must “include the physical perception of pain, suggestion,
and the emotional state, expectations, personality, and cognitive view of the
person experiencing it” (p. 600). The assessment of these areas is crucial for the
successful treatment of chronic pain.

The mechanism of pain is a complex process. The experience of pain
has been to found to have both sensory and emotional components (Wall &
Melzack, 1994). When people experience pain, they not only have physiological
responses, but psychological and behavioral reactions as well. The
psychological reactions to pain usually disappear in patients with acute pain as
the physical cause of their pain is resolved and they resume their normal life-

style. Patients with chronic pain may no longer have ongoing tissue damage, yet

the pain still persists. Taub, Worsowicz, Gnatz, and Cifu (1998) describe a
chronic pain syndrome as “an abnormal condition in which pain is no longer a
symptom of tissue injury, but pain and pain behaviors become the primary
disease process” (p. 8-49). Moreover, speciﬁc foci of chronic pain appear to
affect the probability of improvement in treatment. For example, the location of
pain, the patient’s age, and incentives to maintain pain behaviors for ﬁnancial
gain and disability payments may also affect treatment outcomes. The treatment
of chronic pain becomes a challenge for the clinician because the patient no
longer responds to traditional treatment approaches.

Medical professionals working with people in pain need to consider not
only the physical signs and symptoms of the patient, but the patient’s cognitive-
emotional state as well. The patients may begin to magnify their symptoms in an
attempt to convince the physician that a particular diagnosis exists. The patients
do not willfully try to exaggerate the symptoms, but their report is inﬂuenced by
the emotional nature of the pain. Anger, fear, and frustration can all act to
increase symptom magniﬁcation (Chatﬁeld, 1998). Treatment approaches need
to encompass both the sensory component of pain as well as a variety of other
factors.

Cultural, environmental and personality factors greatly impact one’s
response to pain. Headley (1991) writes, “the perpetuation of pain is now
understood to include emotional, behavioral, and physiological components,

which offer treatment-intervention possibilities targeting these multi—dimensional

aspects of pain” (p. 600). Patients with long-standing pain are fairly stressed
both physically and mentally.

Stress can add to muscle tension, which in turn causes more pain.
Increased pain can cause the muscles to tighten up and spasm. A pain-spasm-
pain cycle becomes established and additional stress can work to continue this
vicious cycle (Philips, 1988; Vlaeyen, 1991). Multiple sources of stress and
anxiety can negatively impact a person’s coping mechanism.

Texidor (1998) describes the importance of patients learning to manage
their pain-anxiety cycles. He states “It is appropriate that individuals
experiencing chronic pain become aware of the possible contributions they may
inadvertently make to their pain by the automatic invocation of their stress
response to any given stimuli or perception in the ensuing associated physiologic
reactivity” (p. 5).

The pain-anxiety cycle is difﬁcult for patients to break, especially without
appropriate treatment intervention. Treatment for these individuals needs to
include not only the physiology of the pain, but also the psychological, emotional,
and sociological components that add to the pain. “Depression, anxiety, familial
attitudes, motives of secondary gain, and the economic impact of the pain all
must be investigated to better identify somatic and psychological aspects of pain"
(p.19) (Warﬁeld, 1990).

Schraeder (1996) focused on the mind/body link when a patient is faced
with both psychological and physiological challenges. In her review of the

literature on stress and immunity after traumatic injury, she reports, “serum

cortisol elevation occurs in many physically and emotionally stressful
situations...changes are especially sensitive to stressful situations such as
novelty, uncertainty, frustration, and conﬂict” (p. 354). The author encourages
healthcare providers to allow patients to regain a sense of control through
education as well as involving them in the decision making process. Schraeder
reports that this will add to a patient’s emotional and physiological well being.

The patients’ environment and attitude can also have an effect on their
perception of pain. Fordyce (1976) believes “...there are many complex social
and interpersonal effects relating to a pain problem.” If a person has negative
attitudes, beliefs and expectations, the suffering from the pain experience will be
increased.

Chronic pain can impact a person physically, socially, economically,
behaviorally, and psychologically. Patients with chronic pain frequently report
difﬁculty with employment, sleep, the ability to cope with stress, relationships,
and ﬁnances (Williams & Richardson, 1993). Many patients with chronic pain
limit their physical activity. Fordyce (1976) points out that “restricted activity
leads to unemployment and to altered social and recreational patterns.” Patients
often avoid activities such as housework, recreation, exercise, intimacy, and work
due to their complaints of pain (Philips, 1988). Coping strategies such as the
use of imagery, relaxation, and distraction techniques can be taught to patients to
help them feel more in control of their pain or at least of their reaction to it

(Diamond & Coniam, 1997).

An interdisciplinary team approach to treatment that focuses on the
cognitive and emotional aspects of pain along with functional restoration through
physical work has been utilized with chronic pain patients. In this interdisciplinary
approach, an interactive professional team provides simultaneous therapeutic
services to reach a desired outcome (Texidor, 1998). Through their cooperative
efforts, such a team can help the patient change physically, cognitively, and
behaviorally.

A cognitive-behavioral approach to treatment assumes that individuals are
active processors of information whose thoughts and behaviors can be
inﬂuenced by both themselves and the environment. It assumes that people can
learn more adaptive ways of thinking, feeling, and behaving by being an active
participant in the process of change (Wall & Melzack, 1994). A functional
restoration program based on a cognitive-behavioral perspective assists the
patients with the physical treatment they need to help them return to function and
provides them with the skills they need to form positive coping strategies related
to the pain. The emphasis is to treat the “whole person” utilizing behavioral and
cognitive approaches.

Behaviorally, the patients work towards daily physical goals. Rather than
waiting for the pain to stop and then returning to functional activity, the patient is
gradually returned physical activities. The program assists the patients
physically by providing them with the opportunity to perform aerobic, stretching,
and strengthening exercises. The patients utilize an exercise-quota system to

help reverse patterns of inactivity. The patients start at their current functional

level and gradually move up in activity level on a graded, daily graph. They do
not move ahead of their daily goal if they are having a “good day” and they do not
move below their goal on a “bad day”. The quota system allows the locus of
control to shift back to the patients as they perform their pre—determined level of
activity for the day instead of allowing the pain to dictate their activity for them.

The behavioral goal is to extinguish conditioned responses to the pain and
to decrease overall pain behaviors such as limping, guarding, moaning, etc.
Patients learn they can actually feel better with more activity without having
increased pain or major setbacks.

Cognitive assistance is given by providing the patients with education and
emotional support. Education is provided to the patients to assist them in their
understanding of the chronic pain cycle. A functional restoration program
teaches the patients how a body is adversely affected by avoidance behaviors
and lack of activity. Patients are taught how other aspects of the pain, such as
lack of sleep, stress/anxiety, limping Iguarding, and negative self-talk all can
contribute toward a downward spiral.

The emotional component of the program focuses on changing the
patients’ views of their pain and changing their emotional responses to the pain.
The program psychologist, in both group and private sessions, performs the
majority of the emotional retraining with the patients.

The goal of cognitive-behavioral approach to treatment is to help patients

change the their emotional and behavioral response to the pain (Vlaeyen, 1991).

However, the effectiveness of this treatment approach with chronic pain patients
is in need of further study.

A cognitive-behavioral treatment program may not be effective with all
chronic pain because patients with chronic pain differ signiﬁcantly in their
reported symptoms of psychological distress (Shutty, & DeGood, 1987;. Vlfrlliams,
Urban, Keefe, Shutty, and France, 1995; & Turk, Rudy, & Boucek, 1993). In
addition, the nature and magnitude of symptoms reported by males are not
identical to those reported by females (Shutty & DeGood, 1987; Williams et al.,
1995). The differential impact of a cognitive—behavioral treatment program on
males and females with chronic pain is not known and should be investigated.

Recent studies have shown that patients with chronic pain differ
signiﬁcantly in their reported symptoms of psychological distress. Investigators
have been able to identify cluster groups of chronic pain patients (Shutty &
DeGood, 1987; Williams et al., 1995; and Turk et al., 1993). For example,
Williams et al. identiﬁed three cluster groups of chronic pain patients for both
male and females. The subgroups reported low, medium, and high levels of
distress based on responses scored in the standard manner of a standardized,
psychological test called the Symptom Checklist -90-R (SCL-90-R).

Shutty & DeGood (1987) were also able to classify both male and female
chronic pain patients into three cluster groups that represent low, moderate, and
high distress groups, using the SCL-90—R. As in the Williams et al. (1995) study,

the researchers found a stable three-cluster solution was most appropriate for

both males and females using standard scoring methods from a psychological
test instrument.

Although various clusters of chronic pain patients have been found,
researchers suggest that subgroups identiﬁed for chronic pain patients need to
be replicated in other studies (Turk et al., 1993; Williams et al., 1995; Williams &
Keefe, 1991). Moreover, the effects of treatment programs related to these
clusters have yet to be studied. By identifying clusters of patients with different
symptoms, health care providers can direct speciﬁc treatment interventions to the
various distress groups. As Turk et al. (1993) suggest, “identifying clusters of
patients according to physical, psychosocial, and behavioral data should
enhance our understanding of pain, assist in the prescription of speciﬁc
therapeutic interventions, and improve our ability to predict treatment outcome”
(P- 50).

The purpose of the present study is to answer the questions that follow.
What is the overall effect of a cognitive-behavioral treatment program on
symptoms of psychological distress reported by chronic pain patients? Can a
cognitive-behavioral treatment program affect one area of psychological
symptoms related to chronic pain more signiﬁcantly than other areas? Can
clusters of chronic pain symptoms reported in the literature be replicated in the
present study? Finally, to the extent that the data permit, what differential effects
does a cognitive-behavioral treatment approach have on identiﬁed cluster groups

within gender?

10

_S_ta_tement of the Proglem
This study was designed to determine the effects of a cognitive—behavioral
functional restoration program on chronic pain patients who completed a seven-

week treatment program at the Functional Recovery Program of Michigan.

MEG—5%

Three hypotheses will be tested in this investigation:

1. Chronic pain patients will demonstrate a signiﬁcant decrease in the Global
Severity Index (GSI) score on the Symptom Checklist 90-R (SCL-9OR)
from pre- to post-testing following the completion of a seven-week
functional restoration program. The decrease in score will represent a

lower overall self-reported intensity of perceived distress.

2. Chronic pain patients who completed the seven-week functional
restoration program will report signiﬁcantly more improvement on the
somatization (SOM) scale of the SCL-90-R than on other scales of the
SCL-90-R. The somatization scale most accurately reflects the level of a
patient’s distress arising from perceptions of bodily dysfunction.

Therefore, this speciﬁc subscale will be most affected by the intervention.

3. Prior to treatment, three distinct groups will best characterize chronic pain
patients replicating the three-cluster solution observed by Williams et al.,

(1995).

11

Need for the Study

The diagnosis and treatment of pain is one of the most costly health care
issues in today’s society (Tait, Chibnall, & Krause, 1990; Tollison, 1998). It has
been estimated that the average cost to the national economy of disability related
to chronic pain in the United States is 90 billion dollars (Ng, 1981 as cited in Tait
et al., 1998). In individuals with chronic pain, psychological reaction to the pain
becomes the problem. Thus, it is necessary to assess psychological factors
when attempting to evaluate a chronic pain patient.

This study is concerned with outcome measures on the SCL-90-R of
chronic pain patients after successfully completing a seven-week treatment
program. The purpose of this study is to determine if a cognitive-behavioral
approach to chronic pain has an impact on SCL-90-R scores after treatment.

The score of particular interest is the Global Severity Index (GSI), which is the
best indicator of the current level of an individual’s psychological distress. Also,
this study will attempt to identify and replicate subgroups of chronic pain patients,
and the extent to which a functional restoration program impacts the SCL-90-R
scores of the speciﬁc subgroups.

Results of this study may serve to guide future outcome-based research in
the treatment of chronic pain patients. Health care workers may be better able to
channel chronic pain patients into the most appropriate treatment based on their

psychological proﬁles.

12

Scene of the Stu_d_y

This retrospective study examines the effectiveness of a speciﬁc treatment
program in reducing the intensity of perceived distress reported by the
participants. It is limited to adult patients, 22 to 63 years of age, who
successfully completed the Sinai-Grace Hospital’s Functional Recovery Program
of Michigan located in West Bloomﬁeld, Michigan, during the time period of 1997-
1999.

Limitation of the Study

This study will be subject to two limitations. First, the study only deals with
chronic pain patients who have successfully completed a functional restoration
program. It does not include those patients who dropped out and may have
sought alternative treatment approaches. Secondly, the study only includes

patients who are injured as a result of a work or auto related accident.

Deﬁnition of Terms
Acute Pain: An unpleasant signal associated with tissue damage or biological
dysfunction. The pain will generally disappear once healing takes place
(Chapman & Turner, 1990; Headley, 1991). For purposes of this study, acute

pain will be referred to as pain that has lasted three months in duration or less.

Chronic Pain: Chronic pain is commonly deﬁned as pain that lasts longer than

six months. Some believe pain should be labeled chronic if it lasts longer than

13

the expected healing time (King 8 Goddard, 1994; Lynch et al., 1992; Vlaeyen,
1991). For purposes of this study, chronic pain will be referred to as pain that

had lasted greater than three months in duration.

X_-ra_L: A test that uses high-energy radiation to make images and pictures of the
body to help diagnose fractures and diseases. An x-ray is a diagnostic test that
physicians can use when trying to make a differential diagnosis with a patient in
acute or chronic pain (available on-line at www.medicinenetcom under “tests

and procedures”).

ElectromALogram (EMG) Test: A test of the intrinsic electrical properties of
skeletal muscle by means of surface or needle electrodes. The test is used to
determine if a muscle is contracting or not. An EMG is a diagnostic tool that
physicians can use when trying to make a differential diagnosis with a patient in
acute or chronic pain (available on-line at vvww.medicinenet.com under “tests

and procedures”).

Computerized Tomaggramhv (CT) Scan: An x-ray procedure, which combines
many x-ray images with the aid of a computer to generate cross-sectional views
and three-dimensional images of the internal organs and structures of the body.
A CT scan is a diagnostic test that physicians can use when trying to make a
differential diagnosis with a patient in acute or chronic pain (available on-line at

wvvw.medicinenet.com under “tests and procedures”).

14

Mamtic Resonance Imaging (MRI) Test: A radiology technique, which uses
magnetism, radiowaves, and a computer to produce images of body structures.
The image and resolution is detailed enough to detect tiny changes in structures
within the body. A MRI is a diagnostic test that physicians can use when trying to
make a differential diagnosis with a patient in acute or chronic pain (available on-

line at www.medicinenet.com under “tests and procedures”).

Mveloggm: A picture produced of the spinal cord by the passage of x-rays
through the body on specially sensitized film. A myelogram is a diagnostic test
that physicians can use when trying to make a differential diagnosis with a
patient in acute or chronic pain (available on-line at vvww.medicinenet.com under

“tests and procedures”).

15

CHAPTER II
REVIEW OF LITERATURE

The purpose of this study is to compare pre-treatment and post-treatment
measures of the GSI and Somatization measures on the SCL-90-R following a
functional restoration program. Also, the study will attempt to determine if
subgroups of chronic pain patients can be identiﬁed and replicated as in prior
studies.

The review of the literature for this study is divided into ﬁve sections:
1) physiological mechanisms of pain and the Gate Control Theory of Pain;
2) assessment and treatment of pain; 3) implications for health care workers; 4) a
multidisciplinary approach to treatment; and, 5) subgroups of chronic pain

patients.

Physiological Mechanisms of Pain and the Gate Control Theory of Pain

The mechanism of pain is a complex process. When an injury occurs, a
complex series of biochemical and cellular events occur. The sensation of pain
originates in receptors located throughout our body. The receptors send nerve
signals to the spinal cord where specialized pain neurons send the information
on to the brain. Not only does the cortex of the brain interpret that something
painful has occurred, but a signal is simultaneously sent out to the body to
withdraw, tense up or protect itself in whatever way seems appropriate

(Sapolsky, 1994).

16

Many theories of pain have been proposed and modiﬁed throughout the
years. Space does not permit a full discussion of the history of theories of pain.
Readers interested in this topic are referred to Bonica (1990) and to Umphred’s
book (1985), where Mirabelli outlines various theories of pain.

The various theories are an attempt to explain some of the clinical aspects
of pain, but all fall short of being considered a comprehensive, general theory for
pain. Theories of pain that people hold often inﬂuence the treatment approach
undertaken by care providers. For purposes of this study, the review of pain
theory will be limited to the Gate Control Theory of pain.

While many of the previous theories have attempted to explain bits and
pieces of the nature of pain, one theory developed in the mid-1960’s has been
widely accepted as a general explanation of pain circuits. The Gate Control
Theory proposed by Wall and Melzack (1994) demonstrates the importance of
both the central and peripheral nervous systems in the pain process. The theory
proposes that ascending ﬁbers that carry information about pain from the
periphery to the spinal cord are not all one type. Sharp pains stimulate different
nerves than dull, gnawing pains. A-delta ﬁbers are myelinated ﬁbers that carry
sharp, stabbing pain. The myelinated ﬁbers are able to transmit nerve impulses
faster than unmyelinated ﬁbers. A C-ﬁber is unmyelinated and carries slow,
constant, and diffuse pain signals.

The sensation of pain originates in receptors located throughout the body
called nocioreceptors. The receptors create and send nerve impulses to the

spinal cord. There they are reprocessed and sent through open gates to the

17

thalamus, which in turn sends the information on to the cerebralcortex of the
brain. Once the nerve signal reaches the brain, the information is processed and
integrated with an individual’s current mood, state of mind, and past experiences.
All of this information together will inﬂuence the perception of the pain and guide
one’s response. The gate theory proposes that the interactions among sensory
phenomena and cognitive-evaluative and motivational-affective factors create the
experience of pain (Turk, Rudy, & Boucek, 1993). Pain thus becomes not only a
sensory phenomenon, but a perceptual one as well.

As the pain impulses are transmitted to the brain; the brain sends
impulses back to the body to help modulate the pain. This dual pathway allows
sensory information to be modulated and can impact the amount of pain one
perceives. The gate control theory holds that the substantia gelatinosa appears
to be the site of the “gate” control within the spinal cord. Painful stimuli are
transmitted to the spinal cord where modiﬁcations can result from either
excitatory or inhibitory inﬂuences within the spinal cord and/or from descending
inﬂuences from the brain. If the brain sends a signal back down to close the
gate, the pain signals are blocked and we experience less pain (Sapolsky, 1994;
Turk, 1993; Mirabelli, 1985; Vlaeyen, 1991).

Neurotransmitters and other chemicals in the nervous system can
modulate the perception of pain by increasing or decreasing the pain in response
to environmental factors or emotions. The gate control theory gained support
with the discovery of receptors in the central nervous system for naturally

occurring opioids in the body such as endorphins, enkephalins and substance P.

18

Electrical impulses are created in proportion to the sensation received, thus more
pain means more impulse ﬁring. If the brain sends a signal to open the gate
wider, then the pain signal increases. Substance P is a neurotransmitter that
signals pain. It causes sensitization of the C-ﬁber by causing the cell to release
irritants such as histamine and serotonin, which increase the pain response, and
heightens our awareness of pain. This sensitization can cause the pain signal to
be transmitted with minimal stimulation.

The inhibitory message to blunt the perception of pain is carried by
endorphins and enkephalins. These inhibitors are released by the brain, bind to
receptors in the brain and spinal cord, and inhibit the opening of the gate.
Enkephalins are molecules produced by the central nervous system to numb
pain by inhibiting the production of Substance P. Endorphins help produce an
analgesic effect and many sites correspond to the anatomical areas identiﬁed by
Wall and Melzack (cited in Mirabelli, 1985). Certain events can decrease our
endorphin levels such as pain, depression, interrupted sleep, and a lack of
physical activity. Since endorphins give us our sense of well being, it is no
wonder that the patient with chronic pain seems ﬁxed in a downward spiral

(Mirabelli, 1985; Warﬁeld, 1990).

Assessment and Treatment of Pain
The medical assessment of pain often starts with a patient history, an
exam by a physician, and a battery of diagnostic tests. The tests could include

an x-ray, CAT scan, MRI, EMG, or a myleogram (please refer to the deﬁnitions of

19

terms inn Chapter I for a description of each test). Referrals to other medical
specialists can be part of the assessment process as well. The medical work up
is designed to determine the cause of a patient’s pain so that the physician can
best determine which method of treatment would be most appropriate.

Treatment can also take on a variety of forms. Prescription medication
and bedrest may be sufﬁcient to alleviate some types of pain. Other diagnoses
may need physical or occupational therapy to help decrease the symptoms.
When pain is localized to one small area, the physician can choose to utilize local
steroid injections to decrease the inﬂammation. Pain that persists may be
treated with nerve blocks, spinal epidural injections, or even with the placement
of a spinal cord stimulator. These procedures become progressively more
invasive. Sometimes it is determined that surgical intervention is necessary.
Patients may also choose to turn away from traditional medical treatments and
opt for alternative treatments such as acupuncture or herbal remedies. With the
variety of treatment options available it is necessary that the physician consider
not only the physical signs and symptoms of the patient, but the patient’s

cognitive-emotional state as well.

Implications for Health Care Workers
The health care system itself may perpetuate the problems of pain
patients by the limits it places on them. Restrictions given to patients may lead to

unemployment and reduced functioning in their daily activities. When people feel

20

they no longer can do things they enjoy or maintain their responsibilities, they
may begin to feel emotional stress.

Bonica (1990) points out that, “In most cases, apprehension, fear, worry,
anxiety - all mental effects of the pain - seems to have as much to do with the
physical deterioration of the patient as does the pain itself... (p.18)”. The person
may feel isolated, uncertain, out of control and have observable pain behaviors.
Pain behaviors refer to an “observable communication of pain and suffering”
(Vlaeyen, 1991). The behaviors are commonly in the form of motor responses
such as limping or restricting the use of a body part (Hinnant, 1994). One reason
patients may develop illness behaviors is because “disability is an element of a
chronic pain syndrome that may be perceived by patients as less stigmatizing
than acknowledgement of psychological distress” (p. 192) (Deshields, Taid,
Gfeller, & Chibnall, 1995).

The challenge physicians face when dealing with chronic pain patients is
to delineate between what needs to be treated medically and what symptoms
need to be treated with assistance from other health care providers. Once the
primary injury has been treated, clinicians need to recognize and respond to the
secondary effects of injury such as limping, guarding, dysfunctional movement
patterns, and increased pain behaviors. Movement patterns need to be
normalized in order to prevent shortening and changes in muscle and soft
tissues, which may lead to more pain. There is a link between physical and

psychosocial stress on a body that needs to be taken into consideration as well.

21

A Multidisciplinary Approach to Treatment

Patients with long-standing pain are fairly stressed both physically and
mentally. Linton (2000) performed an extensive review of the literature on
psychological variables in the etiology and development of neck and back pain.
The author had various conclusions based on his evaluation of the studies. He
concluded that psychological variables are clearly linked to the transition from
acute to chronic pain; cognitive factors (attitudes, cognitive style, fear-avoidance
beliefs) are related to pain and disability; and depression, anxiety, distress, and
related emotions are related to pain and disability. A treatment approach that
encompasses the multitude of factors related to chronic pain would be most
affective.

When patients have been in long-standing pain, they no longer feel in
control of their body or current situation. According to Diamond and Coniam
(1997), the main objectives in treating chronic pain are ”to increase self-
perceived control over pain, to increase self-perceived independence, to increase
levels of physical and social activity, and to reduce levels of emotional distress”
(p. 159). With chronic pain, patients often lack understanding as to the source of
their pain. They fear that they may be suffering from a severe pathology if health
care workers cannot give a thorough rationale for the pain they are experiencing.

Geisser and Roth (1998) performed a study that focused on whether or
not patients with chronic neck and back pain were able to identify the physiologic
source of their pain. Patients were placed in three groups depending on their

responses. One group was unsure of the cause of their pain. The second group

22

did know the cause of their pain, and they agreed with the clinical diagnosis
given to them by the physician. The third group identiﬁed a cause of their pain
that differed from their clinical diagnosis. The authors found that the third group,
those who disagreed with their clinical diagnosis, reported the highest levels of
pain and the greatest level of affective distress. The authors also concluded that
the “unsure” group (group number one) and “disagree” group (group number
three) had the lowest levels of perceived control over pain. Lack of knowledge
causes increased distress and an increased perception of disability. Patient
education and support can be a key component in a treatment program trying to
rehabilitate a patient with chronic pain.

A therapy program designed to restore function as well as to educate
patients on proper pain coping mechanisms would be an effective mode of
treatment for these patients (Morley, Eccleston, & Williams, 1999). Due to the
multitude of potential physiologic and psychosocial problems, a team approach to
treatment may yield optimum treatment outcomes (Headley, 1991; Jenkins,
1999; Hankin, Spencer, Kegerries, Worrell, & Rice, 2001). The chronic pain
patient can beneﬁt greatly from a multidisciplinary approach to treatment
(Fishbain, Rosomoff, Steele-Rosomoff, & Cutler, 1995; Fordyce, 1976; Philips,
1988). Fordyce (1976) states, “...chronic illness requires behavior change” (p.
29). One example of a treatment approach to chronic pain is a cognitive-
behavioral model.

A cognitive—behavioral approach to treatment can help patients manage

their pain and teach them to cope effectively with the multiple factors that add to

23

their pain (Kelly, 1996). Turner, Jensen, & Romano, (2000) attempt to describe
cognitive-behavioral therapy. According to Turner et al., the theory behind this
approach to treatment “holds that individual’s beliefs and coping behaviors
related to their pain play important roles in their adjustment” and that “cognitive-
behavioral therapies aim to identify and modify maladaptive patient beliefs and
increase the use of adaptive cognitive and behavioral coping skills” (p.115).
Research into the effectiveness of a cognitive-behavioral treatment program
combined with functional restoration of the patient with chronic pain is indicated.

In a research study by Strong (1998), patients with chronic low back pain
in an existing inpatient pain management program were split into two groups.
One group consisting of ﬁfteen patients followed the standard pain management
program and was considered the placebo group. A second group of ﬁfteen
patients followed the traditional pain management program, but had additional
education utilizing cognitive-behavioral principles. The group with the additional
education improved signiﬁcantly over time and signiﬁcantly more than the
placebo group at post-treatment. The authors attributed the improved results to
the patients having a feeling of control over their pain, and their use of positive
coping strategies. A program that focuses on educating the patient on the
cognitive/emotional aspect of pain and teaches them to utilize positive coping
strategies may greatly assist in the recovery of patients with chronic pain.

The goal of a functional restoration program is not pain reduction, but to
increase a patient’s ability to function better and cope with the pain and stress of

his or her current situation. Because managing stress is so important to

24

recovery, a treatment approach needs to be holistic to cover rehabilitation of both
the body and the person. In a study by Frost, Lamb, and Shackleton (2000), 129
patients with chronic low back pain attended an outpatient functional restoration
program. The authors found that there was a high level of psychological distress
among the patients prior to treatment based on their responses to the Osvvestry
Low Back Pain Disability index and the General Health Questionnaire. At ﬁfty-
ﬁve weeks post-treatment, patients were reporting lower levels of distress and
increased ability to function. The authors believed that the positive results of
their study seemed to justify the functional restoration program, but they thought
that more trials were necessary to fully establish this mode of treatment.

In the treatment of chronic pain, interventions designed to target both the
physical and psychological aspects of pain can utilize measures of a patient’s
response to stress as a way to assess treatment outcomes. A psychological self-
report by the patients regarding their stress level could be utilized to get an idea
of the patients’ perception of their injury or disability. “Self-report measures of
symptoms reﬂect the patients’ unique experience of their distress and condition
(p. 535)” (Holcomb, Adams, & Ponder, 1983). Standardized tests such as the
Symptom Checklist 90-Revised (SCL-90-R) can be a reliable and objective way
to test the patients’ current perceptions of their pain and suffering. It is important
that the test covers a wide range of symptom dimensions in order to get an
accurate picture of the complex pain response.

In a study by Wilson, Dworkin, Whitney, & LeResche, (1994), a distinction

was made between psychological distress and somatization. The authors point

25

out that somatization is the tendency to report numerous somatic symptoms,
which are symptoms pertaining to the body. They go on to say that
psychological distress is represented by reports of numerous affective and
cognitive symptoms such as those arising from feelings or emotions. In their
study of 220 patients with chronic temporomandibular pain, they found that
patients with a high level of somatization were three times more likely to report a
painful placebo site on clinical examination of the face and neck muscles than
those with a low level of somatization. The authors concluded that reports of
pain were more closely linked to the report of somatic symptoms than to reports
of affective/cognitive symptoms.

A standardized test that highlights somatization may be a useful tool to
assess pain reports by chronic pain patients. Patients are more likely to report
bodily dysfunction to health care providers. Knowing the somatization level of
the patients may better assist the health care worker in understanding the state
of distress the patients are presenting in relation to their perception of bodily
dysfunction.

Interdisciplinary treatment of chronic pain patients is indicated because of
the many factors involved in the pain process. The patient needs to be an
integral part of the treatment team. When patients start to regain control over
their bodies, their emotions and their life, their stress levels can be greatly
reduced. They may no longer perceive themselves as disabled and unable to
function. Treatment targeted at both the physical progress patients make and

the change in their stress response is indicated.

26

Subgroups of Chronic Pain Patients

The term “chronic pain patient” tends to place people into a single
category. However, it has been shown that patients with chronic pain differ
signiﬁcantly in their reported symptoms of psychological distress. Several
attempts have been made to identify cluster groups of chronic pain patients.
Cluster analysis generally is used to classify data by forming it into a set of
homogeneous groups.

Various researchers have carried out cluster analyses of chronic pain
patients. Turk et al. (1993) advocated the use of cluster analysis with chronic
pain patients. They proposed that the purpose of cluster analysis is to “(1)
develop a typology or classiﬁcation system, (2) investigate useful conceptual
schemes for group entities, (3) generate hypotheses through data exploration,
and (4) test hypotheses, or determine if types deﬁned through other procedures
are in fact present in a data set” (p. 49). Through their study, they were able to
identify primary subgroups of chronic pain patients based on factors analyzed
using the West Haven-Yale Multidimensional Pain Inventory (WHYPI). Three
clusters were identiﬁed based on response patterns on the psychosocial and
behavioral scales. The authors report that cluster one reﬂects pain patients with
an unusually high level of social distress. These patients held the perception that
their families and signiﬁcant others were not very supportive of them. Cluster two
consisted of patients who believed their pain to be at a very high level and
reported the pain interfered with many parts of their lives. The third group was

labeled the “adaptive copers” as they reported lower levels of dysphoric mood

27

and they believed they had a better ability to control their own lives than the
patients in the ﬁrst two groups. Other researchers such as Williams et al. (1995)
and Shutty and DeGood (1987) also were able to produce subgroup ﬁndings.

Williams et al. (1995), using the SCL 90-R, were able to identify three
subgroups of chronic pain patients. Their analysis of SCL 90-R scores
differentiated patients into high, medium, and low scoring subgroup clusters. S-
scores were analyzed separately for men and women. Patients in cluster one
reported the highest level of psychological distress; those in cluster two a
moderate level; and patients in cluster three a low level of distress. The authors
point out that even though cluster three had the lowest reports of psychological
distress, their somatization subscale scores were still high for both men and
women. The researchers suggested that cluster one patient’s may be “very likely
to benefit from cognitive behavioral interventions designed to reduce their
psychological distress and emotional suffering” (p. 89).

Shutty and DeGood (1987) successfully identiﬁed three subgroups of
patients using cluster analysis on 221 patients with chronic low-back pain based
on the standardized scoring method (S-scores) of the Symptom Checklist-90R.
The S-scores were analyzed separately by gender. The investigators found that
three clusters were most appropriate for both males and females to distinguish
homogeneous groups. Shutty and DeGood utilized k-means cluster analyses
and compared the amount of within-cluster variance for differently sized cluster
solutions. Williams et al. (1995) used an agglomerative hierarchical cluster

analysis with Ward’s minimum variance as the clustering method and squared

28

Euclidean distance as the proximities measure. For details on the sub groupings
of each study, please refer to the individual research projects. Shutty and
Degood , and Willams et al., used different methods of clustering and found
similar results of a three-cluster solution, which implies that the ﬁnding is robust.
Many studies suggest that subgroups for chronic pain patients need to be
replicated (Turk et al., 1993; Williams et al., 1995; Williams & Keefe, 1991). By
identifying clusters of patients, the health care providers may direct speciﬁc
treatment interventions to the various distress groups. As Turk et al. suggest,
“identifying clusters of patients according to physical, psychosocial, and
behavioral data should enhance our understanding of pain, assist in the
prescription of speciﬁc therapeutic interventions, and improve our ability to
predict treatment outcome” (p. 50). A study focusing on the change in levels

according to subgroups after a treatment intervention is indicated.

Summam

It is apparent that pain is a complex process, especially when someone
has the diagnosis of chronic pain. Treating chronic pain from purely a medical
model can have little impact and may even perpetuate the problem as patients
go through a series of invasive tests and procedures. Patients with chronic pain
need to have a treatment approach that examines both their physical and
psychological state. Psychological assessments can help provide a foundation

from which the treatment approach needs to be developed. Objective outcome

29

measures such as the SCL-90-R can help the medical society to more accurately
assess pain and direct treatment for the individual with chronic pain.

lf chronic pain patients can be delineated into speciﬁc subgroups based
on psychological testing, medical personnel may be able to better direct the
patient into the most appropriate form of treatment. Attempts have been made to
determine if subgroups of chronic pain patients exist. There is a need for
validation of these subgroups, and for future studies to determine from which

treatment each subgroup may derive the most beneﬁt.

30

CHAPTER III

RESEARCH METHODS

The purpose of this study was to compare pre—treatment and post-
treatment measures of the Global Severity Index (GSI) and the somatization
subscale (SOM) of the SCL-90-R following a functional restoration program.
Also, the study attempted to determine if subgroups of chronic pain patients

could be identiﬁed and replicated as in prior studies.

Participants

The participants for this retrospective study were 100 patients diagnosed
with chronic pain. The sample was comprised of 54 men and 46 women, who
ranged in age from 22 to 63 years (M = 42.8, SD = 8.6). The years of education
completed by the patients ranged from 6 to 16 (M = 12.2, SD = 1.7). The
distribution of the participants according to their job classiﬁcations is as follows:
professional, technical, or managerial (10%); clerical, sales, or processing
(23%); service (14%); machine and bench work trades (19%); structural (20%);
and miscellaneous or unknown (14%). The average number of months
following injury that treatment was begun was 24.3 (SD = 27.8) and ranged from
3 to 172 months; however, the vast majority of patients (71%) began treatment
within 24 months of their injury and nearly all patients (88%) were treated within
36 months of their injury. These patients complained about chronic pain
involving the back (54%), the neck (20%), a single extremity (12%), multiple

sites (13%) or head aches (1%). Most of the patients (65%) had not undergone

31

any surgery prior to treatment, whereas 25% had experienced one injury-related
surgery, 9% had experienced two surgeries, and 1% had three surgeries prior to
treatment.

Each patient was rated for the number of “pathognomonic signs” present
prior to treatment (none, one, multiple), which primarily included the presence of
conditions such as sleep disorder and major depression. Among the sample,
23% were rated as having none of these conditions, 19% were rated as having
one of these conditions, and 58% were rated as having two or more (“multiple”).
Treatment costs for most of the patients were covered by workers compensation
(74%), whereas 25% were covered by automobile insurance, and the remaining
1% were covered by other means. Twenty-eight percent of the patients had

retained an attorney at the time of the initial assessment.

Instrumentation

The Symptom Checklist-90-R instrument is a psychological symptom
inventory used to assess psychopathology (Coumos & Cabaniss, 1997).
Leonard R. Derogatis, Ph.D, developed the test in 1976 and revised it in 1983.
According to Derogatis, “The SCL-90 is a multidimensional symptom self-report
inventory comprised of 90 items, each rated on a ﬁve-point scale of distress (0
to 4) from ‘not at all’ to ‘extremely’. The instrument is scored on nine primary
symptom dimensions plus three global indices of pathology" (p. 281) (Deragotis,

Rickles, & Rock, 1976). (See Table 1).

32

Global lndices

Table 1. The Primary Symptom Dimensions of the SCL-90—R and the

 

Dimension

Description

 

Somatization (SOM)
Obsessive-Compulsive (O-C)
Interpersonal Sensitivity (l-S)
Depression (DEP)

Anxiety (ANX)

Hostility (HOS)

Phobic Anxiety (PHOB)

Paranoid ldeation (PAR)

Psychoticism (PSY)

Global Severity Index (GSI)

Positive Symptom Distress Index
(PSDD

Positive Symptom Total (PST)

12 items reflecting distress arising from
perceptions of bodily dysfunction

10 items which include symptoms
identiﬁed as 0-0 behavior

9 items that focus on feelings of
inadequacy and inferiority

13 items that reﬂect the range of the
manifestations of clinical depression
10 items that reﬂect general signs of
anxiety such as nervousness and panic
attacks

6 items that reﬂect thoughts, feelings,
or actions that are characteristic of
anger

7 items which focus on an irrational
fear response that leads to avoidance
behavior

6 items that represent paranoid
behavior as a disordered mode of
thinking

10 items which provide a graduated
continuum from mild interpersonal
alienation to dramatic psychosis

This score combines information
concerning the number of symptoms
reported with the intensity of perceives
distress

A measure of response style that
indicates whether the respondent was
augmenting or attenuating symptomatic
distress

Reﬂects the number of symptoms
endorsed regardless of the level of
distress; a measure of symptom
breadth

33

The SCL-90-R is user-friendly, designed at a sixth grade reading level and
available on a cassette for those who cannot read. The SCL-90-R takes about
20 minutes to complete. The battery measures one’s recent emotional state
(deﬁned as the patient’s experiences one week prior to taking the test) and can
be used as an outcome or status measure of psychological distress (Peveler &
Fairbum, 1990). The questions from the SCL-90-R focus on the “state” of the
participant rather than “trait” qualities because the answers patients give are
based on their experiences over the past week.

The SCL-90-R is one of the most widely used assessment systems for
psychopathology and is used extensively in the literature (Williams et al., 1995;
Shutty & DeGood, 1987). It is normed on the United States population. There
are three reference groups including non-patients, psychiatric outpatients, and
psychiatric inpatients (Deragotis, 1976; Peveler & Fairbum, 1990). The test has
a built in lie scale that can assess if patients are over-endorsing or downplaying
symptoms, and if they are being inconsistent with their answers. Computerized
scoring for the SCL-90-R is available from National Computer Systems (N08)
and was utilized in this study. Raw scores were converted to standard subscale
scores using the methods described by Derogotis (1983).

Internal consistency reliability of the domains was tested using the
coefﬁcient alpha, which is a multipoint variation of the Kuder—Richardson formula
20. Values ranged from a low of .79 to a high of .90. The test is reliable with the
“majority of coefﬁcients between .80 and .90” for test-retest reliability on each of

the symptom constructs (p.28) (Derogotis, 1983). Cronbach alpha values for the

34

separate scales of the SCL-90-R could not be calculated for the current ctudy
because individual item data were not available to the investigator. However, a
large robust literature exists for the SCL-90-R that establishes the reliability and
validity of each scale for use with clinical and non-clinical populations (Deragotis,
1983)

The instrument was validated for internal structure with the Minnesota
Multiphasic Personality Inventory (MMPI). Values for comparable domains
range from 41-75. The results “illustrate highly acceptable levels of
convergent-discriminantt validity” (p. 33) (Deragotis, 1983). The SCL-90-R
dimensions had their highest correlations with comparable MMPI constructs in
all areas except the Obsessive-Compulsive domain, which had no directly
comparable scale on the MMPI.

The SCL-90—R provides a graphed presentation of the nine symptom
dimensions. There are three primary summary scores. Deragotis et al. (1976)
report, “the global indices of pathology are the Global Severity Index (GSI), the
Positive Symptom Distress Index (PSDI), and the Positive Symptom Total (PST).
The GSI combines information on numbers of symptoms and intensity of
distress; the PSDI is a pure intensity measure; and the PST communicates data
on number of symptoms only” (p. 284). The GSI is the arithmetic average of all
90 items, so scores range from 0 to 4. The GSI represents global distress across
all nine scales (i.e. the average severity of all domains measured by the scale).
The GSI is computed by “ﬁrst summing the scores on the nine symptom

dimensions and the additional items. This sum is then divided by the total

35

number of responses (90 if there are no missing responses). The PST is
calculated by counting the number of items endorsed with a positive (nonzero)
response. The PSDI is calculated by dividing the sum of all item values by the
PST ” (p.14) (Deragotis, 1983). The SCL-90-R covers a wide range of emotional
problems and can be used to show changes that occur with rehabilitation.

The SCL-90-R has nine symptom categories: somatization, obesessive—
compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic
anxiety, paranoid ideation, and psychotics. The somatization scale is considered
to be a measure of “subjective distress arising from the perception of bodily
dysfunctions” (Derogatis et al., 1976). One source of patients’ distress is the loss
of control they feel over their situation. The pain coupled with their perceived

inability to function can overwhelm them.

Procedures

Each participant was referred to the Functional Recovery Program of
Michigan after being examined by a physiatrist (a medical doctor specializing in
physical medicine and rehabilitation). The patients signed a consent form for
treatment when meeting with the physician for the ﬁrst time (see Appendix A).
Once referred by the physician, the participants met with the program
psychologist to complete a personal data and interview sheet (see Appendix B),
and the SCL-90-R (see Appendix C). The patients had to meet admission
criteria in order to be a candidate for the program (see Table 2). The patients

determined to be candidates for the program then met with the interdisciplinary

36

team and decided if they wanted to enter into the functional restoration program
and signed an agreement to participate (see Appendix D). The program was a
voluntary treatment option. Approval for the study was obtained from the
University Committee on Research Involving Human Subjects (UCRIHS) (see
Appendix E).
TestingEnvironment

Each participant was administered the SCL-90-R prior to admission into
the treatment program and again at the end of the seven-week program. The
SCL-90-R was individually administered. The program psychologist gave the
participants administrative instructions. The participants took the test in a quiet
room and were allowed to sit or stand as needed to allow for maximum comfort.
If the patients had difﬁculty reading the information, a family or staff member was
allowed to read the question to the patient. The assistant was instructed to only
read the question to the patient, but not to interpret the questions or lead the
patient to an answer. The test time took approximately 15-20 minutes, but the

patients were allowed as much time as needed to fully complete the SCL-90-R.

Treatment Prtgra_m
The Functional Recovery Program of Michigan is located in West
Bloomﬁeld, Michigan. The functional restoration program specializes in a
cognitive-behavioral treatment approach for chronic pain. At the time of this
study, the program consisted of an interdisciplinary team including a program

psychologist, nurse, vocational counselor, physical therapist, occupational

37

therapist, and recreation therapist. A physiatrist who is the medical director

heads the team.

Table 2. Admission Criteria for the Functional Restoration Program

 

. Able to comprehend and communicate to allow program participation

0 Must be 18 years of age or older

. Willing to complete the assessment process

. Experienced chronic non-malignant pain for a minimum of three months

. Experienced reduction in vocational or avocational activites

. Not currently utilizing proper pain coping strategies determined by the
program psychologist based on responses to the SCL-90R, and the
interview questions

. Reporting or demonstrating mild/moderate emotional distress

. Willing to work towards patient stated goals, such as return to work,
recreational activities, learn positive coping strategies, etc.

. Medically stable

. \Mlling to sign the program agreement

 

The patients with chronic pain underwent a seven-week functional
restoration program after completing a medical and psychological assessment
process. Participants met with the rehabilitation team prior to their entry into the
program to ﬁnalize their personal goals in the areas of household, work,

recreation, socialization and medication use. The patients were not asked to rate

38

their pain level, as the goal of the program was not pain reduction, but functional
restoration. The treatment was offered four times a week in a group setting. For
a description of the program and a sample daily schedule, please refer to
Appendix F. The starting dates for treatment for the patients were staggered.
Patients were continuously admitted to the program on an on-going, weekly
basis. This allowed for the senior patients to act as role models and sources of
support for the newer patients.

The patients participated in a variety of physical activities including
strength training, stretching exercises, aerobic conditioning and functional tasks.
Patients receiving treatment in the morning would start their day with a 30-minute
stretching routine lead by one of the therapists. They would then listen to a
guided imagery tape for ten minutes to help them relax. Then the patients would
begin their exercise routine of weights and aerobic activity utilizing the treadmill
or bike. They had daily graphs to follow that helped them to slowly increase their
aerobic time and intensity of resistance. The starting points on the graphs were
based on the participants’ performance over the ﬁrst three days in the functional
recovery program. The physical, occupational, and recreational therapists
guided the participants through their activities and were available to provide
feedback and to answer questions.

Participants would then meet in a room to listen to a lecture on an
educational topic. Patients receiving treatment in the afternoon would join the
morning group so that they could all hear the lecture together. The educational

sessions were lead by the various members of the rehabilitation team. The

39

sessions covered a variety of topics relating to chronic pain from both a physical
and psychological approach. Some sessions focused on how the body works
and functions and allowed the patients to begin to participate in both functional
and recreational tasks. Through the educational sessions, the patients were
taught techniques on how to improve sleep, handle anxiety, and utilize proper
pain coping strategies. This assisted patients with their ability to manage their
pain from a cognitive level.

Following the lecture, all the participants engaged in recreational and
aquatic exercise classes together because the pool and recreation areas were
only available for a limited amount of time. After a second lecture, the morning
group was dismissed and the afternoon group engaged in their stretching,
relaxation, aerobic and weight exercises prior to their dismissal.

The patients met with the program psychologist individually to review their
pre-treatment SCL-90-R test results. One limitation of the study is that we could
not control for the Hawthorne effect from patients knowing their pre-test results.
The patients needed this knowledge to help them learn their areas of difﬁculty in
order to work productively with the program psychologist. The psyChologist
would then meet with the patients on an “as needed” basis, averaging 2-3 visits
during the seven-week program. Upon completion of the program, the patients
completed the SCL-90—R standardized test again. Results from the SCL-90-R

pre and post testing were the focus of analysis for this study.

40

Treatment of Data
The data analyzed in this study was from a previous project performed at
the Functional Recovery Program of Michigan. The following analyses were

conducted according to each speciﬁc hypothesis.

Hvoothesis 1. Chronic pain patients will demonstrate a signiﬁcant decrease in
the Global Severity Index (GSI) score on the Symptom Checklist 90-R (SCL-90R)
from pre- to post-testing following the completion of a seven-week functional
restoration program. The decrease in score will represent a lower overall self-
reported intensity of perceived distress.

This hypothesis will be tested using multivariate repeated-measures
ANOVA, with time (pretest vs. posttest) as a within-subject factor. The GSI score

will be the dependent variable.

mpothesis 2. Chronic pain patients who completed the seven-week functional
restoration program will report signiﬁcantly more improvement on the
somatization (SOM) scale of the SCL-90-R than on other scales of the SCL-90-
R. The somatization scale most accurately reﬂects the level of a patient’s
distress arising from perceptions of bodily dysfunction. Therefore, this speciﬁc
subscale will be most affected by the intervention.

Treatment responses will be investigated by examining change in the
individual SCL scales from pre-treatment to post-treatment. Change scores (i.e.,
difference scores) will be calculated by subtracting post-treatment (Time 2)

scores from pre-treatment (Time 1) scores. These change scores will be

41

analyzed using multivariate repeated-measures ANOVA, with scale as 3 within-
subject factor. A main effect of scale would indicate that the nine scales showed
different amounts of change over time. Post hoc tests will employ simple paired
contrasts to compare the change on each of the SCL-90-R scales relative to
change on the SOM scale.

Hypothesis 3. Prior to treatment, three distinct groups will best characterize
chronic pain patients replicating the three-cluster solution observed by \erliams
et al., (1995).

Cluster analyses will be conducted on pretest data to determine whether
subgroups of chronic pain patients can be established based on initial SCL-90-R
scale scores. A two-step approach employing both hierarchical and non-
hierarchical methods of cluster analysis will be used to segment the patient
sample (Aldenderfer & Blashﬁeld, 1984; Hartigan, 1975; Milligan, 1980). The ﬁrst
step in partitioning the population will use a hierarchical technique (Ward’s
minimum variance method using squared Euclidean distances) to establish the
most appropriate number of clusters and identify any obvious outliers
(Aldenderfer & Blashﬁeld, 1984; Borgen & Barnett, 1987). The second step in
the analysis will use a non-hierarchical, nodal clustering method (k—means). The
k—means method begins with a speciﬁed number of clusters determined by the
hierarchical analysis then reﬁnes the hierarchical solution by assigning cases to
the clusters in a manner that best minimizes the Euclidean distance or error

(Aldenderfer & Blashﬁeld, 1984).

42

Exploratory analyses investigated potential differences between the
clusters in treatment response associated with demographic and illness-related
variables. If subgroups are identiﬁed, it will be of interest to the investigator to
determine if signiﬁcant differences exist in the level of SCL—90-R scores following
the treatment intervention among the subgroup clusters.

Cluster analysis generally is used to classify data by forming it into a set of
homogeneous groups. Cluster analyses will be used to identify subgroups of
chronic pain patients based on their responses to the SCL-90R. Shutty and
DeGood (1987) utilized k-means cluster analyses and compared the amount of
within-cluster variance for differently sized cluster solutions. Williams, et al.
(1995) used an agglomerative hierarchical cluster analysis with squared
Euclidean distance used in the proximities matrix and, Ward’s minimum variance
used as the clustering method. For details on the sub groupings of each study,
please refer to the individual research projects. Shutty and Degood, and
Williams et al., used different methods of clustering and found similar results of a
three-cluster solution, which implies that the finding is robust.

For purposes of this study, attempts were made to replicate the ﬁndings of
the Williams et al. (1995) study utilizing their statistical methods. The researcher
believes that hierarchical methods tend to be better for establishing the most
appropriate number of clusters, whereas nodal (e.g., k—means) methods are
better for assigning cases to the clusters, once the number of clusters has been

determined. A two-step approach that employs the advantages of both methods

43

was utilized in this study. The Statistical Package for the Social Sciences

(SPSS) was used for all factor analyses (Nie, Hull, & Jenkins, 1975).

CHAPTER IV

RESULTS AND DISCUSSION

This chapter contains two major sections: 1) results of the statistical
procedures used to test each of the three hypotheses in this study; and 2) a
general discussion of the results obtained. In the ﬁrst section, the results
pertaining to each hypothesis will be presented separately. All results are

reported at the .05 level of signiﬁcance unless otherwise speciﬁed.

MB.
Hypothesis 1: Chronic pain patients will demonstrate a signiﬁcant decrease in
the Global Severity Index (GSI) score on the Symptom Checklist 90-R (SCL-90R)
from pre- to post-testing following the completion of a seven-week functional

restoration program.

Data considerations

Treatment response was investigated by examining changes in the GSI
score and the individual SCL scale scores from pre-treatment to post-treatment.
Table 1 presents descriptive statistics for the pre-treatment and post-treatment
SCL-90-R variables. Although a multivariate, repeated-measures ANOVA had
been planned to examine treatment change, the data violated assumptions
necessary for conducting parametric statistics. Examination of the distributions

of the GSI and the SCL-90-R scale scores at pre- and post-treatment indicated

45

signiﬁcant positive skew for many of the variables (Z > 4.0). Attempts to
transform the variables using traditional methods (e.g., logarithmic and square
root transformations) were unsuccessful. Therefore, group comparisons were

performed using nonparametric tests.

Wilcoxon Signed-Ranks Tests

Wilcoxon signed-ranks tests, analogous to paired-sample t tests, were
used to compare pre— and post-treatment scores on the SCL-90—R scales and the
GSI (i.e., within-subject comparisons). One-tailed tests were conducted because
directional hypotheses predicted lower scores at post-treatment than at pre-
treatment. The results of these comparisons are presented in Table 3. As can
be seen in Table 3, the GSI score showed a signiﬁcant decrease from pre-
treatment to post-treatment (p<.004). Thus, the results support Hypothesis 1.
Additionally, all individual SCL-90-R scales except HOS, PAR, and PHO showed

signiﬁcant improvement over time.

Hypothesis 2: Chronic pain patients who completed the seven-week functional
restoration program will report significantly more improvement on the
somatization (SOM) scale of the SCL-90-R than on other scales of the

SCL-90-R.

46

Table 3. Descriptive Statistics and Wilcoxon Signed-Ranks Tests for SCL-90-R

 

 

 

Scores

SCL-QO-R Score Wilcoxon Signed Ranks
M SD Z P

Global Severity 1 .16 0.65

Index1

Global Severity 1.00 0.72 -2.69 .004

Index;

Anxiety 1 01 0.75

Anxietyz 0.86 0.83 -2.34 .009

Depressiom 1 .53 0. 93

Depressionz 1 .21 0.95 -3.55 < .001

Hostility1 0.85 0.77

Hostilityz 0.77 0.87 -1.25 .106

Interpersonal 0. 92 0.79

Sensitivity1

Interpersonal 0.78 0.77 -2.17 .015

Sensitivityg

Obsessive- 1 .47 0.96

Compulsive1

Obsessive- 1 .29 0.94 -1 .76 .039

Compulsivez

Paranoid 0.84 0.75

ldeaﬁon1

Paranoid 0.78 0.75 -0.67 .252

ldeaﬁonz

Phobic Anxiety1 0.69 0.94

Phobic Anxietyz 0.63 0.93 -0.41 .341

Psychoticism 0.68 0.57

Psychoticismz 0.62 0.62 -1 .77 .038

Somatizatiom 1 .56 0.65

Somatizationz 1.35 0.71 -3.30 < .001

 

47

Treatment responses were investigated by examining change in the
individual SCL-90-R scales from pre-treatment to post-treatment. Change scores
(i.e., difference scores) were calculated by subtracting post-treatment (Time 2)
scores from pre-treatment (Time 1) scores. Examination of the distributions of
the change scores revealed univariate outliers on three of the SCL-90-R scales
(Depression, Interpersonal Sensitivity, and Obsessive-Compulsive), which
produced signiﬁcant skewness in the data for these scales (2 > 3.0). As
recommended by Tabachnick and Fidell (2000), the impact of these outliers was
minimized by using the vvinsorizing technique.

Winsorizing is a technique that reduces the impact of statistical outliers.
Univariate outliers are cases with an extreme score on one variable. One way to
detect an outlier is to evaluate the standardized (i.e., z score) equivalent of the
score. The cutoff for outlier status depends on each researcher’s tolerance for
deviation from the normal distribution and on the sample size; however, standard
conventions are to label a score as a univariate outlier if z > 3, z > 3.29, etc.
Graphical methods (e.g., boxplots, histograms) also are helpful in identifying
outliers. Once an outlier or outliers are identiﬁed, they must be reduced, or one
extreme score may disproportionately affect the result. One method to eliminate
the outlier is to delete the entire case from the study. This may be unacceptable
to many researchers because it reduces the sample size and produces a more
select sample. If deleted, cases with extreme values are no longer represented
in the sample. Winsorizing resolves the problem of a skewed distribution and

disproportionate inﬂuence by reassigning the value of the case a raw score that

48

is one unit larger (or smaller) than the next-most deviant score in the distribution.
In this manner, the extreme case is represented in the sample, but its
disproportionate inﬂuence is reduced (Tabachnick & Fidell, 2000). In the present
study, these transformations were successful in correcting the distributions on
the variables to meet the criteria for parametric tests.

The change scores were analyzed using multivariate repeated-measures
ANOVA, with SCL-90-R scale scores as a within-subject factor. According to
Wilks’ criterion the ANOVA was signiﬁcant, indicating that the nine scales
showed different amounts of change over time, F(8, 92) = 3.25. Eta squared
(etaz) for the analysis was .22, indicating a large effect size. According to Cohen
(1977), an eta2 of .06 represents a medium effect size, whereas an eta2 of .14
represents a large effect size. Post hoc tests employed simple paired contrasts
to compare the change on each of the SCL-90-R scales relative to change on the
Somatization scale. The results of these analyses are presented in Table 4. As
can be seen in Table 4, the magnitude of the change on the Somatization scale
exceeded that of all other scales except the Depression scale. However, change
on the Somatization scale was signiﬁcantly greater than that on the Paranoid
ldeation, Phobic Anxiety, and Psychoticism scales (p < .05), but was not
signiﬁcantly greater than the changes on the Anxiety, Interpersonal Sensitivity,
Obsessive-Compulsive, and Hostility scales. The effect sizes of the differences
were small. The results provide only partial support for the second hypothesis in
that the change in Somatization was not signiﬁcantly greater than the changes on

all the other scales.

49

Table 4. Post hoc Tests for SCL~90~R Change Scores Relative to Change on

 

 

Somatization

Scale Mean SD

Change Change F(1,99) Eta’ p

SOM1-SOM2 0.20 0.61
ANX1-ANX2 0.15 0.69 0.96 .01 .330
DEP1-DEP2‘ 0.30 0.75 3.28 .03 .073
HOS1-H082 0.09 0.77 2.78 .03 .099
181-1821 0.14 0.58 1.33 .01 .251
ocl-oc2 ‘ 0.17 0.73 0.33 .00 .566
PAR1-PAR2 0.06 0.67 4.59 .04 .035
191101-91102 0.06 0.73 5.26 .05 .024

PSY1-PSY2 0.07 0.49 6.35 y .06 .013

 

F(8, 92) = 3.25, etaz = .22.

Note. Post hoc tests compare each pre-post treatment change on each SCL-90-
R scale to pre-post treatment change on the Somatization scale.

1. Transformed variable: Winsorized univariate outlier.

Hypothesis 3: Prior to treatment, chronic pain patients will be best characterized
by three distinct groups, replicating the three-cluster solution observed by prior

researchers (e.g., Williams et al., 1995; Shutty & DeGood, 1987).

50

ﬂier Analysis

Cluster analysis generally is used to classify data by forming it into a set of
homogeneous groups. In the present study, cluster analysis was used on pre-
test SCL-90-R data to delineate groups of participants who produced similar
symptom proﬁles. Thus, the goal was to determine whether these patients had a
unitary clinical presentation or whether there were meaningful subsets of
respondents with distinct symptom proﬁles.

A two-step approach employing both hierarchical and non-hierarchical
methods of cluster analysis was used to segment the patient sample
(Aldenderfer & Blashﬁeld, 1984; Hartigan, 1975; Milligan, 1980). The ﬁrst step in
partitioning the population used a hierarchical technique (Ward’s minimum
variance method using squared Euclidean distances) to establish the most
appropriate number of clusters and identify any obvious outliers (Aldenderfer &
Blashﬁeld, 1984; Borgen & Barnett, 1987). The second step in the analysis used
a non-hierarchical, nodal clustering method (k—means). The k-means method
begins with a specified number of clusters determined by the hierarchical
analysis then reﬁnes the hierarchical solution by assigning cases to the clusters
in a manner that best minimizes the Euclidean distance or error (Aldenderfer &
Blashﬁeld, 1984).

To replicate the analyses conducted by Shutty and DeGood (1987), the
cluster analyses also were performed separately for each gender. To evaluate
the consistency of the results with prior research ﬁndings, these cluster

assignments were compared to a cluster analysis conducted using the total

51

sample combined and to cluster assignments using the criteria described by
Williams et al. (1995) in their study of SCL-90-R proﬁles observed in chronic pain

patients.

Hierarchical Analysis. Several analyses of the hierarchical results were used in
determining the appropriate number of clusters. A common technique for
determining the best number of clusters involves evaluating the “tightness” of the
clusters by examining increases in the mean square error for each solution
(Aldenderfer & Blashﬁeld, 1984; Borgen 8 Barnett, 1987). To help identify large
relative increases in the cluster homogeneity, the percentage change in the
agglomeration coefﬁcient was calculated for 2 to 5 clusters. A cluster analysis
was conducted on the total sample (i.e., men and women combined). The
results indicated that a three-cluster solution was most appropriate, as the
greatest change in within-cluster variance was observed when three clusters
were employed.

An agglomeration schedule providing information on individual cluster
membership for three-, and four- and ﬁve-cluster solutions further supported a
three-cluster solution: The majority of cases retained the same cluster
membership from the three—cluster through the ﬁve-cluster solution. Changes in
cluster membership primarily reflected the divisions of a main cluster into smaller
cluster groupings rather than assignment of the case to an entirely different
cluster branch (i.e., few cases “crossed over” to different cluster segments).

Thus, the cluster solution in the present study replicated a three-cluster solution

52

similar to those reported by Shutty and DeGood (1987) and Vlﬁlliams et al.

(1995).

K-Megns Analysis. The k-means analysis assigned 19 cases to Cluster 1, 40

 

cases to Cluster 2, and 41 cases to Cluster 3. The means of each symptom

dimension for the three clusters are plotted in Figure 1.

 

 

 

 

 

 

 

 

 

4 --o--Cluster1 (n= 19)
3 5 --I- Cluster2(n=40)
- —a—Cluster 3 (n = 41)
e 3 °
8 ', "o‘
(D 2.5 r’ o
o: x ‘ ‘
I D, O L 4’ ‘ :0
g)? 2 ‘ ' '
El) 15 /A\ )1" AL ‘11" 481-
(D . // \\ ’7 V\ I
c ’ \ I
g 1 ' “*4 K ,’ f
E \\ J/
05 YA\A m/ Aw
0 I T l l I I r 1 1

 

ANX DEP HOS IS OC PAR PHOB PSY SOM
SCL-90—R Scale (Total Sample)

Figure 1. Profiles of SCL-90—R Scales for the three-cluster solution

As can be seen in ﬁgure 1, with the exception of a spiked elevation on
Phobic Anxiety and Interpersonal Sensitivity among patients in Cluster 1, the
symptom proﬁles of the three clusters are generally of similar shape. However,

the groups are separated by level of endorsement, with Cluster 1 showing the

53

highest level of distress and Cluster 3 showing the least distress. Because the k-
means cluster analysis is designed to maximize distance between the clusters,
tests for differences between cluster centers on each symptom dimension are not
required; however, a check of these univariate tests conﬁrmed signiﬁcant group
differences on all scales (all ps < .001). As expected, a univariate ANOVA
testing group differences on GSI at Time 1 (which represents the average
elevation of the 9 scales) indicated signiﬁcant differences across the three
clusters, F(2, 97) = 312.07, p < .001. Tukey post hoc tests indicated that Cluster
1 GSI (M = 2.20, SD = 0.30) was signiﬁcantly greater than Cluster 2 (M = 1.28,
SD = 0.22), Cluster 2 GSI was signiﬁcantly greater than Cluster 3 (M = 0.56, SD
= 0.23), and Cluster 1 GSI was signiﬁcantly greater than Cluster 3 (all ps < .001).

These results support the third hypothesis.

Analyses for Men and Women

Similar to the total sample cluster analyses, two-step cluster analyses
were conducted for the separate samples of men and women. To identify large
relative increases in the cluster homogeneity, the percentage change in the
agglomeration coefﬁcient was calculated for 2 to 5 clusters. The largest
increases were observed in going from three to two clusters (men 79.6%; women
75.2%), indicating that the three-cluster solution was most appropriate for both
men and women. For both samples, the next largest increase in the
agglomeration coefﬁcient occurred in the stop from four to three clusters (men

49.4%; women 52.0%). Agglomeration schedules providing information on

54

individual cluster membership for three-, four-, and ﬁve-cluster solutions further
supported the three-cluster solutions: Among men, 50% of the cases retained
the same cluster membership from the three-cluster through the ﬁve-cluster
solution; and, among women, 41% of the cases retained the same cluster
membership from the three-cluster through the ﬁve—cluster solution. In all cases,
changes in cluster membership reﬂected the divisions of a main cluster into
smaller cluster groupings rather than assignment of the case to an entirely
different cluster branch (i.e., no cases “crossed over” to different cluster
segments).

The combined sample cluster analysis (N = 100) assigned all but 14 cases
to the same cluster as was observed in the cluster analyses conducted for each
gender separately. Thus, the cluster assignments made by the gender-separate
cluster analyses were identical to the cluster assignments made by the total
sample cluster analysis for all but 14 cases. All 14 of the cases assigned to
different clusters in the combined sample analysis were women, with 7 women
reassigned from Cluster 3 (Low GSI) to Cluster 2 (Moderate GSI), and 7 women
reassigned from Cluster 2 (Moderate GSI) to Cluster 1 (High GSI). Thus, the total
sample cluster analysis tended to overpathologize these women in assigning
cluster membership. However, chi—square analyses indicated that the
proportions of men and women assigned to each cluster did not differ
signiﬁcantly for either the combined-sample cluster assignments, X"(2, N = 100)
= 2.78, p = .248, or the gender-separate cluster assignments, X2(2, N = 100) =
0.60, p = .742.

55

For men, the k-means analysis assigned 7, 23, and 24 cases to Clusters 1
through 3, respectively. The means of each symptom dimension for men in the
three clusters are plotted in Figure 2. For women, the k-means analysis
assigned 5, 17, and 24 cases to Clusters 1 through 3, respectively. The means
of each symptom dimension for women in the three clusters are plotted in Figure

3.

 

 

 

 

 

 

 

 

 

 

4 --o--Cluster1(n=7)
3.5 — I — Cluster 2 (n = 23)

a) —¢-—Cluster3 (n = 24)
5 3 o
0 '0 \‘
“3 2.5 ,4 ~. .. -0. 4;,
0,: .o -. .o-‘ a r
g 2 LL ' I 243
.5 l\ x" 1‘ “o" ‘-.-o
c 1 l' I.____I’ \ 1/ [A
g \ i/
2 0 5 A 10- \\ z/

. A, V 7"

O I T T 1 I j I T j

ANX DEP HOS IS 00 PAR PHOB PSY SOM
SCL-90—R Scale
Men: N = 54

Figure 2: Proﬁles of SCL-90-R scales for the three-cluster solution: Men

56

 

 

 

 

 

 

 

 

 

 

 

4 --o--Cluster1(n=5)
35 —I-ClusterZ(n=17)
' o + Cluster 3 (n = 24)
e 3 -- .
8 - O .0
g 2.5 of’. .Ae. .. O" ‘U"; \‘\‘
0' 2 LA\ .0--. l!\ ~‘ .oﬁ_
0;) /ﬁ ‘\ /, ‘\ O"
—l I \ / \ I,
8 1.5 4 \ ’1 \ I. I’
C 1 y’ \— f” \x / f
m M' Y/
m
2 0.5 M
o I T I I I I I 1 1

ANX DEP HOS IS OC PAR PHOB PSY SOM

SCL-90-R Scale
Women: N = 46

Figure 3: Proﬁles of SCL-90-R scales for the three-cluster solution: Women

As was observed in the total sample cluster analysis, with the exception of
elevations on Phobic Anxiety, the symptom proﬁles of the three clusters were
similar. However, the groups were separated by level of endorsement, with
Cluster 1 showing the highest level of distress and Cluster 3 showing the least
distress. A check of the univariate tests conﬁrmed signiﬁcant group differences
on all scales for both cluster analyses (all ps < .001). As expected, a univariate
ANOVA testing group differences on GSI at Time 1 (which represents the
average elevation of the 9 scales) indicated signiﬁcant differences across the
three clusters for the sample of men, F(2, 51) = 169.21, p < .001. Tukey post
hoc tests indicated that Cluster 1 GSI (M = 2.22, SD = 0.19) was signiﬁcantly
greater than Cluster 2 (M = 1.28, SD = 0.21 ), Cluster 2 GSI was signiﬁcantly

greater than Cluster 3 (M = 0.54, SD = 0.24), and Cluster 1 GSI was significantly

57

greater than Cluster 3 (all ps < .001). Similarly, for the sample of women,
univariate ANOVA indicated a signiﬁcant difference in GSI across the three
clusters, F(2, 43) = 86.33, p < .001. Tukey post hoc tests indicated signiﬁcant
differences between all combinations of comparisons between Cluster 1 (M
=2.48, SD = 0.35), Cluster 2 (M = 1.66, SD = 0.32), and Cluster 3 (M = 0.73, SD
= 0.30).

Overall, in examining the cluster solutions for both men and women, these
analyses appear to replicate a three-cluster solution, similar to those reported by

Shutty and DeGood (1987) and Williams et al. (1995).

Characteristics of Cluster Members
Descriptive statistics for variables describing the three clusters as

assigned in the gender-separate analyses are reported in Table 5. Overall, the
clusters were similar on the demographic variables examined (age, education,
and gender). ANOVAs indicated that the three clusters did not differ with regard
to age [F(2, 97) = 0.66, p =94] or years of education [F(2, 97) = 0.14, p = .87]. A
chi-square analysis indicated that the proportions of men and women assigned to
each cluster did not differ signiﬁcantly, X2(2, N = 100) = 0.60, p = .742.
Therefore, men and women were equally likely to be assigned to each of the
three clusters.

Additional tests were conducted to compare the clusters on illness-related
variables. Nonparametric Kruskal-Wallis tests were conducted to test for group

differences on months post injury and number of surgeries, because these

58

Table 5. Characteristics of patients in Clusters 1, 2 and 3

 

Cluster 1 Cluster 2 Cluster 3
Variable n=12 n=40 n=48

 

M SD M SD M SD

 

Age (years)1 43.5 10.6 42.5 9.1 42.9 7.7
Education (years)1 12.0 1.28 12.3 1.8 12.3 1.8
Percent Men2 58.3 57.5 50.0

Months post injury3 21.5 17.9 23.9 31.9 25.4 26.5

Number of surgeries3 0.3 0.8 0.5 0.6 0.5 0.7
GSI Time 11 2.33 0.29 1.44 0.32 0.64 0.29

Percent with Attorney2 58.3 20.0 27.1

Pathognomonic Sign (percent) 2

None 0 5 43.8
One 0 0 39.6
Multiple 100 95 16.7

Primary complaint2

Back pain 41.7 60.0 50.0
Neck pain 16.7 15.0 27.1
Other 41.7 25.0 22.9

 

1. Analysis of variance; 2. Chi-square tests; 3. Kruskal-Wallis tests.

***p<.001.

59

variables were badly skewed and did not have normal distributions. The Kruskal-
Wallis test is the nonparametric analog of univariate ANOVA and detects
differences in distribution locations. It is similar to the Mann-Whitney test, but it is
appropriate for comparing the scores of three or more groups. Neither months
post injury [KruskaI-Wallis X2(2) = 1.07, p = .60] nor number of surgeries
[Kruskal-Wallis X2(2) = 1.12, p = .55] were signiﬁcantly different between the
groups.

The association of the patient’s chief presenting complaint with cluster
membership was investigated using chi-square analysis. To ensure adequate
expected values in each cell for the analysis, presenting complaints focusing on
the extremities, headache, and multiple other sites were collapsed into a single
category “other” and compared to primary complaints involving back pain or neck
pain. The chi-square analysis indicated that the clusters did not signiﬁcantly
differ in this regard, X"(4, N = 100) = 3.70, p = .45. Chief presenting complaint
did not account for group differences in clusters.

Chi-square analysis did indicate that patients in Clusters 1 and 2 were
signiﬁcantly more likely to have multiple pathognomonic signs than were patients
in Cluster 3, X2(4, N =100) = 65.19, p < .001. As can be seen in Table 3, 100%
of the patients in Cluster 1 and 95% of the patients in Cluster 2 were rated as
having multiple (i.e., more than one) pathognomonic signs, whereas 44% of
patients in Cluster 3 had no pathognomonic signs and only 17% were rated as
having more than one pathognomonic sign. Additionally, chi-square analysis

indicated that patients in Clusters 1 were more likely to have an attorney than

60

were patients in Clusters 2 and 3, X2(2, N =100) = 6.77, p =.034. Nearly 60% of
the patients in Cluster 1 had an attorney, whereas only 20% of the patients in
Cluster 2 and 27% of the patients in Cluster 3 had attorneys (see Table 5). In
summary, the three clusters were similar on most demographic variables;
however, the two clusters presenting with the highest levels of distress were
more likely to have multiple comorbid conditions, and the cluster presenting the

most distressed also was more likely to have retained an attorney.

Williams et al. (1995) Gu_id;lines Applied to Gender Cldster Alalyses

The stability of the assignments to the three clusters was tested further by
assigning each case to a cluster using the guidelines speciﬁed for men and
women by Williams et al. (1995). Using these criteria, only 19% of cases (7 men
and 12 women) were assigned to clusters different than those specified by the
separate-gender cluster analysis conducted on the present sample. Men were
assigned to Clusters 1 through 3 using the Williams et al. criteria as follows:
Cluster 1 = 10, Cluster 2 = 18, and Cluster 3 = 26. Women were assigned to
Clusters 1 through 3 using the Williams et al. criteria as follows: Cluster 1 = 2,
Cluster 2 = 23, and Cluster 3 = 21. When comparing the Williams et al. cluster
assignments to the cluster assignments of men using separate-gender cluster
analyses, 7 cases were differently assigned: 4 cases were assigned to a cluster
indicating greater distress, whereas 3 cases were assigned to a cluster indicating
less distress. Comparing Williams et al. cluster assignments to the cluster

assignments of women using the separate-gender cluster analyses, 6 cases

61

were assigned to a cluster indicating greater distress, and 6 cases were assigned
to a cluster indicating less distress.

Overall, the results of the cluster analyses conducted on chronic pain
patients for the present study were highly consistent with results reported in
previous research using both purely statistical (Shutty & DeGood, 1987) and

criteria-based (Williams et al., 1995) assignment of cases to clusters.

Discussion

The results of this study support the belief that a cognitive-behavioral
treatment approach, provided through a functional restoration program, can have
a signiﬁcant impact on patients’ self-reported distress levels. The GSI score of
the patients showed a signiﬁcant decrease from pre-treatment to post-treatment
(p<.004). Additionally, all individual SCL-90—R scales except Hostility, Paranoid
ldeation, and Phobic Anxiety showed signiﬁcant improvement over time (Table
3). In the present study, there are several reasons why these three scales may
not have showed signiﬁcant change.

The chance for improvement on the scales of Hostility, Paranoid ldeation,
and Phobic Anxiety might be less due to the pre-test scores. The pre-test mean
on these three scales were low to begin with (Hostility 0.85, Paranoid ldeation
0.84 and Phobic Anxiety 0.69) compared to the pre-test mean scores for Anxiety
(1.01), Depression (1.53), Obsessive-Compulsive (1.47), and Somatization
(1.56). Therefore, there was less room for change on the Hostility, Paranoid

ldeation, and Phobic Anxiety scales because of their lower initial scores.

62

Another explanation lies in the fact that one would not expect change on
phobia, paranoia, and hostility because the treatment approach was designed
primarily to change somatization, and feelings about one’s pain condition, which
are commonly reﬂected in anxiety and depression. The characteristics measured
by the scales of Hostility, Paranoid ldeation, and Phobic Anxiety were not
targeted in treatment. The lack of change on these scales serves as evidence
for the discriminant validity of the treatment. Aspects of the patients’ symptoms
that were targeted for change, did change; those aspects of the patients’
symptoms that were not targeted for change, did not change. Thus, change in
the Somatization and Depression scales following treatment is not simply due to
the passage of time. If all of scales had changed, one would suspect that
patients might simply get better without any intervention.

Change on the Somatization scale exceeded the change on all other
scales except the Depression scale. However, change on the Somatization
scale was only signiﬁcantly greater than changes on the Paranoid ldeation,
Phobic Anxiety, and Psychoticism scales (p < .05). The effect sizes of the
differences were small.

These ﬁndings suggest that a cognitive-behavioral approach to treatment
of chronic pain may help patients gain better control over their current situation
and help them feel less distressed in general. This ﬁnding is consistent with the
proposal that a therapy program designed to restore function as well as to
educate patients on proper pain coping mechanisms is an effective mode of

treatment for these patients (Morley et al., 1999). The literature generally

63

supports the notion that due to the multitude of potential physiologic and
psychosocial problems, a team approach to treatment may yield optimum
treatment outcomes (Headley, 1994; Jenkins, 1999; Hankin et al., 2001). The
ﬁndings of the current study provide support for the use of a multidisciplinary
approach to treatment with chronic pain patients. Several authors believe that
chronic pain patients can beneﬁt greatly from a multidisciplinary approach to
treatment (Fishbain et al., 1995; Fordyce, 1976; Philips, 1988). This belief was
upheld and substantiated by the research findings.

Medical professionals should not restrict the use of the cognitive-
behavioral approach only to the treatment of chronic pain patients. Many
patients in acute pain begin a downward spiral if not properly directed by health
care professionals. People in the health care ﬁeld need to recognize when pain
has gone beyond a patient’s physical complaints and begins to affect a person’s
functional abilities, relationships, and mood. Proper referrals to other health care
professionals may help prevent the downward slide into a chronic pain
syndrome. Realistic expectations can be outlined for the patients so that they
know what they can safely do, and when to progress their rehabilitation. Some
patients are given restrictions for their activities, but then are never told when it is
safe to move beyond these restrictions. Lack of physical activity and decreased
mobility will cause secondary deconditioning effects, which can add to the
original pain problem.

Even in athletic populations, there is reason for concern. Athletes tend to

push themselves very hard physically. When they are unable to participate in

64

their sport due to an injury, they can become very anxious and depressed. They
may have planned to go to college or be paid professionally for their abilities.
Some may try to hasten their recovery, which could lead to greater problems.
Others may deteriorate physically in areas unrelated to the injury as they try to
recover by restricting their activity level to an excessive degree. Proper guidance
and goal setting by a trained health care team can help athletes restore function
and learn proper pain coping mechanisms to utilize during the recovery phase.

One goal of the current study was to determine whether patients with
chronic pain had a unitary clinical presentation or whether there were meaningful
subsets of respondents with distinct symptom proﬁles. The study attempted to
determine if subgroups of chronic pain patients could be identiﬁed and replicated
as in prior studies. The results of this study support the ﬁndings of investigators
who have identiﬁed subgroup clusters of patients with chronic pain. Williams et
al., (1995), using the SCL 90-R, were able to identify three subgroups of chronic
pain patients. Their analysis of SCL 90—R scores differentiated patients into high,
medium, and low scoring subgroup clusters. S-scores were analyzed separately
for men and women. Patients in cluster one reported the highest level of
psychological distress; those in cluster two a moderate level; and patients in
cluster three a low level of distress.

Shutty and DeGood (1987) successfully identiﬁed three subgroups of
patients using cluster analysis on 221 patients with chronic low-back pain based
on the standardized scoring method (S-scores) of the Symptom Checklist-90R.

The S-scores were analyzed separately by gender. The investigators found that

65

three clusters were most appropriate for both males and females to distinguish
homogeneous groups.

A cluster analysis was performed on the total sample in the current
research study (i.e., men and women combined). The results of the analysis
indicated that a three—cluster solution was most appropriate, which is consistent
with the prior studies. Thus, the cluster solution in the present study replicated a
three-cluster solution similar to those reported by Shutty and DeGood (1987) and
Williams et al. (1995).

One limitation of the study is that a measure of the severity of the disease
is missing. At present, we do not know whether patients in Cluster 1 (the most
distressed profile) had greater disease severity and more pain than did patients
in the other two clusters. If indeed they were in more pain, it could be that their
pain subsided during the treatment causing the decline (improvement) in their
SCL-90-R scores. We have no way of knowing what aspect of the program
might have effected the change observed. It may have been the behavioral
aspect of the treatment that resulted in improved physical health and reduced
pain levels (e.g., strength training, stretching exercises, aerobic conditioning and
functional tasks). It may also have been the focus on cognitive changes
associated with the management of chronic pain (e.g., improved sleep,
diminished anxiety, and enhanced strategies for coping with pain). A future study
focusing on a measure of disease severity may help clarify which aspect of the

treatment program may effect the changes observed.

66

CHAPTER V

SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS

Summam

The purpose of the present investigation was to compare the pre- and
post-treatment performance on the Global Severity Index (GSI) and the
somatization psychological subscale of the SCL-90-R of 100 patients with
chronic pain who successfully completed the Functional Recovery Program of
Michigan. The study also attempted to determine if subgroups of chronic pain
patients could be identiﬁed and replicated as in the study by Williams et al.,
(1995), based on their performance on the SCL-90-R.

Data were analyzed using nonparametric Wilcoxon signed—ranks tests.
Analysis of the data indicated that the GSI score showed a signiﬁcant decrease
from pre-treatment to post-treatment (p<.004), thereby supporting the ﬁrst
hypothesis. In addition, performance on all individual SCL-90-R scales except
the Hostility, Paranoid ldeation, and Phobic Anxiety scales showed signiﬁcant
improvement over time.

The Somatization scale change scores were analyzed using multivariate
repeated-measures ANOVA, with SCL-90-R scale scores as a within-subject
factor. Post hoc tests employed simple paired contrasts to compare the change
on each of the SCL-90-R scales relative to change on the Somatization scale.
The results indicated that the change on the Somatization scale exceeded

change on all scales except the Depression scale. Change on the Somatization

67

scale was significantly greater than changes on the Paranoid ldeation, Phobic
Anxiety, and Psychoticism scales (p < .05), but not signiﬁcantly greater than the
changes on the Anxiety, Interpersonal Sensitivity, and Obsessive-Compulsive
scales, with a trend on Hostility (p = .099). The fact that the Somatization and
Depression scales had the most signiﬁcant change is not surprising considering
that they are most closely linked to a patient’s distress level. These scales had
more room to show change because of the level of elevation displayed on initial
evaluation compared to the other symptom dimensions. Also, because the
treatment was targeted at reducing a patient’s distress level and help them to
better cope with their situation, one would expect these scales to change.
These results provided partial support for the second hypothesis.

One goal of this study was to determine whether chronic pain patients had
a unitary clinical presentation or whether there were meaningful subsets of
respondents with distinct symptom proﬁles. In the present study, cluster
analyses were used delineate groups of participants who produced similar
symptom proﬁles on the SCL-90—R. A two-step approach employing both
hierarchical and non-hierarchical methods of cluster analysis was used to
segment the patient sample. The ﬁrst step used a hierarchical technique (Ward’s
minimum variance method using squared Euclidean distances) to establish the
most appropriate number of clusters and to identify any obvious outliers. The
second step in the analysis involved a non-hierarchical, nodal clustering method
(k-means). Overall, the analyses for both men and women yielded three-cluster

solutions similar to those reported by Shutty and DeGood (1987) and Williams et

68

al. (1995). These results afﬁrmed the third hypothesis.

Conclusions

The following conclusions are drawn from the data within the limitations of

this study:

1.

Patients who successfully completed the Functional Recovery Program
of Michigan showed a signiﬁcant decrease on the GSI score of the
SCL-90-R from pre-treatment to post-treatment.

There was a signiﬁcant improvement from pre-treatment to post-
treatment on all individual SCL-90-R scores except Hostility, Paranoid
ldeation, and Phobic Anxiety. The characteristics measured by those
scales were not targeted in treatment. It would not be expected that
these scales would change, and the lack of change serves as evidence
for discriminant validity of the treatment.

. Performance changes on the Somatization scale from pre-treatment to

post-treatment exceeded changes on all other scales except the
Depression score.

Performance changes on the Somatization scale from pre-treatment to
post-treatment was signiﬁcantly greater than the changes on the PAR,
Phobic Anxiety, and Psychoticism scales.

. The three-cluster solutions derived for both men and women with

chronic pain are similar to those reported by Shutty and DeGood
(1987) and Williams et al. (1995).

Recommendations

The following suggestions are offered for future research on the topic

investigated in this study:

1. In this study, the data collected were from patients with chronic pain
whose treatment costs were covered by workers compensation and
automobile insurance. Because patients were receiving
compensation in some form from the workers compensation and

69

automobile insurances, secondary gain issues (e.g., continuation of
medical and healthcare beneﬁts, disability claims on autos and
credit cards) could have inﬂuenced responses to the SCL-90-R and
apparent treatment outcomes. Replication of the study should
include patients with other insurance coverage to assess if
secondary gain played a role in the ﬁndings of this study.

. The current study did not address what aspect of the treatment
program might have effected the observed changes. Future
studies may want to focus on a measure of disease severity in a
patient’s proﬁle, and/or examine the patients’ perceptions of the
effectiveness of various aspects of the treatment program.

. Because all of the SCL-90-R scores changed except Hostility,
Paranoid ldeation, and Phobic Anxiety, it is recommended that
future research focus on personality traits that are more resistant to
change, such as paranoia and phobia. The current method of
treatment was not targeted at changing characteristics measured
by these scales. Future treatment may want to focus more on
modifying personality traits to see if treatment outcomes are
affected.

. Future studies may want to focus on factors that may have
contributed to the large variance in the present population. Some
possibilities include assessing differences in age, the number of
months since the injury occurred, and nature of occupation.

. The participants in Cluster 1 and 2 were signiﬁcantly more likely to
have multiple pathonomonic signs than were patients in Cluster 3.
Also, patients in Cluster 1 were more likely to have an attorney than
were patients in Clusters 2 and 3. Do persons with multiple
comorbid conditions or persons in the process of litigation perform
differently on the SCL-90-R than other pain patients? Do they
respond differently to cognitive-behavioral treatment?

. The participants in the present study were limited in number. It is
recommended that a large number (e.g., several hundred) of
subjects be studied to determine if a 3-cluster solution is still the
most appropriate for patients with chronic pain.

. This study did not analyze whether one cluster group responded
differently to a cognitive-behavioral approach to chronic pain

treatment than another cluster. Future research should examine
the response of various cluster groups to the treatment program.

70

The response of gender-specific cluster groups to treatment should
also be examined.

. An analysis of patient “readiness to change” based on the
transtheoretical model of behavior change (Kems & Rosenberg,
2000) may provide predictive information on the response of
patients to treatment, which could then be compared to treatment
outcomes.

. In this study, participants were not asked what aspects of the
treatment program, if any, helped them the most. In future
research, a post-treatment interview should be held to gather this
information from the patients.

71

APPENDIX A

CONSENT FOR TREATMENT

72

 

I‘J

Wayne State L'ru'versuy Sinai-Grace Hospital . ICC
Functional Recovery Prom
6600 West Maple Road
Was: Bloomﬁeld. Michigan
48322

Outpatient Consent Form

Name: Social Security #

 

CONSENT: I consent to medical care including routine procedures, examinations, tests,
immunization, regional and local anesthesia and other treatment by Dr] Service and
hisrher assistants, associates or consultants as is necessary in their judgement. I realize that the clinic
is a teaching facility affiliated with Wayne State University and the Detroit Medical Center and
consent to medical care being performed by students, residents, physician extenders or medienl
support staff. I consent to the testing and disposal of specimens of my blood, urine and other bodily
fluids, tissues and products. I understand that an HIV (human-immuno) deﬁciency virus test may be
done upon me without my further consent if a doctor, health professional or employees sustains a
percutaneous, mucous membrane or open wound exposure to my blood or other bodily ﬂuid.

ADDITIONAL CONSENT FORMS: I understand that for certain procedures deemed necessary by
my physician(s), I will be required to sign a special consent form. Further, if I do not ﬁilly
understand a procedure or its risks. consequences and alternative methods of treatment, I have the
right to question the appropriate health care professionals.

RELEASE OF INFORMATION: The clinic and each provider who treats me may release to
whomever is pctentially responsible for payment and/0r subsequent treatment, information ﬁ'om my
medical and/or ﬁnancial records as necessary or desirable for my care or for the clinic and/or provider
to obtain payment for audits of such payments. This authorization includes all records, including
records of mental health and substance abuse services, treatment AIDS, HIV infection, AIDS Related
Complex, and Hepatitis.

This authorization for release shall be eﬁeaive for ﬁve (5) years ﬁom the date ofthis consent unless a

revocation or authorization in writing is ﬁled at the clinic to terminate this authorization. Such
revocation is prospective and not retrospective, and only applies to release of information for other
than to obtain payment.

INSURANCE: I authorize the doctor and the staﬁ" to review my insurance coverage with my
insurance company. I certify that any and all information provided by me in furtherance of my
application for health care beneﬁts are true. I authorize payment of insurance beneﬁts to me made
directly to the doctor. I agree to pay in ﬁill any and all charges not covered by insurance or other

beneﬁts.

NO GUARANTEES: I understand that the practice of medicine is not an exact science and that no
guarantees or promises have been made to me as a result of treaUnents or examinations by the doctors
or assistants.

I HAVE READ THIS FORM. IT HAS BEEN FULLY EJG’LAINED TO ME. AND ALL OF
MY QUESTIONS ABOUT IT HAVE BEEN ANSWERED. I UNDERSTAND ITS
CONTENTS.

 

 

PATlBIT SIGNATURE DATE PATIENT'S GUARDIAN SIGNATURE DATE

 

\HTNESS DATE

73

APPENDIX B

PERSONAL DATA AND INTERVIEW SHEET

74

9'6.

Sinai-Grace Hoapltal

Detroit Medical Center/ Wayne State Universu-nzry

Functional Hacavarv Program

 

8800 West Maple Road
. Suite 333
Date West Bloomfield, MI 48322
248-661-9903 Phona

Full Legal Name of Patient “8'55”” ‘3‘

 

 

 

 

 

 

 

 

Address . MI (Zip)
Telephone: Home (_) __-___ Work L ) - x FAX
Age __ Birth Date Birthplace
Sex: (_) Male (_) Female Patient’s Social Secwurity Number - -
Current Marital Status: (_) Never Married L.) Married

(_) Separated (_) Divorced (__) Widowed
What is the last grade yoo completed in school? Where?
Armed Forces experience? __ What branch? Rflank M.O.S.

Who referred you here?

 

Why was this evaluation requested?

 

Who is your personal physician?

 

Office address Telephcrone number (__I -

When did you last see a physician?

 

For what reason?

 

Check all items which describe your current living situation:
(_) Alone (_) With spouse—first name
(_) With children (_) With brother or sisters
(_) With invlaws (_) With your parents
(_) With others (roommate, share apartment, etc)

 

 

Number of children _ Ages of children

 

Names of children living at home

 

Our Strength Your Health. @

www.mora

75

PERSONAL DATA-Page 2
Are you presently employed? Yes No

What is your specific occupation?

 

Briefly describe what you do:

 

The name of your place of employment?

 

How long have y0u worked for this employer?

 

If disabled or unemployed, when injured? last employed?

 

Do you have an attorney representing you regarding your injury?
Name Telephone ( l ‘ -
Address 4 MI

What is y0ur current source of financial support?

 

Briefly describe problems which are of current concern to you:

 

 

 

Have you ever received treatment for nervous or emotional difficulties? Yes _ No _
if yes, please indicate when. the problems you were experiencing, and the agency or
psychotherapist who treated you:

 

 

Have you ever taken psychological tests? Yes __ No __ if yes. when and where?

 

 

What are your goals for entering the Functional Recovery Program?

 

 

 

76

PERSONA

What medications are you currently taking
conditions?

L DATA—Page 3

for nervousness. pain. sleep. depression, or ether

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF DOSAGE r TIMES DATE WHO PURPOSE
MEDICATION PER DAY STARTED PRESCRlBED
1
2
Current intake of beer. wine, or whiskey each day: drinks
Current intake of caffeine (tea/coffee/sodal each day: drinks

Current usage of tobacco each day

Please
( l Headaches
( l Migraine headaches
( l Muscle tension headaches
Sinus headaches
Dizzy spells
Fainting
Heart palpitations
High blood pressure
(._~_I___J
Stomach ulcer
requent indigestion
035 of appetite
apid weight loss
ncreased appetite

i)
(l
(l
(l
ll

l
i

F
i L
R

Rapid weight gain

Over weight (_ pounds)
Diarrhea

Constipation

Diabetes

Hypoglycemia
Seizures or spells
Tooth aches

Teeth grinding

Jaw pain

l Jaw clenching

l Financial worries

) Problems at home

) Loss of interest in sex
l Other sexual concerns

l
l
l
l
l
l
l
l
l
l
l
l
l
l
l

l
l
i
l
l
(
l
i
i
i
(
l
(
l
(
l
(

check any of the following symptoms or sensations which a

 

 

pply to you these days:
i l Tired most of the time

( ) Unable to get to sleep

( l Wake up too early

( ) Wake up frequently

( l Wake up without feeling rested

( ) Nightmares (about 7)

l ) Unpleasant dreams

i ) Sensitive to bright lights

( l Sensitive to loud noise
( l Feeling tense

( l Feeling frightened

( l Feeling sad

( l Feeling like crying

l ) Loss of interest in socializing

( l Feeling irritable

( l Worry much of the time

i ) Loss of desire to live

i l Unable to enjoy life

( l Dislike weekends or vacations

i l Shy around other people

i ) Uncomfortable in crowds

( l Difficult to make friends

i l Unable to relax

( ) Problems making decisions

( l Difficult to concentrate

( l Negative thoughts about myself
i ) Chronic pain
i l Other
( l Other

! .

 

 

77

APPENDIX C

SAMPLE SCL-90 R INSTRUMENT

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85

APPENDIX D

AGREEMENT TO PARTICIPATE IN THE FUNCTIONAL RECOVERY
PROGRAM

86

000

Sinai-Grace Hospital

C‘etrmt Medical Center,” Wayne State University

DMCISINAI-GRACE HOSPITAL
FUNCTIONAL RECOVERY PROGRAM OF MICHIGAN
AGREEMENT TO PARTICIPATE

l, , voluntarily agree to attend and participate in all aspects of the
DMCJSinai—Grace Hospital‘s Functional Recovery Program which include the physical. psychological
and educational sessions. The purpose of the program is to learn strategies to return to functioning and
manage pain. I understand that functioning may return before pain is relieved. Following are the steps I
need to take to maximize my beneﬁts and complete the program:

1. l realize that I must have a positive attitude towards the program and the treatment approach.
Remaining positive will allow the greatest benefit from treatment. If I have concerns about the
treatment, the treatment staff, or my pain related problems. I understand that I should bring those
concerns to the attention of the staff and not the other patients. I agree that l will not discuss these
ccncems with the other patients. The Rules of Common Courtesy details this expectation and l have
reviewed the Rules of Common Courtesy.

to

I agree to set baselines for functioning and gradually increase my activity level based on the task
goal identified. I realize that l should not try to do more than my goal on a good day or less than my
goal on a bad day.

.(L)

Consistency of treatment is essential for success. Therefore, I agree to attend my scheduled
sessions. The attendance policy details this expectation and l have reviewed the attendance policy.

4. I will carry over my increased activity level in my home environment. Therefore. participation by my
family or signiﬁcant other is expmted and I will make every effort to have them participate in the
program, when appropriate.

5. I am aware that during the period of time that I am in the program, my treating physician for my pain
problem is Dr. Ellenberg. I will not treat with another physician during my stay in the program for my
pain problem. If I am taking narcotic medication for my pain, I understand that I will need to wean off
of the narcotics per the prescribed weaning schedule.

6. I understand that at my discharge conference I will be given a set of recommendations to continue to
increase my ﬂexibility. strength and endurance and manage pain as l return to functioning. At that
time I will also be given a set of abilities that apply for my home, recreation and employment
activities.

To maximize my beneﬁts and successfully complete the program, I understand that all parts of this
agreement must be followed. I understand that failure to comply with this agreement could result in
discharge from the program.

 

 

 

 

Signed: Date:
FRR Ste]: 0816'
agreerienwni-NOO) Our Strength. Your Health.

87

APPENDIX E

APPROVAL LETTER FROM THE UNIVERSITY COMMITTEE ON RESEARCH
INVOLVING HUMAN SUBJECTS

88

 

OFFICE OF
RESEARCH
AND
GRADUATE
STUDIES

University Committee on
Research Involving
Human Subjects

Michigan State University
246 Administration Building
East Lansing, Micnigan
48824-1046

5t 7.6552180

FAX: Si 7/353—2976

pg; www.msuecu/user/ucrihs
3.03:1. ucrihs©msuedu

rm Michigan .500 university
,an 55 ingrrrution 1' Diversi'nr
51331107.; m Aaron

USU Is an affirmslii's-Jcr/on.
(,1: a ' _‘;.,’)L-'ITUI'II'I‘ “‘le .‘uhon

MICHIGAN STATE

UNIVERSITY

 

August 13, 2001

TO: John HAUBENSTRICKER
213 IM Sports Circle
MSU ‘

RE: IRB# 01-531 CATEGORY: EXEMPT 1-E
APPROVAL DATE: August 7, 2001

TITLE: OUTCOME MEASURES OF CHRONIC PAIN PATIENTS ON THE SYPTOMS
CHECKLIST (SCL 90 R) AFTER COMPLETION OF A
COGNITIVE-BEHAVORIAL TREATMENT PROGRAM.

The University committee on Research Involving Human Subjects' (UCRIHS) review Of this
project is complete and I am pleased to advise that the rights and welfare Of the human
subjects appear tO be adequately protected and methods to obtain informed consent are
appropriate. Therefore, the UCRIHS approved this project.

RENEWALS: UCRIHS approval is valid for one calendar year, beginning with the approval
date shown above. Projects continuing beyond one year must be renewed with the green
renewal form. A maximum of four such expedited renewals possible. Investigators wishing to
continue a project beyond that time need to submit it again for a complete review.

REVISIONS: UCRIHS must review any Changes in procedures involving human subjects, prior
to initiation Of the change. If this is done at the time Of renewal, please use the green renewal
form. To revise an approved protocol at any other time during the year, send your written
request to the UCRIHS Chair, requesting revised approval and referencing the project's IRB#
and title. Include in your request a description of the change and any revised instruments,
consent forms or advertisements that are applicable.

PROBLEMS/CHANGES: Should either of the following arise during the course of the work,
notify UCRIHS promptly: 1) problems (unexpected side effects, complaints, etc.) involving
human subjects or 2) changes in the research environment or new information indicating
greater risk to the human subjects than existed when the protocol was previously reviewed and
approved.

If we can be Of further assistance, please contact us at (517) 355-2180 or via email:
UCRlHS@msu.edu. Please note that all UCRIHS forms are located on the web:

. [ '
http../!\~.n.-.N.~.I.msu.edu.’ucar. ucrzhs

Sincerely,

/7 .
@ﬂyL’l/LW/ﬂ

Ashir Kumar, MD.
UCRIHS Chair

AK; bd
Cc: Maureen Walczyk
708 Kingsley Circle
Wixom, MI 48393
89

APPENDIX F

FUNCTIONAL RECOVERY PROGRAM
SAMPLE SCHEDULE

90

DMC--SINAJ GRACE HOSPITAL
FUNCTIONAL RECOVERY PROGRAM

PROGRAM INFORMATION

1) W
Th FFP is a 2i day state of the art out patient rehabilitation program. designed to

e
i IIbr ove fir ncticn ing a. Ia help individuals with Chronic, non -malignant pain. We are a
compre; Iensive integrated adult pain management program.

e p cgra I is housed in the Jewish Community Center a premiere hea‘th c. ub setting.
The em Ip'nCSI s is treatment of the whole person. utilizing stretching aerobic. and

str en ItIg hening exercises Pool therapy, psychological support services and adapted
reore ati on groups are a. so included. A series Of21 different education sessions are
provided in conjunction with treatment to assist with returning to a pie in jury lifestyle.
Individuals who successfully complete the program have the skills and knowledge
needed to continue their recovery independently.

Individuals with palno of II Iree months or more may be candidates. Individuals must be
morivated to function and participate voluntarily. Rather than waiting for the pain to
stop and then return to functioning, the FRP philosophy Is to gradually return to

u Ill

activities which will eventually allow the pain to become less intense over a six to nine

month period of time. A Program Agreement between patient and st att‘ Iorm the basis

for understanding the expected benefits and method Of treatment. (See attached).

2) WW
Appropriate candidates are I8 years Of age or Older and are:
l. Willing to camp: 'ete the assessment process
2. Able to comprehend and communicate to allow program participation.
3. Experiencing chronic. non-malignant pain Of three months or more duratlon.
A. Experiencing a reduction in their vocational and avocational activities.
5. Willing to sign the Program Agreement.
O. Nat utilizing proper coping strategies.
7. Reporting or demonstrating m: Id to moderate emotional distress.

Willing to work toward sta ed glaas.

0)

Q. Medfac Ily sicble

91

PROGRAM INFORMATION PAGE 2

.3) WW

Individuals referred to the FRP complete a three step assessment.
I. Evaluation by our medical dlrectar.

2. Psychological screening with our neurorehabiiitation psychologist and tour Of the
Functional Recovery Program.

3. Pie-admission team conference to discuss treatment recommendations and
individual interest in pursuing admission.

4) W

Contact he Vocational Counselor at (248) cpl-9903 to schedule an evaluation and
check on insurance coverage. Referrals are accepted from patients. physicians, nurse
case managers, or Insurance adjusters.

5) WWW

While in treatment at the FRP, all pain related medications are supervised/directed by
the medical director. Other medications not related to pain (le-blood pressure
medication) may be prescribed by your primary care physician. Patients are gradually
weaned Off narcotics in order to restore the body's natural ability to respond to pain.

Narcotic medications act on the brain and spinal cord to reduce the perception of
pain. When used for prolonged periods of time for chronic painInarcotlcs can be
addicting. They also inhibit the production of endorphins. (powerful pain-killing
chemicals we naturally produce).

We ask that patients not seek outside medical care for their pain problem while they
are in treatment in the FRP. Every effort is made to coordinate services with other

treating physicians while the patient Is under our care.

Once treatment is discontinued. there is a reduction in the need for medical care and
follow up. Our medical director is available for short term follow up. Patients may also

elect to follow up with their referring physician.

6) W

This type of disorder usually affects the family as well as the patient. TO assist in return to
health the family is a vitally important element. We welcome and encourage the
involvement Of family members/signiﬁcant others. Opportunities for family involvement
re encouraged at the weekly team conferences and on treatment days with staff
approval. The program psychologist Is also available to work with signiﬁcant others

dealing with the patients pain problem.

92

PRC‘GRAI‘I/l INFORMATION PAGE 3

7) WW .

We don't expect it to be gone completely by discharge. Long term pain reduction is
reported six to nine months post-discharge once a normalized life is resumed. Ninety-
three percent Of patients indicated that they were satisfied with services received at
the FRP in 1995. However, even though there may be continuing discomfort, individuals
have improved coping and functional ability.

8) WW

Return to 0 normal lifestyle: improved function: improved tolerance for social.
recreational and vocational goals. Individual patient goals are realized: improved
sleep. stress management. overall functioning, etc. . .

Patients completing the FRP can do 30 minutes Of aerobic exercise. a complete set Of
strengthening exercises, have increased flexibility. and normal gait (walking) patterns.
In order to continue successful lifestyle management and relapse prevention. PGTIGRTS
will need to continue with an independent exercise program to include stretches,
strength training. aerobic exercises. and other techniques.

9) LWWWMZ

If transportation is a problem, Jewish Family Service provides rides to and from locations
in Wayne. Oakland and Macomb counties. There are several low to moderate cast
hotels in the area for patients who live tOO far to drive dailv.

Assistance with these arrangements can be Obtained by contacting the program.

IO) WWWEDW

The FRP meets for 2i treatment days. over seven weeks. Treatment is provided on
Monday. Wednesday and Friday. In addition a weekly team conference Is held every
Thursday along with stretches and aerobics. The team conferences are a very
important part Of the Program. as progress towards goals are reviewed and modified
with the patient. family and treatment team. See the attached sample schedule.

11) W

The Functional Recovery Program Staff are highly trained and experienced
professionals who have been sub-trained in the specialty Of chronic pain. Staff include
the medical director (physician), neurarehabilitation psychologist, physical therapist.
occupational therapist, vocational counselor and support staff.

93

W
MONDAY -- WEDNESDAY -- FRIDAY

Morning program hours are: 8:00 AM to 12:00 PM

 

Afternoon program hours are: 10:00 AM to 2:00PM
8:00 AM Morning exercise (stretches. weights. aerobic exercise)
9:00 AM iorning individual psychology meetings.’

I000 AM Education Group El

I I:CO AM Track (walking)

I l:l5 PM Pool exercises/Recreational activity

I250 PM Morning program ends/Afternoon exercise
I120 PM Afternoon individual psychology meeting ’
2:00 PM Afternoon program ends

' Patients may need to add 30 minutes one day per week in order to meet individually with
the psychologist.

W
THURSDAY MORNING-3

Fifteen minute meeting for team conference with patient, family and treatment team.

Stretching exercises.

Aerobic exercise.

Total time: About one hour.

ptinrormaacc

94

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