Part 1 of this 2 part series provided a general overview of psychologists’ roles in pre-implant evaluations, as well as explained the goals, objectives, and common issues encountered in these biopsychosocial assessments. Part 2 details the results from a follow-up study of patients who completed a pre-implant psychological evaluation and subsequently received a surgically implanted pain management device.
Objectives
The primary objective of this study was to correlate patient satisfaction of a spinal implant for pain control with pre-surgery depression, age, gender, and an exaggerated emotional component to the pain as evident on the McGill Pain Questionnaire (MPQ) [7]. These variables were noted in the participant’s pre-surgical psychological evaluation and followed up with mailed questionnaires. This information contributes to the discussion on pre-implant psychological interventions to increase the chance of patient satisfaction. Implicit in this paradigm is increased communication between professionals and patients and ultimately a reduction in long-term health care costs.
Given that patients are an integral part of the health care paradigm, we need to understand their interaction and tailor approaches that increase patient satisfaction after implants and ultimately decrease overall medical utilization. Some questions that need to be explored include:
- What contributes to patient satisfaction?
- Why do some patients report miscommunication and unhappy interactions with providers
- Why do some patients suffer from emotional turmoil—either caused by or aggravated by their medical issues?
- What aspect of patient satisfaction is important to a patient’s perceived success of a surgical procedure.
- Why do some patients with the same physical condition improve while others did not? This understanding is an important step towards incorporating the proper treatments to encourage a positive surgical outcome.
Methods
This study utilized a quantitative approach to allow for an analysis of how depression, emotionality, age, and gender related to patient satisfaction after a surgery for a spinal implant. Out of the 120 potential participants randomly provided by a Pacific Northwest medical facility, sixty-two individuals participated in the survey; 26 (41.9%) participants were Male and 36 (58.1%) participants were Female. Sixty-two (100.0%) participants were Caucasian. Quantitative assessments of the pre-surgical evaluations and a follow-up mailed questionnaire derived a statistical analysis of these variables.
This was a retrospective study that tried to determine if any suspected risks affected the outcome of patient satisfaction. Due to the still-emerging literature on this relatively new procedure, retrospective studies have been widely used. For example, Horsch, Schulte, and Cologne [8] conducted a retrospective study that demonstrated a Spinal Cord Stimulator (SCS) was extremely beneficial in limb preservation in peripheral vascular disease. Retrospective continuous nonrandomized studies have their limitations and cannot be generalized beyond this population. However, they can serve as a preliminary analysis of the factors under study and help to guide future research projects.
Demographics
Descriptive analysis used frequency (number of occurrences out of total participants) and percentages for the nominal (categorical/dichotomous) data. In the study, 26 (41.9%) participants were male and 36 (58.1%) participants were female. All of the sixty-two (100.0%) participants were Caucasian. The target population was male and female adults (ages 36-83) who had a pre-implant psychological evaluation for a pain management device – spinal cord stimulator or an intrathecal pump – and were being treated at an Oregon medical clinic. The demographic data analyzed came from the post-surgery mailed questionnaire. The questions were designed to give insight to any extraneous variables that may have an impact on patient satisfaction.
The demographic variables are as follows: Thirty-one (50.0%) participants had a Spinal Cord Stimulator (SCS) Implant, 12 (19.4%) had an Intrathecal Pump Implant (IP), 12 (19.4%) had an Implant trial but did not proceed to full implantation, and seven (11.3%) decided not to get an implant after the pre-surgical psychological evaluation. Three (4.8%) participants were in pain for three to four years; four (6.5%) were in pain for five to six years; four (6.5%) were in pain for seven to eight years; and 51 (82.3%) were in pain for nine or more years.
Results
The results indicated that no significant relationship existed when comparing depression and patient satisfaction and also that depression did not significantly predict post-implant patient satisfaction. There was no significant relationship when comparing age group and patient satisfaction; gender and patient satisfaction; and McGill Pain Questionnaire results and patient satisfaction.
The results did show a positive correlation coefficient between a diagnosis of depression on the (pre-implant) and age at the time of surgery and the McGill Pain Questionnaire, number of years spent in pain prior to surgery, and number of previous surgeries. The findings showed that the older the patient was, the better coping mechanisms and less depression they had—perhaps because the older generation was raised in a time when pain was not dwelled upon as it is nowadays. Younger participants reported more depression, intense pain, and less effective coping skills than older participants of the same race. Miaskowski [9] points out the same inferences made by Erikson [10], namely, that the age at which chronic pain occurs impacts the individual as a function of interrupted life challenges and normal aging/life goals.
Thirty-one (50.0%) participants had fewer medical appointments after implantation, 19 (30.6%) had the same amount, and 12 (19.4%) endorsed not applicable due to not choosing to get the implant. Eight (12.9%) participants worked prior to their implant; eleven participants (17.7%) did not work prior to implant; twenty-nine (46.8%) participants were retired; and 14 (22.6%) participants were on Social Security Disability. Six (9.7%) participants returned to work after implant, 11 (17.7%) did not, and 45 (72.6%) participants endorsed not applicable. Forty-two (67.7%) participants still have the implant, 10 (16.2%) do not, and 10 (16.2%) endorsed not applicable because they had decided against having the implant after their participation in the pre-implant psychological evaluation.
Post-surgical pain patients who had experienced a reduction in their pain tended to be participants who were satisfied with the spinal implant for pain control. Overall, thirty-nine (62.9%) participants were satisfied with their implant and 16 (25.8%) were not satisfied. The latter group included some of those who decided not to proceed with the implant or decided after the first external trial of the device to not proceed to the full implant.
In this study, 50.9% of the participants reported 50% or more of pain relief, and 62.9% of participants expressed satisfaction of the spinal device. Overall, forty-two (68.9%) participants thought that the pre-surgical psychological evaluation was beneficial, and 19 (31.1%) did not.
Discussion
This study was implemented with the intention of understanding what contributes and correlates with patient satisfaction of a spinal implant for pain control. This study helped refine an emergent theory of the role of patient satisfaction in spinal implants and offers a contribution to current empirical knowledge. This study is meant to be a foundation for future studies, which must continue to refine the development of standard protocols for conducting psychological pre-implant evaluations and correlating variables to patient satisfaction. This author believes that the results of this study may lay a foundation upon which to begin building and testing additional theories on patient satisfaction of spinal implants for pain control.
Spinal cord stimulator vs. intrathecal pump
Participants who had a spinal cord stimulator or an intrathecal pump were put into the same category in this current study. Subsequent studies will need to decipher the differences between these two types of implants and contributing factors.
Ethnicity
It must be recognized that there is great ethnic variability in the chronic pain population. The majority of chronic pain sufferers in the Northwest are of Caucasian descent with the sample in this study being entirely Caucasian, but this is not true for all areas of the country. Each geographic location has its own distinct ethnic identity and future research needs to take this into account. Pain is impacted by a variety of biopsychosocial and cultural dimensions [11]. One must not downplay the role of culture and ethnicity to the pain experience. In today’s social climate, there is an increasing need for research sensitivity and responsibility to address the ethnicity correlates to the chronic pain experience. Within other geographical regions, it is important to develop culturally-appropriate assessments for patient satisfaction after spinal surgery for pain control – particularly when there may be significant differences in outcomes among those with differing ethnicities.
Sample size
Ideally, this small introductory non-randomized follow-up study will be replicated and expanded in the future with a greater number of participants. The results of this study cannot be generalized beyond this small patient population. This was just an initial followup study of the impact of a spinal cord stimulator for pain control relative to several variables as previously noted.
Summary
These results can be used to build presurgery protocols to enhance patient satisfaction and to eliminate unneeded biases for depression, age, gender, and emotional correlates to the pain experience. It is acknowledged by many professionals in the chronic pain research field that additional empirical evidence is needed to fully develop an understanding of the correlations between pre- and post-surgical psycho-social variables lending to patient satisfaction [4].
These results can help demonstrate the critical need for a multi-disciplinary language and understanding of this complex interplay of the bio-psycho-social aspects of chronic pain management. Physicians and psychologists will then be better able to implement an appropriate prevention and intervention programs that have been proven successful with chronic pain patients as well as gain additional insight when developing one of their own. Although the psychological evaluation is indicated prior to a trial of an implant, few studies have examined the relationship between psychological assessments and successful pain relief following a trial, and this should be an expanded focus of future research.
Terri A. Lechnyr, PhD
Practical Pain Management is a monthly journal that contains tutorial articles designed to help diagnose and treat various aspects of pain. This publication is sent free of charge to medical practitioners in the United States.
Material adapted (with permission) by CFisher from:
Lechnyr, T.A., (2009). Pre-implant psychological evaluations. Practical Pain Management, 9(1).
References (continued from Part 1):
4. Hale G. Pre-surgical psychological evaluations for implantable device. 2002. http://www.iwci.org/Clues02/June2002.htm Accessed 10/19/06.
5. Lechnyr R J and Lechnyr TA. Psychological
7. Melzach R. The McGill Pain Questionnaire. Churchill Livingston. 1975.
8. Horsch S, Schulte S, and Cologne D. Epidural spinal cord stimulation (SCS) in the treatment of peripheral vascular disease. Results of a retrospective study of 258 patients. 2006. http://isvs.vascularweb. org/ISVS_Contribution_Pages/Abstracts/2006/W C06_33.html. Accessed 4/22/06.
9. Miaskowski C. The impact of age on a patient=s perception of pain and ways it can be managed. Pain Management Nurse. 2000. 1(3): 2-7.
10. Erikson E. Childhood and Society. W. W. Norton & Company. 1963.
11. Melzach R and Wall P. Textbook of Pain. Churchill Livingston. 2005.
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