Chronic Pain Management Programs: An Evaluation - Article Example

Introduction The article “The Effectiveness of a Multidisciplinary Pain Management Programme Managing Chronic Pain” written by Dysvik, E., Guttormsen Vinsnes, A., and Eikeland O.-J., published in the International Journal of Nursing Practice 10 th Issue, pages 224 to 234, is critically analyzed in terms of its quality and implications in nursing practice in relation to chronic pain management strategies. Problem Statement and Purpose This work attempts to explore the feasibility and effectiveness of multidisciplinary team management of chronic pain where collaborative care is offered. Pain is considered as a syndrome based on sensory-discriminatory, affective-motivational, and cognitive-evaluative angles of gate control theory (p. 225, par 1). Health-related quality of life (HQRL) indicating individual’s state of physical and mental health and coping, pain intensity, HQRL, and patient satisfaction could be assessed in response to a multidisciplinary pain management program in order to examine whether these are amenable to change (p. 225, par 1). In the purpose statement, the multidisciplinary pain management program is the independent variable, and the pain intensity, coping strategy, and HQRL are dependent variables, and they have been clearly identified. The population identified includes a wide range of patients who have chronic pain symptoms, and the authors identifies significance of the study in terms of the need of development of a multidisciplinary pain management program that accommodates biophysical, psychosocial, and emotional aspects of chronic pain and treatment of them in a holistic manner. The author proposes to examine further to see if there is any positive change in pain symptoms after introduction of the proposed therapy in terms of coping, HQRL, and pain symptoms so a rehabilitative care plan can be developed. Review of Literature and Theoretical Framework: The literature review guides a reader for a possible treatment program for pain and rehabilitation that would call for a multidisciplinary approach to improve coping strategies and health-related quality of life (p. 225, par 1). The mechanism of coping as a cognitive-behavioral adjustment has been reviewed in detail. The rationale is well supported by evidence from literature that HRQL is considered to be an important outcome of interventions in chronic conditions like pain. Adequate conceptual definitions have been provided as derived from the literature (p. 225, par 2). For this, the authors have cited many specific references, 37 in all, all of them are direct. For example, they have cited the basic concept of modern theory of pain as stated in Gate Control Theory proposed by Melzack and Wall. This is a direct reference from the discourse by these authors (p. 233, par 8) published in Science in 1965, Pain Mechanism, A New Theory. The operational definitions of the variables are, namely, Ways of Coping Checklist and HRQL measured by Short-Form 36 Health Survey. These are all dependent variables and would indicate the effectiveness of the therapy. Pain is measured by visual analogue scale. These variables will be expressed in numbers, and as can be seen, match the conceptual definitions except the factors of subjective variations in observer findings and appreciation of patient satisfaction (p. 227, pa 2-7), and it is unclear how the patient’s satisfaction would be measured, since with a poor response to multimodality therapy, depending on the psychological makeup of the patients, satisfaction may be more. Previous studies in this area did not incorporate the behavioural aspect in the treatment regimen, but this study incorporates training on coping strategies to improve the cognitive-behavioral aspect of pain perception. Hypothesis or Research Questions The authors hypothesize that multidisciplinary chronic pain treatment would improve coping strategies of the patients. This would be evident in improvement in pain perception and would improve HQRL. They have identified and stated appropriately that “multidisciplinary pain management programme would be effective in improving coping and HRQL, and decreasing pain intensity” and due to age, employment, pain duration, pain intensity, coping and HRQL, drop-outs would vary significantly and would be less suitable for participation. The authors also intended to assess patient satisfaction in such a model of therapy. Since an effective pain management program would lead to improvement in HRQL and coping strategies, the dependent variables, by decreasing the pain intensity, the independent variable, experienced by the patients, can be measured to examine improvement in the criteria. This may serve as a guide to an exploratory study to investigate findings to support or refute the hypothesis that multimodality pain management interventions can more effectively manage chronic pain. The form of the hypothesis is scientific, and it aims to arrive at a conclusion by establishing statistical relationships among the variables (LoBiondo-Wood, 2005), and the theoretical analysis points at possibility that the findings in the study would support the hypothesis that is testable (p. 230, par 1-4). Sample Initially, a pilot study was completed with 7 patients to validate the feasibility of the proposed multidisciplinary pain management program and those of the chosen questionnaire. Based on these evaluations, a consecutive sample of 88 patients was included in the quasi-experimental design. Exclusion criteria would apply the conceptual paradigm appropriately on the samples to avoid confounding variables. The patients were of the age group18 to 67. This represents a wide age range; therefore, if the hypothesis is valid, the findings would be applied to patients of all age groups. They have specified the criteria for inclusion and exclusion discretely. These inclusion criteria sorted out 76 patients who perfectly matched the criteria that are needed for this study, since to prove the usefulness of a multidisciplinary pain management program, one needs to find out situations of amenable chronic pain over a prolonged period that fails to respond to conventional therapy (p. 226, par 1-3). Further analysis of the sample indicates that it has proportionate representation of age, sex, marital status, singleness, educational status, and employment status. The difficulty of their situation is indicated by their leave status, disability compensation, retraining programs, and average duration of their symptoms, more than 10 years with a range of 1 to 46 years. The sample size adequate, it could represent a representative sample for any geographic location. However, further research in a multicentric form with larger sample size is indicated to accomplish generalizability (p. 227, par 1-3). Sample clearly indicates the population of interest has been included in the study with clear inclusion criteria with an adequate size. Although the patients were selected from general practitioner clinics, it was a random inclusion that increases generalizability of the research and reduces conscious bias of the researcher (LoBiondo-wood, p.291) fulfilling the criteria of a good sample. Research Design The research design has two components, and it is a quasi-experimental design since the authors manipulates the independent variable into a treatment program delivered by the supervisors. Since this constitutes of intervention to a group that receives a management program, this needs a control. The authors have agreed that it was difficult to design controls. The three important components were therapeutic dialogue, physical activity, and education. Data were routinely collected before and after the intervention. The drop-outs’ suitability were assessed by a three-point Likert scale. The experimental part of the design, VAS was used on a 100 mm horizontal line, with 1 indicating no pain and 100 indicating severe pain. It was sensitive, simple, reproducible, and universal. Coping was assessed by a 42-item version of the Ways of Coping checklist (WCCL) derived from Lazarus and Folkman’s transactional model of stress and coping with high scores in each item indicating the degree to which the coping strategy was used. The HRQL was assessed with SF-36 with norm-based comparisons available. The design flows from the theoretical framework, literature review, and the hypothesis (p. 227, par 3-6) in an effective manner and appropriate for the research purpose. There is manipulation of the independent variable and randomization appropriate for the quasi-experimental research. This is a strong portion of the study and meets almost all the criteria of a good research design. Internal and External validity Out of the outcome measures, the program is expected to improve the coping skills, but there is a risk of less use of passive coping strategies that have been associated with dysfunction, thus the internal validity can be threatened. The study is supposed to take place over a period of 8 weeks. This is over time, and there is a risk of drop-out. However, the authors fully aware of the threat, has included an assessment of drop-outs of the study to evaluate whether the drop-outs were considered suitable for the course. The researchers utilized trained supervisors of different professions for the study; this had controlled a threat to instrument validity. The loss of subjects as drop-outs is a threat to internal validity, but this was taken care of by drop-out assessment. Overall, few threats are identified, but the authors propose to counter them as much as possible. Generalization of the population will be limited due to small sample size and localized geographical area, but that may affect external validity. Overall generalizability is strong in this study because it identifies and remedies most of the threats to internal and external validity. Methods The data collection methods that were utilized were all based on questionnaire, and this can be termed as verbal rating. The coping was assessed by a 42-item instrument called WCCL derived from transactional model of stress and coping, and this instrument measures coping in terms of what a person thinks in response to the stressful encounter. The HRQL based on SF-36 is also a verbal narrative based rating system where, the patients’ statements are regarded as data. Although the data collection system is similar for all the variables, the SF-36 has provision for including physical and mental assessment into the scoring system. This would be performed by the observers; however, this study does not explain how they can be matched with the verbal rating scores narrated by the patients (p. 227-228, pa 4-10). Legal and Ethical Issues Confidentiality was ensured, and an informed written consent was obtained at inclusion. This demonstrates that the autonomy and confidentiality, the basic rights of an individual were ensured, and the patients provided informed consent. Ethical clearance was obtained from appropriate ethical committee (p. 226, pa 2). This is a very strong portion of the study since this has all the necessary characteristics of legal-ethical issues. Instruments All the instruments used explain the rationale as to why they were used. For pain intensity, they used VAS; for assessment of coping, WCCL was administered (p. 227, par 2). HRQL that had been validated by pilot study to examine the extent of error had been applied with observers recording data on an eight-point scale. The supervisors group worked in a structured protocol to make them more familiar with the philosophy of getting rid of chronic pain (p. 225, par 2). Despite no interviewer bias, patient satisfaction was included as an instrument where patients could rate the supervisors in a Likert scale. The questionnaires were designed on the basis of Likert scale with varying points (p. 226, par 2). These are very consistent with the conceptual definitions since basically the patients’ assessments about coping, pain, their physical status, general health, vitality, and social function would be assessed, and the basis of the multimodality therapy is cognitive-behavioral where the responses of the patients are modified by behavioral approaches (p. 227, par 2). The records are appropriate to the problem and hypothesis to be tested. These data were statistically analyzed to arrive at a conclusion. Reliability and Validity The 42-item WCCL and SF-36 HRQL are valid tools, and all of these were validated by the pilot study with 7 subjects at the beginning of the study (p. 227, col1-2, pa 1-6). The alpha values of all the criteria have not been provided, so internal consistency cannot be ascertained. Further statistics, however, rejects the null hypothesis and acceptance of alternate hypothesis that indicates positive relationship with disability and physical health (F (1, 68) = 4.07, P < 0.05) and problem-focused coping (F (1, 65) = 9.81, P < 0.00). These data are valid since these measure accurately what they are supposed to measure. Analysis of Data The data were tabulated in a precise manner with precise titles and headings, and they appear in the table only supplementing the text. Since the researchers knew the mean and standard deviations of the samples, the use of t-test was appropriate to the study design. Table 2 indicates the paired-t test scores pretest and posttest for WCCL, VAS, and HQRL. The areas where significant changes took place pre and post treatment, were subjected to paired-t test. The effect was estimated by corresponding d value estimation. A multifactor ANOVA was used to detect variables that predicted significant change (p. 229, col1-2, pa 1-4). Conclusions, Implications, and Recommendations The hypothesis is supported by the study; the authors declare that this replicates the positive results in similar studies. The authors discuss the problem, purpose, literature, and hypothesis in a nutshell again, and they interpret that a group approach in chronic pain patients that attends multiple factors involved in chronic pain and attended by a multispecialty team may change the effect of pain in the patients’ life if cognitive and behavioral aspects are taken care. However, there are limitations identified by the authors. The supervisors belong to different specialties, and their thought process should follow a common theoretical ground. Since the patients are referred to a specific rehabilitation program, generalization would be difficult. There was no proper control group in this study, although the authors tried to establish waiting list controls. Although the internal validity may be limited due to these reasons, this points to further research in this area with more diverse population incorporating more sensitive methods to arrive at a more specific model of multidisciplinary pain management program. Application And Utilization For Nursing Practice Considering the fact that a large number of patients suffer from chronic pain it is important develop a program for chronic pain management that would involve approaches for rehabilitation that are simple to apply and readily available. The nurses who are involved in care of such patients, should know that pain perception is a complex phenomenon that can be treated by consideration of biological, psychological, and social factors in developing a multidisciplinary rehabilitative strategy (p. 232, par 2-3). This is a valid study despite shortfalls, and in practice this points towards a future direction of pain management in the setting of rehabilitation facilities where nurses are part thereof. It would be possible to replicate the findings and implement it provided team, facilities, finances are available. Reference Dysvik E, Guttormsen Vinsnes A, Eikeland O.-J., (2004). The effectiveness of a multidisciplinary pain management programme managing chronic pain. International Journal of Nursing Practice; 10 : 224–234. Lobiondo-Wood, G., Haber, J., Cameron, C., & Singh, M. (2005). Nursing research in Canada: Methods, critical appraisal and utilization. First Canadian Edition. Toronto, ON. Elsevier Science. Read More