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Research / Research Results An investigation of cognitive deficit in chronic pain patients. University College Dublin As part of our ongoing clinical and research interest into the issue of chronic pain and its impact, individuals with chronic pain were recruited to take part in a research study of cognitive functioning. The goal of this study was to clarify the nature and extent of cognitive deficit associated with chronic pain and to identify the variables that mediate the impact of pain. Cognitive functioning, emotional distress, functional limitation, and multiple dimensions of pain experience were assessed in individuals who suffer chronic pain. Background: Chronic pain is a common but pervasive disorder that can impact on physical, psychological and social functioning. It is estimated that approximately 10% of the Irish population suffer from some kind of chronic pain disorder. Studies on chronic pain patients reveal a wide range of associated symptoms. Apart from the pain itself, sufferers can exhibit fatigue, sleep disturbance, reduced appetite, lethargy, impaired physical functioning, anxiety, frustration, depression, a reduction in social functioning, and a perceived deterioration in their mental abilities. Perceived cognitive problems include forgetfulness, difficulty finishing a task, difficulty maintaining a task, poor concentration, and losing track of one’s train of thought.
General Aim: Despite growing awareness of an association between pain and cognitive impairment, there is still a distinct shortage of information regarding this topic. Only a small number of studies have looked at cognitive deficits in chronic pain and many of these have methodological weaknesses. The primary aim of this study, therefore, was to assess the nature and severity of cognitive deficits present in an outpatient chronic pain population. Specific Aims: Cognitive functioning encapsulates mental abilities such as motor functioning, attention, concentration, information processing, short-term memory, long-term memory, and problem solving. The purpose of this investigation is to measure these functions objectively using scientifically validated tests so that comparisons can be made with other populations.
Importance of Study: The results of this project will provide a better understanding of the nature and extent of cognitive deficit in chronic pain. Identification of the nature and extent of cognitive deficit in pain has important implications for pain management programmes and the manner in which information is presented to patients. Furthermore, identification of variables that mediate the impact of pain will permit targeted intervention to minimise cognitive deficit in this group.
Research Results Chronic pain and its correlates: A preliminary report on a recent study of cognitive function - Dr. Frances Dawson and Dr. Teresa Burke School of Psychology, University College Dublin. The Pain in Europe Survey (Breivik et al, 2006) was the largest and most comprehensive study of chronic pain (CP) in adults ever undertaken in Europe. This pan-European survey was designed primarily to assess prevalence and severity of CP across 16 European countries, and incorporated a very thorough examination of treatments. This study revealed clearly that CP has a significant impact on many aspects of functioning. Despite growing awareness of an association between pain and cognitive impairment, only one item in the Pain in Europe Survey was concerned with cognitive functioning. Here, respondents had to rate their level of agreement with the statement: ‘My pain keeps me from thinking or concentrating clearly’. In Ireland, 52% of respondents agreed (somewhat or completely) with this statement, which was only slightly higher than the European average of 44%. These data indicate that a very high proportion of individuals, both in Ireland and across Europe, experience cognitive difficulties that they attribute directly to pain. Unfortunately, no attempt was made to examine the nature and extent of these problems, and no data were presented to examine the link between these problems and pain related variables such as pain type, severity, or impact on sleep. As part of our ongoing clinical and research interest into CP and its impact, we set out to clarify the nature and extent of cognitive deficit associated with CP and to identify the variables that mediate the impact of pain. Cognitive functioning, emotional distress, functional limitation, and multiple dimensions of pain experience were assessed in individuals who suffer CP. The aim of the project was to investigate the social context of chronic pain (CP) in Ireland, and to assess the extent and nature of the impact of CP in multiple areas of functioning with particular reference to attention, concentration and memory. In total, we conducted four studies. One study investigated the impact of pain in a sample of CP volunteers (n=27), using a very detailed questionnaire. This questionnaire assessed pain, sleep, social functioning and impact, and was supplemented by questionnaires of health, mood, disability and cognitive complaint. No unexpectedly, high levels of sleep disturbance, physical impairment, emotional difficulty, impairment in social functioning and increased self-reported cognitive impairment were observed. However, impact varied considerably from person to person. In terms of the cognitive reports, prospective memory complaints (forgetting what you intended to do) were more common than retrospective memory complaints (forgetting something that has already happened) and cognitive complaints were not found to relate to pain intensity or levels of depression or anxiety. In a second study, formal tests of cognitive function were administered to 19 CP volunteers in an attempt to (1) identify the nature and extent of cognitive impairment and (2) to relate self-reported changes in cognition, as reported in the questionnaire, to objective findings. Subtle problems with attention, concentration and working memory were the most common, with many people having at least one poor test score. Problems with retrospective memory were not generally observed but some individuals had some difficulty on our test of prospective memory. These results are broadly in line with self-reports, suggesting that individuals are generally quite accurate at judging their own level of ability. A third study, designed to gain a better understanding of public perceptions and knowledge of CP assessed knowledge and beliefs about pain in the general population (n=364). Here, a 50-item questionnaire was designed to assess levels of knowledge on physiological and psychological aspects of pain, treatment issues and diagnosis and intervention for pain. Participants rated their level of disagreement-agreement with true and false items on a 7-point scale. Data were then examined for levels of accuracy. Low levels of knowledge were observed on all parts of the questionnaire, particularly treatment items. Finally, we examined beliefs about how pain impacts on an individual’s life among those who do not suffer from CP. Here, we asked 100 healthy adults to think about how it might feel to experience chronic pain, and then to judge the likely impact. The results of this study also showed rather low levels of knowledge and a high level of misperception about the impact of chronic pain. We believe that the results of these studies have important implications for the management of pain and the management of individuals with pain. In relation to impact, including impact on cognition, the results reveal clear evidence that pain has a significant impact on many areas of functioning. To qualify this, however, not everyone was impacted in the same way or to the same extent. The strongest message from our findings is that CP is a variable experience. This has implications for the treatment and management of ongoing pain by professionals, and for the education of new professionals in the area. Individuals with chronic pain should not be treated as a homogenous group. Although pain is a common factor, the etiology of the pain, the level of impact on the individual, and the areas that are impacted is highly variable. Because of this variability, an individualised approach to pain management is advocated. We also recommend increased education about pain and its impact, both for healthcare providers and the public. Based on the low levels of knowledge on certain pain issues in the general population, care-providers at a primary level have an increased responsibility to provide accurate and unbiased information to those in pain. There is also a clear need to educate those fortunate enough not to suffer CP so that myths and misperceptions about CP can be eliminated. A program of education might follow from some of the findings of the present study. Such a programme might deal with common misperceptions about pain, the importance of accurate knowledge of treatment issues and the differential impact of chronic pain on individuals. To this end, we will now seek to publish our detailed findings in both medical and healthcare journals so that a process of education can begin. Breivik et al, (2006) Survey of chronic pain in Europe: Prevalence, impact on daily life and treatment. European Journal of Pain, 10: 287-333
Acknowledgements: The researchers would like to extend a very warm thank you to all who participated in this study. Your time, effort and wisdom is very much appreciated. We also want to thank the ICPA for facilitating this research. Dr. Teresa Burke Informed Consent and Confidentiality: Only individuals who gave informed consent were recruited to the study, and no one was tested until full ethical approval for the study had been obtained from UCD. All data was coded by ID number only, and all data analyses was carried out in such a way as to ensure that no individual could be identified in any resulting publications or presentations.
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