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The Journal of Pain, Vol 7, No 6 (June), 2006: pp 417-427Available online at www.sciencedirect.com

djustment to Chronic Pain in Back Pain Patients Classifiedccording to the Motivational Stages of Chronic Painanagement

tefanie Zenker,* Michael Petraschka,* Michael Schenk,* Anett Reißhauer,†

anja Newie,‡ Kai Hermanns,‡ Klaus-Dieter Wernecke,§ and Claudia Spies*Department of Anesthesiology and Intensive Care Medicine,Department of Physical Medicine,Outpatient Clinics in Berlin, andDepartment of Medical Biometrics, Charité Campus Mitte, University Hospital Charité, Charité-Universityedicine Berlin, Germany.

Abstract: According to Prochaska’s transtheoretical model, the Freiburg Questionnaire stages ofchronic pain management (FQ-STAPM) were used to classify chronic back patients into 4 distinctmotivational stages. The FQ-STAMP was completed by 163 chronic back pain patients. Pain chronicitywas measured by the Mainz Pain Staging System; pain intensity was measured by the numeric ratingscale. Healthcare system expenses were considered as number of consulted physicians, number ofstays in hospital, and number of rehabilitation programs. As psychometric tests, the lower paindisability index (PDI), the Hospital Anxiety and Depression Scale (HADS), and a quality of life score(SF36) were used. Patients were in the following motivational stages: precontemplation in 30%,preparation in 19%, action in 30%, maintenance in 21%. The intensity of pain in the precontempla-tion stage patients was significantly higher compared to patients in the maintenance stage. A lowerpain chronicity was related to a significantly higher motivation. Moreover, there was a significantincrease in healthcare system expenses by the lesser motivated patients. Patients in the maintenancestage used significantly less opioids than patients in the precontemplation stage. The higher moti-vated patients had a significantly lower PDI, a significantly lower HADS, and a significantly higherquality of life compared to less motivated patients.Perspective: The study indicates that the FQ-STAPM might be a useful tool to classify chronic backpain patients and to work out a strategy together with the patient relevant to the outcome of painmanagement among chronic back pain patients.

© 2006 by the American Pain Society
Key words: Chronic back pain, German Freiburg Questionnaire (FQ-STAPM), motivation.
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ack pain is one of the most common health prob-lems for which people consult their physician.13 Theepidemic-like rise in chronic low back pain in West-

rn industrial nations is less an expression of a medical

eceived September 7, 2005; Revised December 30, 2005; Accepted Jan-ary 18, 2006.he work was supported by the German Health Ministry BMG 217-43794-/5 and the German Research Society (DFG-PE 892/2-1).ddress reprint requests to: Claudia Spies, MD, Professor of Anesthesiol-gy, Department of Anesthesiology and Intensive Care Medicine,harité-University Medicine Berlin, Charité Campus Mitte, Schu-annstrasse 20/21, 10098 Berlin, Germany. E-mail: claudia.spies@

harite.de.526-5900/$32.002006 by the American Pain Society

poi:10.1016/j.jpain.2006.01.446

han a psychosocial phenomenon.4 Various biologic andsychosocial risk factors contribute to the continuinghronicity of pain, resulting in enormous direct and indirectosts totaling an estimated 45 billion USD annually.34

hronic pain is an individually variable experience, incorpo-ating physical, psychological, and social dimensions. Theeverity of chronic pain demonstrated significant correla-ion with psychological impairment, depression, disability,nd time off work.27,7,11

More recent approaches of multimodal treatment,ncluding medical, psychological, and cognitive-be-avioral components such as a self-management ap-roach, have shown a significant and lasting effect in
atients with a high incidence of workplace incapaci-
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418 Chronic Back Pain Patients: Assessment With the FQ-STAMP

ation and sick leave.4,12,32 However, as the multimo-al treatment is an active treatment program demand-

ng patient involvement, dropout rates between 5%nd 70% are reported in the literature,32 which re-uces therapeutic effectiveness and cost effectiveness.There has been growing interest in the chronic painatient’s motivation and self-management train-

ng.21,20,12,18 The transtheoretical model (TTM) of behav-oral change proposes that individuals may be at differ-nt stages of being prepared for behavior change androvides a useful way of understanding the concept oftages of change.28 The TTM might help to explain dif-erences in a person’s success during treatment for aange of psychological and physical health problems.18

erns and colleagues20applied the transtheoreticalodel and the stages of change concept to chronic painatients and developed the Pain Stages of Change Ques-ionnaire (PSOCQ). The PSOCQ is composed of 4 reliablecales that are consistent with the stages (precontempla-ion, contemplation, action, maintenance) of the trans-heoretical model. Preliminary support was provided forhe predictive validity and utility of the PSOCQ and forhe relevance of a stages of change model in addressingssues related to the self-management of chronicain.1,19 Keefe and colleagues16 identified the stages ofhange in an arthritis population having persistent painsing a modified version of the URICA (University ofhode Island Change Assessment). This instrument isell suited for complex problem behavior, because it

ields scores for each stage of change for each individualnstead of classifying individuals into a single stage. It isased on Prochaska’s transtheoretical model of change.According to Prochaska’s transtheoretical model, Mau-

ischat and colleagues22 validated a questionnaire of aerman version of the PSOCQ, the FQ-STAPM assessing

tages of chronic pain management, in a mixed popula-ion of chronic pain patients. Item- and factor analysisesulted in 4 stages: precontemplation, preparation, ac-ion, and maintenance. No separate stage terminationas identified. The results generally replicated the find-

ngs of Kerns and Habib18and also improved the discrim-nation between the action and maintenance stages.

Taken together, we hypothesize that chronic back painatients who report a commitment to a self-manage-ent approach (ie, patients on the action or mainte-ance stage) endorse less pain chronicity, fewer healthare expenditures, less psychological symptom severity,nd less pain-related disability.The goals of the present study were: (1) to classify

hronic back pain patients into different motivationaltages using the FQ-STAMP; (2) to determine whetherhere is a correlation between the stages of the FQ-TAMP and the stages of chronicity according to theainz Pain Staging System; (3) to determine whether

he stages of chronic pain management differ in termsf sociodemographic, pain-related, and psychometricariables; medicine-taking; and healthcare system ex-
enses.
ethods

ecruitment and ParticipantharacteristicsAfter ethical committee (Charité Campus Mitte: 1514/

001, amendment 02.12.2003) and written informed con-ent, 206 patients with chronic back pain were evaluated.Chronic back pain was defined as pain that persists

onger than 12 weeks. None of the patients had receivedmultimodal pain management including pain therapy,sychotherapy, and physiotherapy. All participants wereolunteers who were recruited from the pain clinic of theepartment of Anesthesiology and Intensive Care Med-

cine, Charité Campus Mitte, the Department of Physicaledicine, Charité Campus Mitte, and 2 outpatient pain

linics in Berlin (Drs. Newie and Hermanns) over a periodrom 2002 to 2004. Of the 206 patients, 168 (81%) pa-ients returned their questionnaires and 163 patientslled in the questionnaire completely and were included

n this observational study. Additionally, the participantsere subjected to personal interviews.The pain therapist confirmed that the patients had

hronic back pain.

uestionnaires

erman Questionnaire FQ-STAMP (Freiburguestionnaire-Stages of Chronic Painanagement)Maurischat et al21 classified chronic pain patients in-

luding back pain patients, into 4 different motivationaltages: precontemplation, preparation, action, andaintenance. The FQ-STAMP contains 17 items, 5 for the

recontemplation, 4 for the preparation, 4 for the ac-ion, and 4 for the maintenance.Item composition of the Freiburg Questionnaire–

tages of Chronic Pain Management (FQ-STAPM) is asollows (translation of the German FF-STABS: Freiburgerragebogen – Stadien der Bewältigung chronischerchmerzen):

1. I’ve been working to learn skills in order to handlemy pain, for more than one month.

2. I suspect that I have long-term pain problems, butthere is nothing that I can really change.

3. Even if my pain didn’t go away, I’d be willing tochange the way I’m dealing with it.

4. When my pain occurs, I stay calm and go about myusual everyday life.

5. A few weeks ago I started to develop strategies thatare helping me to be in better control of my pain.

6. My pain is exclusively a medical problem, thus a mat-ter for doctors to deal with.

7. Time has come for me to think seriously about adifferent approach towards my pain.

8. I’m 100% in control of my pain and its effect on mylife.

9. For several months now, I have been taking sugges-tions from others and acting on them, regarding
how I can better live with my pain.

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419ORIGINAL REPORT/Zenker et al

0. In spite of what the doctors say, I’m convinced thatthere must be a surgery or medication that wouldhelp to get rid of my pain.

1. Within the next months I’ll start to control my pain,before it ruins my life.

2. For several months now my pain has hardly influ-enced me.

3. For several weeks I’ve been learning different strat-egies that influence my pain.

4. The best solution for me is to find a physician, whocan determine how I can get rid of my pain entirely.

5. In the near future I’m seriously intending to dealwith my pain in a different way.

6. I’ve known for a long time, that I can control mypain.

7. I’m asking myself: “Why can’t simply somebody dosomething, so that my pain will go away?”

Precontemplation � (2 � 6 � 10 � 14 � 17)Preparation � (3 � 7 � 11 � 15)Action � (1 � 5 � 9 � 13)Maintenance � (4 � 8 � 12 � 16)Participants rated the degree to which they agreed orisagreed with these items using a 5-point scale (1 �trongly disagree to 5 � strongly agree). Raw scores wereransformed to a mean raw score for each stage. Patientsere assigned to the following groups by using the FQ-

TAMP.The precontemplation stage represented patient per-

eption of chronic pain as a purely medical problem thathould receive some form of treatment, ie, the patient’sotivation is low.Preparation represented the beginning realization

hat coping skills might be of value in management ofain, but without any definitive commitment.The action stage represented a current commitment to

cquire or master pain management skills.The maintenance stage represented perseverance in

he application and continuing use of these skills, ie, theatient’s motivation is high.To assign the participants to the stages, the highestean raw score for each stage of a patient was deter-ined. In case of 2 equal mean raw scores, the mean raw

core of the higher stage of motivation determined thetage of chronic pain management. In case of more thanequal mean raw scores, a classification into a specific

tage was not possible.22 A classification of 155 patientsut of 163 into 4 distinct motivational stages was possi-le. Therefore 8 patients who had 3 equal mean rawcores could not be classified and were excluded fromhe study.

erman Mainz Pain Staging System (MPSS)The Mainz Pain Staging System is an interview-admin-

stered, multi-dimensional measure of chronic pain se-erity 10. The system suggests grading chronic pain inerms of 4 axes: time (persistence), spreading of pain site,edication use, and health care utilization. The whole

cale consists of 10 items. The resulting score is used to a

lassify the pain problem to three stages of chronicity (I�ild, II� moderate, III� severe chronic pain).7,27

erman Pain Questionnaire (DSF)The German pain questionnaire (DSF) has been devel-ped and validated by the Taskforce on “Standardiza-ion and Economy in Pain Management” of the Germanhapter of the International Association for the Study ofain (DGSS). The concept of the DSF is based on a biomedical) – psycho – social pain model. The modular ap-roach to pain assessment consists of: sociodemographicariables (eg, age, gender, body mass index, marital sta-us, educational level and occupation); social factors (eg,etirement status, compensation and/or litigation status,isability for work); pain-related variables (eg, pain sites,emporal characteristics, duration, intensity); pain-asso-iated symptoms (eg, social stress, sleep disorder, addi-ional pain regions); previous pain treatment procedureseg, number of consulted physicians, number of appoint-ents, number of consulted specialization units, number

f stays in hospital, and number of rehabilitation pro-rams; case history); relieving and intensifying factors;omorbid conditions; pain-related disability (Pain Dis-bility Index); affective and sensory qualities of painPain Perception Scale); health-related quality of life (SF-6).23

The Pain Disability Index (PDI) is a 7-item self-reportnstrument based on a 10-point scale that assesses per-eption of the specific impact of pain on disability thatay preclude normal or desired performance of a wide

ange of functions, such as family and social activities,ex, work, life-support (sleeping, breathing, eating), andaily living activities.5

The Pain Perception Scale measures 2 dimensions ofubjectively felt pain, the affective characterization (14tems) as well as modes of sensory characterization ofain (10 items) that allows multifaceted and standard-

zed quantification of pain experience. Scale analysesemonstrate a below average, average, above average,nd far above average of pain perception.9

The SF (short form)-36 is one of the most widely usedealth-related quality of life (HRQOL) instruments andas demonstrated high levels of reliability and validity iniverse patient populations. It has 36 items that measuremulti-item health concepts (ie, physical functioning,

ole-physical, bodily pain, general health, vitality, socialunctioning, role emotional, and mental health) refer to4-week period. This instrument was developed to ad-ress the health-related concepts that are most influ-nced by disease states and their related treatments. TheF-36 can be scored to yield 2 orthogonal factor-basedomponent summary scores for mental and physicalealth. The mental (MCS-36) and physical componentummary (PCS-36) scores were derived from the 8 scalesf the SF-36. The MCS-36 and PCS-36 are scored using aethod that transforms the scores to a standardized

cale (T-scores) with a norm of 50. Sample mean MCS-36nd PCS-36 scores above or below 50 can be interpreted
s having better or worse HRQOL 30.

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ospital Anxiety and Depression ScaleHADS)The Hospital Anxiety and Depression Scale (HADS) is an

asy-to-use self-reporting questionnaire to assess levelsf anxiety and depression. The HADS comprises state-ents that the patients rate based on their experiencever the past week. The 14 statements are relevant toither generalized anxiety (7 statements) or “depres-ion” (7 statements). Even-numbered questions relate toepression and odd-numbered questions relate to anxi-ty. Each question has 4 possible responses. Responsesre scored on a scale from 3 to 0. The maximum score isherefore 21 for depression and 21 for anxiety. A score of1 or higher indicates the probable presence of theood disorder, with a score of 8 to 10 being just sugges-

ive of the presence of the respective state. The 2 sub-cales, anxiety and depression, have been found to bendependent measures. In its current form the HADS isow divided into 4 ranges: normal (0–7), mild (8–10),oderate (11–15), and severe (16–21). Validation studies

or the Hospital Anxiety and Depression Scale have beenerformed in various somatically compromised popula-ions.33

llness and Health Locus of Control ScaleSchmitt et al29 distinguish 3 control beliefs: the pa-

ients’ behavior is regarded as most important for im-rovement during illness (internal locus of control); thewn state of health is seen as dependent from otherersons, who are engaged in the therapeutic processpowerful others locus of control), and the state ofealth is regarded as dependent from fate or chance

nfluences (chance locus of control). Each dimension con-ists of 7 items. The questionnaire is in use for health andllness concepts (eg, patient compliance, treatment).

tatistical AnalysisAll data were analyzed by using the statistics program

PSS (statistical package for the social sciences) PC-ver-ion 10.0.The data were presented descriptively. All characteris-

ics for ordinal and metrically not normally distributedariables were indicated as a median and a variationange; absolute and relative frequencies were used for

able 1. Distribution of Chronic Back Pain Patiehronicity (MPSS) on the Four Stages of ChronMPSS PRECONTEMPLATION1 PREPARATION2

I n � 19 3 (6.4%) –II n � 34 10 (21.3%) 10 (34.5%)III n � 102 34 (72.3%) 19 (65.5%)

bbreviations: MPSS, German Mainz Pain Staging System; FQ-STAMP, Freiburgy post hoc analysis Mann-Whitney U test (pz).

ominal variables. d

Data were exploratively analyzed and statistical mea-ures such as median and interquartile range for ordinalariables as well as absolute and relative frequencies forominal variables are presented. Because of the limitedample sizes and/or nonnormally distributed (continu-us) variables, respectively, nonparametric tests weresed. In the comparison of more than two (independent)roups of patients, the Kruskall-Walis test was applied.ost hoc comparisons of two groups each were carriedut with the Mann-Whitney U test for independent sam-les. Nominal variables were analyzed with the help ofhe (exact) �2 test. Significance was assessed at the P �05 level. The results have to be understood as explor-tive ones. Therefore, no multiple adjustments were car-ied out. The analyses were accomplished by using thetatistics program SPSS (Version 11). The differences re-arding the frequency distribution of the nominal vari-bles were checked for significant results with the �2 testr at a too small case number with an exact test afteronte Carlo. P � .05 was regarded as significant.

esults

tages of Chronic Pain ManagementFQ-STAPM)One hundred fifty-five chronic back pain patients could

e classified in 4 distinct motivational stages. 47 patients30.3%) were in the stage of precontemplation, 29 patients18.7%) were in the stage of preparation, 47 patients30.3%) were in the stage of action, and 32 patients20.6%) were in the stage of maintenance. The highest

ean raw score differed significantly from the other 3tages by using the Kruskall-Walis test (data not shown).

omparison of the Stages of Chronic Painanagement: SociodemographicariablesThe average age was 54 (19–90) years, most participantsere female (67%), and on average patients had suffered

rom pain for 7 (0.5–50) years. 28% of the participants re-orted a high school education or better. 76% of the pa-ients were married or living with a partner, whereas 23%ere living single. A series of chi-square analyses was con-

(%) Classified to the Three Stages ofain Management (FQ-STAMP)

TION3 MAINTENANCE4 P pz

.4%) 13 (40.6%) �.001 p1,2 0.6702.8%) 8 (25.0%) p1,3 0.3680.8%) 11 (34.4%) p1,4�0.001

p2,3 0.204p2,4�0.001p3,4�0.001

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nces among the 4 motivational stages on age, gender,ody mass index, marital status, educational level, and pro-ession. There were no significant differences among theifferent stages (data not shown).

elationship Between the Stages of theQ-STAMP and the Stages of Chronicityccording to the MPSSTable 1 shows the distribution of 155 chronic back painatients, classified in the 3 stages of chronicity (MPSS I,PSS II, MPSS III), on the 4 stages of chronic pain man-

gement (FQ-STAMP). Patients of a lower level of chro-icity according to the MPSS were classified significantlyore frequently in the maintenance stage than in the

recontemplation stage (p1/4 � 0.001), the preparationtage (p2/4 � 0.001), and the action stage (p3/4 � 0.001).he higher the level of chronicity, the significantly loweras the adoption of a self-management approach to

hronic pain.

omparison of the Stages of Chronic Painanagement: Compensation Variables

Patients were receiving partial (16%) and full disabilityompensation (22%) related to their pain, 30% were re-ired, 8.6% were unemployed, and 33.7% were em-loyed. The results of the chi-square analyses indicatedhat there were significant stage differences in compen-ation variables (P � .009). Using the post hoc analysisann-Whitney U, patients in the preparation stage

ought significantly more disability compensation, ap-lied significantly more for disability compensation, andeceived significantly more full disability compensationr old-age pension than patients in the precontempla-ion stage (Table 2; p1/2 � 0.007).

omparison of the Stages of Chronic Painanagement: Pain-Related Variables

One hundred sixteen (75%) patients suffered from lowack pain, 6 (3%) patients suffered from thoracic backain, and 33 (22%) patients suffered from cervical backain. There were no significant differences between thestages and the 3 different locations of back pain (dataot shown).Fig 1 shows the average and maximum intensity of

able 2. Distribution of Chronic Back Pain Patiehe Four Stages of Chronic Pain Management

COMPENSATION VARIABLES PRECONTEMPLATION1 P

o seeking disability compensation 6 (12.8%) 1eeking disability compensation 4 (8.5%)pplication for disability compensation 7 (14.9%)ull disability compensation 10 (21.3%)ension 20 (42.5%)

bbreviation: FQ-STAMP, Freiburg Questionnaire-Stages of Chronic Pain Manapz).

ain by using the numeric rating scale (NRS) in chronic *

ack pain patients grouped into the 4 stages of chronicain management. The chi-square analysis indicated aignificant correlation between the stages and the painntensity (P � .005; P � .005). Using the post hoc analysis

ann-Whitney U test, the average and maximum inten-ity of pain in the precontemplation stage was signifi-antly higher than in the maintenance stage (p1/4 �.002; p1/4 � 0.002) and the preparation stage (p1/2 �.002; p1/2 � 0.017). The maximum intensity of pain inhe precontemplation stage was significantly higherhan in the action stage (p1/3 � 0.015). There were noignificant differences between the stages and pain du-ation (P � .403) respectively present pain intensity, us-ng chi-square analysis. Patients in the precontempla-ion, preparation, and action stages suffered more fromersistent pain compared to the patients in the mainte-ance stage. There were no significant differences be-ween the stages of chronic pain management and socialtress, sleep disorder, and additional pain regions. Pa-ients in the maintenance stage, the action stage, thereparation stage could imagine influencing the painignificantly more than patients in the precontemplationtage (P � .006; p1/2 � 0.02; p1/3 � 0.003; p1/4 � 0.038ata not shown).

(%) Classified to Compensation Variables on-STAMP)ATION2 ACTION3 MAINTENANCE4 P pz

.4%) 8 (17.0%) 14 (43.8%) .009 p1,2 0.0079%) 5 (10.6%) 1 (3.1%) p1,3 0.076.3%) 10 (21.3%) – p1,4 0.064.0%) 14 (29.8%) 7 (21.9%) p2,3 0.171.8%) 10 (21.3%) 10 (31.3%) p2,4 0.558

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igure 1. The average and maximum intensity of pain of 155hronic back pain patients is documented with a numeric ratingcale (NRS ranging from 0 to 10; 0 � no pain, 10 � most severeain). Data represent medians � SEM grouped into the 4 stagesf chronic pain management (FQ-STAMP), using chi-squarenalysis followed by post hoc analysis Mann-Whitney U test (p);

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omparison of the Stages of Chronic Painanagement: Healthcare System

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There were significant differences among the 4tages of chronic pain management in the number ofonsulted physicians (P � .004), of appointments (P �

igure 2. (A) The number of consulted physicians, (B) the numbeD) the number of stays in hospital, and (E) the number of rehabhe 4 stages of chronic pain management (FQ-STAMP). Data reprann-Whitney U test (p); *P � .05.

002), of consulted specialization units (P � .008), of l

tays in hospital (P � .036), and of rehabilitation pro-rams (P � .00). Patients in the maintenance stageonsulted significantly fewer physicians compared toatients in the precontemplation stage (p1/4 � 0.015),

n the preparation stage (p2/4 � 0.001), and in thection stage (p3/4 � 0.005; Fig 2A). Patients in theaintenance stage visited the physicians significantly

appointments, (C) the number of consulted specialization units,ion programs of 155 chronic back pain patients are classified int medians � SEM, using �2 analysis followed by post hoc analysis

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tage (p1/4 � 0.001), in the preparation stage (p2/4 �

.018), and in the action stage (p3/4 � 0.008; Fig 2B).atients in the maintenance stage consulted signifi-antly fewer different specialists than patients in therecontemplation (p1/4 � 0.005), the preparation (p2/4

0.006), and action (p3/4 � 0.003; Fig 2C) stages. Pa-ients in the maintenance stage stayed significantlyess frequently in the hospital compared to patients inhe action stage (p3/4 � 0.006, Fig 2D). Patients in theaintenance stage joined significantly more rehabili-

ation programs than patients in the other stages (p1/4

0.007, p2/4 � 0.007, p3/4 � 0.001; Fig 2E).There were no significant differences between the 4

tages in conventional medical treatment, physiother-py, psychotherapy, and alternative medicine treatmentTable 3).

ain Treatment

omparison of the Stages of Chronic Painanagement: The Use of Peripheralnalgesics, Tricyclic Antidepressants,ntiepileptic Drugs, Muscle Relaxants, andpioidsAnalyses of chi-square tests were performed to iden-

ify differences between the 4 stages of chronic painanagement in the use of peripheral analgesics (nonste-

oidal anti-inflammatory agents, Cox-2-specific-inhibi-or, metamizol, acetaminophen), tricyclic antidepres-ants, antiepileptic drugs, and muscle relaxants. Noignificant differences were found. However, there wassignificant difference in the use of opioids. Patients in

he maintenance stage used significantly less opioidshan patients in the precontemplation stage (p1/4 �

.002) (Fig 3). There was no significant difference be-ween the 4 stages of chronic pain management and the

able 3. Distribution of Chronic Back Pain Patiereatment, Physiotherapy, Psychotherapy andtages of Chronic Pain Management (FQ-STAM

VARIABLE PRECONTEMPLATION1

onventional medicaltreatment

Yes 46 (97.9%)No 1 (2.1%)

hysiotherapyYes 44 (93.6%)No 3 (6.4%)

sychotherapyYes 12 (25.5%)No 35 (74.5%)

lternative medicine treatmentYes 18 (38.3%)No 29 (61.7%)

bbreviation: FQ-STAMP, Freiburg Questionnaire-Stages of Chronic Pain Mana

requency of opioid withdrawals (data not shown). b

sychometric VariablesPatients in the maintenance stage had a significantly

ower level of disability related to pain than patients inhe precontemplation, preparation, and action stagesp1/4�0.001; p2/4 � 0.01; p3/4 � 0.006, Table 4).The Hospital Anxiety and Depression Scale (HADS) de-

ected the presence of depression in 48% of the patientsnd detected the presence of anxiety in 36% of the pa-ients. There were significant differences between the 4tages of chronic pain management in depression andnxiety (P � .001). Patients in the maintenance stage hadsignificantly lower level of anxiety and depression com-ared to patients in the precontemplation (p1/4 � 0.001;

1/4 � 0.001), preparation (p2/4 � 0.009; p2/4 � 0.003),nd action (p3/4 � 0.002; p3/4 � 0.001) stages (Table 4).The health-related quality (HRQOL) of life was de-

reased on average in all patients classified in the 4tages of chronic pain management. Sample meanCS-36 and PCS-36 scores were below 50. There were

ignificant differences among the 4 stages in HRQOL

(%) Classified to Orthodox Medicinernative Medicine Treatment on the Four

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00.0%) 45 (95.7%) 28 (87.5%)2 (4.3%) 4 (12.5%)

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.6154.1%) 17 (36.2%) 10 (31.3%)5.9%) 30 (63.8%) 22 (68.7%)

.5464.1%) 18 (38.3%) 10 (31.3%)5.9%) 29 (61.7%) 22 (68.7%)

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igure 3. Data represent the distribution (%) of 155 chronicack pain patients using opioids on the 4 stages of chronic painanagement (FQ-STAMP); using chi-square analysis followed

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ased on mental and physical components (P � .001; P �.025). Patients in the maintenance stage had a signifi-antly higher quality of life according to physical healthompared to patients in the precontemplation, prepara-ion, and action stages (p1/4 � 0.001, p2/4 � 0.002, p3/4 �.008). Patients in the maintenance stage had a signifi-antly higher quality of life according to mental healthompared to patients in the precontemplation stagep1/4 � 0.012), the preparation stage (p2/4 � 0.006) andhe action stage (p3/4 � 0.022; Table 4).Using the chi-square-test and the post hoc Mann-Whit-

ey U test, we could reveal that patients in the mainte-ance stage significantly regarded their own behavior as

able 4. Distribution of Chronic Back Pain Patieour Stages of Chronic Pain Management (FQ-PSYCHOMETRIC TESTS PRECONTEMPLATION1 PREPARATION2

ain disability index* 46% (29–54%) 36% (28–42%)

ADS†

Normal 6 (12.8%) 6 (20.7%)Mild depression 11 (23.4%) 7 (24.1%)Moderate, severe

depression30 (63.8%) 16 (55.2%)

ADS†

Normal 9 (19.1%) 5 (17.3%)Mild anxiety 17 (36.2%) 11 (37.9%)Moderate, severe

anxiety21 (44.7%) 13 (44.8%)

RQOL‡

PCS 25.3 (18.8–29.6) 27.4 (22.6–32.2)

RQOL‡

MCS 42.0 (32.0–51.6) 38.8 (34.4–50.1)

HLCS§

Internal locus ofcontrol

1 (2.8%) 1 (5.3%)

powerful otherslocus of control

21 (58.3%) 13 (68.4%)

chance locus ofcontrol

14 (38.9%) 4 (26.3%)

Data represent medians � SEM (average impact of pain on disability: 25–75%mpact of pain on disability: �90%).

Data represent % of chronic back pain patients. HADS, Hospital Anxiety and D

Data represent medians (T-score) � SEM. HRQOL, health related quality; MCS

Data represent % of chronic back pain patients. IHLCS, Illness and health locuanagement; using �2 analysis (P) followed by post hoc analysis Mann-Whitne

ost important for their improvement during illness com- S

ared to patients in the precontemplation stage. Patientsn the stage of precontemplation and action stages signif-cantly regarded their state of health as dependent on fater chance compared to the patients in the maintenancetage (P � .001, p1/4 � 0.003, p3/4 � 0.043; Table 4).

iscussionThe results from the present study show that most pa-

ients could be classified into 1 specific motivationaltage of a German version of the transtheoretical model,he Freiburg Questionnaire–Stages of Chronic Pain Man-gement among chronic back pain patients. The FQ-

(%) Classified to Psychometric Tests on theMP)

ACTION3 MAINTENANCE4 P pz

% (25–50%) 18% (5–36%) �.001 p1,2 0.019p1,3 0.059

p1,4 �0.001p2,3 0.531p2,4 0.010p3,4 0.006

.001 p1,2 0.3377 (15.9%) 13 (41.9%) p1,3 0.501

11 (31.8%) 12 (38.7%)] p1,4 �0.00123 (52.3%) 6 (19.4%) p2,3 0.748

p2,4 0.009p3,4 0.002

�.001 p1,2 0.8719 (20.5%) 18 (58.1%) p1,3 0.789

17 (38.6%) 9 (29.0%) p1,4 �0.00118 (40.9%) 4 (12.9%) p2,3 0.697

p2,4 0.003p3,4 0.001

.001 p1,2 0.2679.2 (23.9–35.3) 39.6 (28.5–47.6) p1,3 0.148

p1,4 �0.001p2,3 0.723p2,4 0.002p3,4 0.008

.025 p1,2 0.7623.2 (37.4–53.6) 50.8 (43.2–58.5) p1,3 0.522

p1,4 0.012p2,3 0.435p2,4 0.006p3,4 0.022

�.001 p1,2 0.3282 (6.7%) 10 (41.7%) p1,3 0.043

p1,4 0.00323 (76.6%) 9 (37.5%) p2,3 0.440

p2,4 0.0515 (16.7%) 5 (20.8%) p2,4 0.051

ve average impact of pain on disability: 75–90% and far above average

sion Scale.

mental and physical component summary scores.

ntrol scale. FQ-STAMP, Freiburg Questionnaire-Stages of Chronic Painst (pz).

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39

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TAMP describes the willingness of behavior change for

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ain management as a process characterized by 4 stages:recontemplation, preparation, action, and mainte-ance. According to the transtheoretical model, theseotivational stages were identified in a sample of arthri-

is patients,16 in a sample of fibromyalgic patients,6 andn a heterogeneous sample of chronic pain patients asell.21 Keller and colleagues17 supported the applicabil-

ty of the transtheoretical model for postural behaviorontributing to the prevention of back pain and backain chronicity. With the application of the FQ-STAMP tohe readiness of treatment among chronic back pain pa-ients, a treatment might be assigned according to theatient’s motivational preparedness in order to improveutcomes of pain management.21 Despite the demon-trated efficacy of cognitive-behavioral therapy as a partf the multimodal treatment of chronic back pain pa-ients, it is apparent that patients may vary in the degreeo which they are ready to adopt a self-managementpproach to pain.32,4 Patients who are resistant to self-anagement approaches are less likely to be successful

n a multimodal treatment.20 Therefore, growing inter-st is in the patient’s motivation and self-managementtage.21

In the present sample of chronic back pain patients,0% of the patients were in the precontemplation stage,9% in the preparation stage, 30% in the action stage,nd 21% in the maintenance stage. Habib, Morrissey,nd Helmes12 showed a similar assessment to the stagesmong chronic pain patients, mainly back pain patients.aurischat and colleagues21 classified chronic pain pa-

ients (80% back pain patients) into 13% precontempla-ion stage, 50% preparation stage, 22% action stage,nd 12% maintenance stage. This result demonstrateshat back patients are a heterogeneous group and chal-enges its treatment.

Additionally, the data from the present study providereliminary support for the utility and relevance of atages-of-change model in addressing pain chronicity,ain intensity, healthcare system expenses, medicine tak-

ng, and psychometric variables related to the self-man-gement of chronic pain.The data demonstrate that there is a significant rela-

ionship between motivation and pain chronicity. Pa-ients with a lower level of pain chronicity were classifiedignificantly more frequently in the maintenance stagehan in a stage of less motivated patients. The severity ofhronic pain depended on pain persistence, spreading ofain site, medication use, and health care utilization.7

his is a novel finding in chronic back pain patients. He-er and colleagues14 demonstrated that the state ofhronification of psychomatic pain patients determinedotivation for therapy. Predicting successful treatment,

fingsten and colleagues25 showed that individual per-eptions and experiences were more important thanhysical capabilities in back pain patients.Surprisingly, our data show that patients in stage III of

he pain chronicity are found equally among the lessernd higher motivated patients. Pfingsten and col-eagues27 found no difference in effectiveness of treat-

ent between patients who were graded as severe pain s

atients (stage III) and the other stages. In litera-ure32,4,20 motivation is considered to be important foruccessful multimodal treatment in chronic pain patient.ence, the FQ-STAMP might be a useful tool to identifyatients with severe chronic pain for successful treat-ent.Our data didn’t provide any significant differences

mong the motivational stages on age, gender, bodyass index, marital status, educational level, and profes-

ion. According to literature, these results are controver-ial. For example, Kerns and Rosenberg19 showed signif-cantly more pain patients with a lower educational leveln the precontemplation stage and showed significantifferences on gender as well. Habib, Morrissey, andelmes12 did not confirm these results. As the samples ofatients are too heterogeneous and too small, furtheresearch should focus on a potential association of theotivational stages with sociodemographic factors.Consistent with previous work,21,19 we show that the

verage and maximum intensity of pain of less moti-ated patients is significantly higher than of patients inhe maintenance stage. Patients in the precontempla-ion, preparation, and action stages suffer more fromersistent pain compared to the patients in the mainte-ance stage. These results suggest that the less moti-ated patients might lack pain-coping strategies com-ared to the patients in the maintenance stage.21 Pain

ntensity might be a sign for the high pressure underly-ng the patients. According to the transtheoretical

odel, patients in the action stage could imagine thathey could influence the pain significantly more thanould patients in the precontemplation stage. Patients inhe action stage appear to be working on pain-copingkills in contrast to lesser-motivated patients. Interest-ngly, we couldn’t show a significant difference betweenhe action stage and the precontemplation/preparationtage. All participants of our study were recruited fromain clinics. Maurischat and colleagues22 recruitedhronic pain patients via different facilities (eg, orthope-ic clinic, rehabilition units, pain clinic). Therefore, theomposition of the participants might be not compara-le between the 2 studies.According to Maurischat and colleagues,21 there was a

ignificant increase in healthcare system expenses byesser-motivated patients. These patients consulted sig-ificantly more physicians, stayed more frequently inospital, and joined more rehabilitation programs thanatients in the other stages. Patients in the lower stagesepresent their perception of chronic pain as a purelyedical problem that should receive some form of treat-ent. The own situation is seen as mainly dependent on

ealth care utilization.15,31 These results are consistentith our data revealed by the classification of the pa-

ients to the pain chronicity stages.Maurischat and colleagues21demonstrated that pa-

ients in the precontemplation stage took medicineore frequently than patients in the maintenance stage.ur data is consistent with this finding. Moreover, we

ould show that patients in the maintenance stage used
ignificantly less opioids than patients in the precontem-

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lation stage. No significant differences were found inhe use of peripheral analgesics, tricyclic antidepressants,ntiepileptic drugs, or muscle relaxants. Interestingly,nly 21% of the patients in stage I of pain chronicity usedpioids compared to 87% of the patients in stage III ofain chronicity. Pain-related inactivity, difficulties in cop-

ng with pain, and feelings of helplessness and hopeless-ess of the less motivated patients may be due to in-reased medicine taking, eg, opioids.Finally, our results revealed significant differencesetween the motivational stages of chronic pain man-gement on psychometric variables. The patients inhe maintenance stage had a significantly lower PDI, aignificantly lower HADS, a significantly lower level offfective pain perception scale, a significantly higheruality of life, and they significantly regarded theirwn behavior as most important for the improvementuring illness compared to less-motivated patients.enerally, the psychometric data are consistent with

he characteristics of the stage model (FQ-STAMP)ased on the transtheoretical model. Maurischat andolleagues21 demonstrated a stage-dependent corre-ation between depression, anxiety, and control be-iefs (locus of control) as well. Keefe and colleagues16

howed high levels of psychological and physical dis-bility in the preparation stage. Our results reflect thathe high psychosocial burden expressed by the pa-ients and the prevalence of depressive and anxietyisorders emphasize the importance of effective diag-ostic strategies to recognize mental disorders, andpecialized psychological treatment. This treatmentight provide psychological support and effective in-

erventions for patients with chronic back pain.13 c

ain in fibromyalgic patients. Pain 90:37-45, 2001

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owever, we couldn‘t demonstrate a significant dif-erence between the patients in the action stage andhe precontemplation/preparation stage. The trans-heoretical model is a dynamic model. Patients in thection stage develop strategies to control their pain.ailure of the treatment in the action stage will in-rease their level of psychological and physical disabil-ty. This result is confirmed by the clinical experience inhe pain therapy.One limitation of the present study concerns the re-

ruitment procedure that may have led to a selectiveample of patients. For example, patients who were notnterested in the study may have not returned their ques-ionnaire. Despite the fact that the study had 81% feed-ack and is considered representative, this might partlyxplain the variety of different results among the studiessing the transtheoretical model. The study is a cross-ectional study. Therefore, the study is limited on provid-ng longitudinal data.

Taken together, our results confirm previous find-ngs.21,20 These results support the relevance of the FQ-TAMP in addressing the association with pain chronic-ty, health care utilization, and pain-related andsychometric variables among chronic back pain pa-ients. Patients who start a program at least partly con-inced that managing pain is their responsibility benefitar more than patients whose notions of pain manage-ent remain focused on medical management.2 The in-

erplay of motivation and disability in treatment pro-rams might predict the outcome of pain managementnd might require distinguished communication skills todapt to the patient needs. Future research should spe-
ifically address this question.3,8,10,24,26,30
eferences

. Biller N, Arnstein P, Caudill MA, Federman CW, Guber-an C: Predicting completion of a cognitive-behavioral painanagement program by initial measures of a chronic pain

atient’ s readiness for change. Clin J Pain 16:352-359, 2000

. Burns JW, Glenn B, Lofland K, Bruehl S, Harden RN: Stagesf change in readiness to adopt a self-management ap-roach to chronic pain: the moderating role of early-treat-ent stage progression in predicting outcome. Pain 115:

22-331, 2005

. Carey TS, Evans A, Kalsbeek W, McLaughlin C, Fryer J:are-seeking among individuals with low back pain. Spine0:312-317, 1995

. Casser H, Riedel T, Schrembs C, Ingenhorst A, Kuhnau D:he multimodal interdisciplinary therapeutic program inhronic back pain. A new treatment strategy. Orthopade8:946-957, 1999

. Chibnall JT, Tait RC: The Pain Disability Index: factor struc-ure and normative data. Arch Phys Med Rehabil 75:1082-086, 1994

. Dijkstra A, Vlaeyen JW, Rijnen H, Nielson W: Readiness todopt the self-management approach to cope with chronic

. Frettloh J, Maier C, Gockel H, Huppe M: Validation of theerman Mainz Pain Staging System in different pain syn-romes. Schmerz 17:240-251, 2003

. Gallagher RM, Rauh V, Haugh LD, Milhous R, Callas PW,angelier R, McClallen JM, Frymoyer J: Determinants of re-urn-to-work among low back pain patients. Pain 39:55-67,989

. Geissner E: The Pain Perception Scale--a differentiatednd change-sensitive scale for assessing chronic and acuteain. Rehabilitation (Stuttg) 34:XXXV–XLIII, 1995

0. Gerbershagen U: Organized treatment of pain. Deter-ination of status. Internist (Berl) 27:459-469, 1986

1. Gerbershagen HU, Lindena G, Korb J, Kramer S: Health-elated quality of life in patients with chronic pain Schmerz6:271-284, 2002

2. Habib S, Morrissey SA, Helmes E: Readiness to adopt aelf-management approach to pain: evaluation of the paintages of change model in a non-pain-clinic sample. Pain04:283-290, 2003

3. Harter M, Baumeister H, Reuter K, Wunsch A, Bengel J:pidemiology of comorbid mental disorders in rehabilita-ion patients with musculosceletal and cardiovascular dis-ases. Rehabilitation (Stuttg) 41:367-374, 2002

4. Heger S, Krumm B, Wollner M, Lieberz K: Motivation for

is

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1atP

1t

1mp

2RpP

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3


n-patient psychotherapy among patients of a psycho-omatic pain clinic. Schmerz 17:101-109, 2003

5. Hildebrandt J, Pfingsten M, Franz C, Saur P, Seeger D:ultidisciplinary treatment program for chronic low back

ain, part 1. Overview. Schmerz 10:190-203, 1996

6. Keefe FJ, Lefebvre JC, Kerns RD, Rosenberg R, Beaupre, Prochaska J, Prochaska JO, Caldwell DS: Understandinghe adoption of arthritis self-management: stages of changerofiles among arthritis patients. Pain 87:303-313, 2000

7. Keller S, Herda C, Ridder K, Basler HD: Readiness todopt adequate postural habits: an application of the Trans-heoretical Model in the context of back pain prevention.atient Educ Couns 42:175-184, 2001

8. Kerns RD, Habib S: A critical review of the pain readinesso change model. J Pain 5:357-367, 2004

9. Kerns RD, Rosenberg R: Predicting responses to self-anagement treatments for chronic pain: application of the

ain stages of change model. Pain 84:49-55, 2000

0. Pfingsten M, Schops P, Wille T, Terp L, Hildebrandt J:eadiness to adopt a self-management approach to chronicain: the Pain Stages of Change Questionnaire (PSOCQ).ain 72:227-234, 1997

1. Maurischat C, Auclair P, Bengel J, Harter M: Measuringhe willingness of chronic pain patients to change pain man-gement behavior—a study on the transtheoretical model.chmerz 16:34-40, 2002

2. Maurischat C, Harter M, Auclair P, Kerns RD, Bengel J:reliminary validation of a German version of pain stages ofhange questionnaire. Eur J Pain 6:43-48, 2002

3. Nagel B, Gerbershagen HU, Lindena G, Pfingsten M: De-elopment and evaluation of the multidimensional Germanain questionnaire Schmerz 16:263-270, 2002

4. Pfingsten M, Franz C, Hildebrandt J, Saur P, Seeger D: a

ultidisciplinary treatment program on chronic low backain, part 3. Psychosocial aspects. Schmerz 10:326-344, 1996

5. Pfingsten M, Hildebrandt J, Saur P, Franz C, Seeger D:ultidisciplinary treatment program on chronic low back

ain, part 4. Prognosis of treatment outcome and final con-lusions. Schmerz 11:30-41, 1997

6. Pfingsten M, Leibing E, Franz C, Bansemer D, Busch O,ildebrandt J: Fear-avoidance-beliefs in patients with backain. Schmerz 11:387-395, 1997

7. Pfingsten M, Schops P, Wille T, Terp L, Hildebrandt J:lassification of chronic pain. Quantification and gradingith the Mainz Pain Staging System. Schmerz 14:10-17, 2000

8. Prochaska JO, DiClemente CC: Stages of change in theodification of problem behaviors. Prog Behav Modif 28:

83-218, 1992

9. Schmitt GM, Lohaus A, Salewski C: Control beliefs andatient compliance: an empirical study exemplified by ado-

escents with diabetes mellitus, bronchial asthma and alope-ia areata. Psychother Psychosom Med Psychol 39:33-40,989

0. Shahriar J, Delate T, Hays RD, Coons SJ: Commentary onsing the SF-36 or MOS-HIV in studies of persons with HIVisease. Health Qual Life Outcomes 1:25, 2003

1. Sollner W, Doering S: A psychological therapy methodsn chronic non-radicular backache. Orthopade 26:535-543,997

2. Turk DC, Rudy TE: Neglected factors in chronic painreatment outcome studies--referral patterns, failure to en-er treatment, and attrition. Pain 43:7-25, 1990

3. Zigmond, AS, Snaith, RP: The Hospital Anxiety and De-ression Scale. Acta Psychiatrica Scandinavica; 67:361-370,983

4. Zimmermann M: Chronic pain. Epidemiology and man-
gement in Germany. Orthopade 33:508-514, 2004

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