ELSEVIER
Journal of Back and Musculoskeletal Rehabilitation Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 41-51
Utilizing psychological assessment in rehabilitating patients with occupational musculoskeletal injuries William D. Alexy*a, Patrick M. Webb b , Laura A. Crismore c , Daniel 1. Mark d a Physiotherapy Associates, bPurdue
6110 N. Meridian, W,Dr., Indianapolis, IN 46208, USA University, School of Science at Indianapolis, Indianapolis, IN, USA cColumbus Regional Hospital, Columbus, IN, USA d Hillhaven Corporation, Columbus, IN, USA
Abstract Patients with occupational musculoskeletal injuries who participate in multidisciplinary rehabilitation programs will likely undergo psychological assessment as a part of the evaluation process. Although the importance of examining non-physical influences on the patient's recovery is widely recognized among clinicians, it is often unclear how findings from psychological assessment are being utilized to facilitate rate of recovery from injury. The purpose of this study was to encourage a re-examination of current psychological assessment practices among multidisciplinary rehabilitation programs and to describe how the Minnesota Multiphasic Personality Inventory (MMPI-2) was utilized with a work-hardening patient sample (n = 86). For the overall patient sample, the MMPI-2 depicted relatively high levels of somatic focus and low levels of psychological distress. To enhance clinical utility, a clustering method identified profile groupings that were distinguishable on the basis of known personality and behavioral correlates. Two profile groupings (Scale 1; Scales 1-3/3-1) were discussed with recommendations for how clinicians may facilitate rate of recovery from injury. The MMPI-2 appears to be particularly useful in identifying treatment conditions that may favorably influence rate of recovery from occupational musculoskeletal injuries.
Keywords: Psychological assessment; Work-hardening; MMPI-2; Rate of recovery
1. Introduction
Virtually all multidisciplinary rehabilitation programs that treat patients with occupational musculoskeletal injuries include standardized psychological assessment as an integral part of the
* Corresponding author, e-mail: [email protected] piu.edu
intake patient evaluation. There is general agreement among clinicians at pain centers [1], functional restoration [2], and work-hardening [3] programs that non-physical factors (e.g. presence of mood disorder, symptom magnification, secondary gain) are often significant negative influences on the recovery process from work-related injuries. It can be expected then that clinicians will look toward findings from psychological assessment for
1053-8127/96/$15.00 © 1996 Elsevier Science Ireland Ltd. All rights reserved. PII:SI053-8127(96)00188-1
42
W.D. Alexy et al./ Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 41-51
useful information having bearing on treatment intervention, therapy performance, and rehabilitation outcome. In keeping with the goal-directed focus of the recently published clinical practice guidelines for treating chronic non-malignant pain syndrome patients [4], concerted attention should be given to investigating how psychological assessment can be better utilized to facilitate rate-of-recovery from injury. If there is one source of agreement among present-day clinicians, employers, insurance carriers, and ostensibly patients themselves it is that a high premium is placed on recovery from work-related injury that occurs sooner rather than later. We define rate-of-recovery from injury as being the efficiency by which a patient proceeds through a course of treatment intervention, ranging from onset of injury to that point in time when maximum functional restoration or specified behavioral objectives have been achieved. The purpose of this study was (1) to encourage multidisciplinary rehabilitation programs to closely examine the basis for their current psychological assessment practices, and (2) to report on how the Minnesota Multiphasic Personality Inventory (MMPI-2) can be utilized to facilitate rate-of-recovery from injury with a work-hardening patient sample.
1.1. Psychological assessment Decisions regarding the selection of psychological assessment procedures ideally should be based on empirically-derived expectations for how the assessment findings will serve to guide rehabilitation programming and intervention. Given the substantial amount of time and expense involved with administering, scoring, and interpreting assessment information, a compelling clinical rationale ought to be evident linking assessment with intervention. Curiously, although predictive validity continues to be the gold standard, recent survey research has indicated that psychological assessment practices in rehabilitation settings provide relatively little guidance in formulating intervention strategies [5]. Part of the problem with psychological assess-
ment practices in rehabilitation stems from confusion that is created by the large number of competing standardized tests and scales. The literature does, however, offer some guidance in addressing this situation. Turk and Melzack [6], for example, reviewed numerous pain assessment instruments in an effort to identify their relative strengths and weaknesses. Another difficulty associated with assessment practices undoubtedly results from uncertainty in knowing which aspects of patients' psychological functioning should be formally assessed. Is it cost-effective to assess several dimensions of psychological status (i.e. 'the more we know about the patient, the better') or is there clinical rationale for limiting psychological assessment to areas such as symptom checklists (e.g., SCL-90-R) [7], pain inventories (e.g., Multidimensional Pain Inventory) [8], or coping strategies (e.g., Coping Strategies Questionnaire) [9]? Clinical staff are advised to closely examine the clinical rationale for their current assessment practices. Are findings from psychological assessment predictive of relevant outcome, such as return-to-work status, program compliance, and response to treatment? Can anything be inferred from the assessment about dimensions of the patient-clinician relationship that may have bearing on the recovery process? Will the patient's therapy performance be enhanced under conditions of relative high or low structure? Are there significant unresolving issues of a psychological nature (e.g., history of emotional trauma) that are impeding rate-of-recovery from injury? If so, how might these issues be effectively addressed in the context of treatment that is directed toward physical and functional restoration? Psychological assessment practices that are geared toward addressing such questions can make meaningful contributions to the clinician's efforts at facilitating rate-or-recovery from occupational musculoskeletal injuries.
1.2. Minnesota Multiphasic Personality Inventory The Minnesota Multiphasic Personality Inventory (MMPI) is currently the most widely used
WD. Alexy et at. / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 41-51
and highly researched objective psychological inventory [10]. First published over 50 years ago, the restandardized version (MMPI-2) [11] consists of 567 items to which the test taker marks (T) or (F). Raw scores are plotted on gender-appropriate T-score profile forms from which clinical interpretations are made, given scale elevations, codetypes, and configuration patterns. The Profile for Basic Scales consists of four validity scales and 10 clinical scales. Table 1 provides a brief identification and description of these scales. In-depth description of the MMPI-2, including its development, psychometric properties, scoring procedures, and interpretive strategies are available [10-13]. Most rehabilitation patients diagnosed with occupational musculoskeletal injuries can complete the MMPI-2 in 1-2 h. Item responses for the Basic Scales Profile can be either hand-scored (10-15 min) and interpreted or computer-scored and interpreted. The test is reasonably priced and
43
is not especially time-consuming for professional staff who are qualified to interpret the test [11]. Although the MMPI-2, like other standardized tests, has its relative strengths and limitations [6], we believe that some of the test's special properties warrant its use in rehabilitation settings with musculoskeletal injuries. For example, insights regarding a patient's psychological defenses, general level of adjustment, specific symptoms, major needs, coping strategies, and interpersonal relationships are obtainable through clinical profile interpretation. Inferences can also be made about the patient's relative receptiveness to treatment, which obviously is pertinent to rate-of-recovery. 2. Materials and methods 2.1. Patient sample
Participants in the study were 86 patients (61 males; 25 females) with occupational muscu-
Table 1 Identification and brief description of MMPI-2 Basic Scales' Validity scales L (Lie) ScaleF (Infrequency) Scale K (Correction) Scale ? (Cannot Say)-
._-_.__._--_.._ - - - - - - - - - - - - - - - - - - -
15 items reflecting common human faults to which most people are willing to admit. 60 items that are answered in the keyed direction by less than 10% of the standardization group for the original MMPI. 30 items designed to reveal the test taker who attempts to present himself in the best possible light. the number of items that have been left unanswered; reported as a raw score.
Clinical scales Scale 1 (Hypochondriasis) Scale 2 (Depression) Scale 3 (Hysteria) Scale 4 (Psychopathic Deviate) Scale 5 (Masculine-Feminine Interests) Scale 6 (Paranoia) Scale 7 (Psychasthenia) _.Scale 8 (Schizophrenia)Scale 9 (Mania) Scale 10 (Social IntroversionExtraversion) -
32 items that reflect a person's preoccupation with physical problems. 57 items concerned with feelings of depression and malaise. 60 items dealing with specific physical complaints along with a denial of concern about the physical problems. 50 items reflecting antisocial acts and feelings as well as hostility and/or anger. 56 items that measure stereo typic masculine or feminine interests. 40 items that indicate feelings of suspiciousness and wariness of other people's motives. 48 items concerned with feelings of anxiety and concern, and obsessive ruminations. 78 items that reflect feelings of alienation, differentness, confusion, and bizarre sensations. 46 items that show excessive energy, psychomotor accelerations, and imperturbability. 69 items measuring social shyness, the preference for solitary pursuits, and a lack of social assertiveness.
"Duckworth lC, Levitt, EE. Minnesota Multiphasic Personality Inventory Critiques, Vol. X. Austin, TX: PRO-ED, 1994;424-425.
2. In: Keyser DJ and Sweetland RC, eds. Test
44
WD. Alexy et at. / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 41-51
loskeletal injuries who were physician-referred to the Ergoplex Work-Hardening Center in Indianapolis, Indiana. Table 2 presents the patient demographic data. The majority of the patients met diagnostic criteria for chronic non-malignant pain syndrome [4]. Spine-related disorders comTable 2 Work-hardening patient demographics Characteristic
Value
Gender Male Female
71% (n 29% (n
Age
M = 39.6; SD = 9.4; (n = 86)
Ethnicity Caucasian African - American Hispanic Marital status Married Divorced Single Widowed Education High school and beyond Less than high school Diagnosis (site of injury) Back Shoulder Knee V-Extremity Neck Other Age of injury (months) Surgery Yes No Time since surgery (weeks)
=
61)
=
25)
83% (n
= 71)
16% (n 1% (n
= =
14) 1)
65% (n = 56) 20% (n = 17) 14% (n = 12) 1% (n = 1)
55% (n 45% (n
= =
47) 39)
48% (n = 41) 23% (n = 20) 12% (n
=
8% (n
=
7% (n 2% (n
= =
10) 7) 6) 2)
M = 7.1; Md = 5.0; SD = 6.1
63% (n 37% (n
= =
54) 32)
M = 20.2; Md = 16.0; SD = 18.3
Prior injury" Yes No
69% (n 31% (n
=
59)
=
27)
Litigation h Yes No
14% (n
=
12)
59% (n
=
50)
"Resulting in lost time from work. unavailable for 27% (n"" 24) of patient sample.
h Data
prised 55% (n = 47) of the sample; 45% (n = 39) were non-spine-related disorders. Recent injuries « 6 months) were represented by 58% (n = 50) of the sample; old injuries (6 months and greater) accounted for 42% (n = 36) of the sample. The length of time (months) that patients were employed at the job where the injury occurred ranged from 1 month to 35 years (M = 114.2 (9.5 years); Md = 40 (3.3 years); SD = 123.7). The majority of job categories held by patients were packaging and material-handling occupations; onjob physical demands were mostly medium and heavy [14]. Patients who were litigating reported that they were actively involved in a personal injury lawsuit at the time of admission to the program. Workers Compensation benefits were being received by 98% of the patient sample. 2.2. MMPI-2
The MMPI-2 was administered to all participants during the intake patient evaluation and within 2 days of beginning work-hardening rehabilitation. Information and instructions verbally given to patients for completing the MMPI-2 were as follows: (1) We are asking you to complete this personality inventory for the purpose of helping staff learn more about how they can best approach working with you while you are participating in the work-hardening program. (2) The results of the testing (feedback) will be discussed with you by our consulting psychologist within a few days. (3) We are asking you to read each of these items and to decide whether the statement is (T) or (F) for you. (4) You may come upon some items that do not seem to be clearly (T) or (F) for you; or you may conclude that an item is sometimes (T) and sometimes (F). Give it your best guess. We need an answer for every item. (5) Tell it like it is. Don't try to portray yourself in either a favorable or unfavorable light. Just respond to the items. Usually your first impression is the best answer.
45
W.D. Alexy et al.j Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 41-·51
(6) About mid-way through, you will probably want to stop and take a break. Feel free to do this; then come back and finish up the test. 3. Results
3.1. Basic scales profile Fig. 1 presents the MMPI-2 mean T-score elevations for the patient sample. The validity scale
T
l
F
K
,
Hs+.SK
D 2
Itt 3
configuration (Scales L,F,K) is suggestive of individuals who are conforming and who may tend to resort to denial mechanisms. Scale 1 (Hypochondriasis) and Scale 3 (Hysteria) are most highly elevated and a negative slope (left side high, right side low) characterizes the profile, suggesting the presence of internal conflicts and excessive somatic concerns. What is perhaps most noteworthy about this profile is the relatively low levels of psychological distress (F scale, Scale 7) and acting-out potential. One would not infer from this profile that these PtI+.4K 4
lit
5
PI 8
PI+1K 7
Sc+1K
8
1II+.2K
9
Si
o
120
::-120
liS
=-115
-
Work-Hardening Patient Sample (N=86)
II. 115
-=
Male (Q=61) Female (.u=25) - - - --
101
::-115
IS
-
::-15
:
-
75-=
15-=~--------------~--~--------------------__------------------------___ IS
.• 35 30
T
~I
~I
-=,
::"'30
L
F
,
Hs+.SK
o
2
Itt 3
PtI+.4K 4
lit
5
PI 8
PI+IK 7
Sc+IK
8
1Io+2K
9
Si
o
T
Fig.!. MMPI-2 mean T-score elevations for basic scales profile. Means, SD, and correlation matrix available from first author upon request.
W.D. Alexy et aLI JoumalofBack al," Musculoskeletal Rehabilitation 7 (1996) 41-51
46
patients, overall. are motivated. to recover 'ft~m injury, based on a need to reduce psychological discomfort. Male and female mean T~score differences' in Fig. 1 were found to be statistically insignificant.,
3.2. Profile groupings 01 ..
Table 4.. "., ElCamples.of perso~~I\ty andlx)havio,ral ,correlates· as&Qciated with high Scaje 1 profiles
1. 2. 3. 4.
Symptoms vague, non-specific, and difficult to isolate Symptoms used to manipulate and control others Strong element of secondary gain from symptom pattern Pattern represents stable chronic mode of adjustment that is difficult to modify 5. Pessimistic/defeatist/cynical outlook toward life 6. Make others miserable ' . 7. Demanding and critical of others 8.· ~pr-e.sses hostility indirectly 9. Fatigue; pain; r~uced efficiency in life 10. Medication use or abuSe is common 11. Resists psychological explanations 12. Expert 'doctor shoppers' - critical of treatment staff
. Although the Basic Sca~es Profile shown, i~ Fig. 1 may begin to suggest relevant clinical issues for the patient sample, it' clearly. is of,limi~~d va~ue. Experienced cliniCians are already aware that many patients with occupational musculoskeletal injuries are exceedingly focused on somatic complaints and are often seemingly 'resigned' to. their .... " Ipentified' inQ(een [10], .Graham [12], Duckworth and Anderson [13]. situatIon. In an effort to maximize the utility of the MMPI-2 profiles for the patient sample, individual profiles well~' .·groueeQ'i accordin~ to' known 'patients' included in this profile grouping, ml?an codetypes [10,12,13], profiles with assorted elevaT-score elevations and personality and behavioral tions;, and those that were within normal limits. . cOrrelates are not provided. ' Table 3 identifies the 5 profile groupings that .. The. 1-3/3-1 prople grouping comprised 17.4% emerged from this clustering method. (n ,;" '15) of the patient sample. Patient prQfiles Scales 1 (Hypochondriasis) profile grouping were included in this grouping when both Scale 1 comprised 14% (n = 12) of the patient sample. (Hypochondriasis) and Scale 3 (Hysteria) were Patient profiles were included in this grouping the only clinical scales at a level of clinical sigwhen Scale 1 was the only clinical scale at a level nificance (T ~ 65). Fig. 3 portrays the mean of clinical significant (T ;?; 65). Fig. 2 portrays the T-score elevations for the 1-3/3-1 profile groupmean T-score elevations for the Scale 1 profile ing. Personality and behavioral correlates of high grouping. Personality and behavioral correlates 1-3/3-1 profiles which may be useful to cllniassociated with high Scale 1 profiles which may be cians are listed in Table 5. useful to clinicians are listed in Table 4. The Assorted Elevated profile grouping comScale .3 (Hysteria) -profile grouping comprised· prised 23.2%.(~';'" 20)" of the patient sample. 2.3% (n = 2) of the patient sample. Patient proP~tie~t p~dfiles were included in this grouping files were included in the grouping when Scale 3 .'when ~ne or more clinical scales were at a level was the only scale at a level of clinical signifi- ,. .: of clinical significante (T ~ 65), other than Scale cance (T :
4.2.1-3/3-1 (Hypochondriasis/Hysteria) patients As much as high Scale 1 patients present a major challenge to clinicians, high 1-3/3-1
50
W.D. Alexy et at. / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 41-51
patients bring another set of complications to the recovery process. These patients convert psychological problems into somatic complaints (Table 5). Classic conversion symptoms may be present where the somatic complaints are of psychological origin, or the somatic complaints may be based in organic pathology. In either case, these patients are using somatic symptoms to avoid thinking about or dealing with sources of psychological distress and conflict, and in so doing, rate-of-recovery is impeded. Clinicians who treat high 1-3/3-1 patients typically find that they are reasonably compliant and responsive during therapy. Circumstances, however, tend to 'come up' resulting in missed therapy sessions, and these patients don't seem to make as much progress as would be clinically expected. The primary psychological objectives with these patients are to identify sources of major distress that might be at the root of their somatic preoccupations, lessen resistances to recognizing how physical symptoms and psychological distress are related, and provide psychological intervention as needed. Psychological assessment should carefully examine potential sources of distress (present and past) with high 1-3/3-1 patients. For most of these patients, the source of distress that is linked with somatic symptoms seems to reside within a significant-other relationship where the impact of hurt and unfulfilled needs, emotional trauma, and/or major loss remains active. It is highly desirable that multidisciplinary staff are present when these patients are given feedback from the MMPI-2, since the symbolic pairing of the physical and psychological may be advantageous in helping patients merge these two domains. We also recommend that over the course of the patient's rehabilitation program multidisciplinary staff actively and frequently engage these patients in open discussion about progress being made with their identified source of psychological distress. Understandably, the clinician's demonstrated sensitivity to the patient's situation, along with the timing of this type of patient-clinician interaction will likely influence the patient's rateof-recovery.
5. Conclusion Psychological assessment practices in multidisciplinary rehabilitation programs should be developed around the theme of utilizing findings to assist clinicians in facilitating rate-of-recovery from injury. The MMPI-2 is particularly useful in working with patien.ts diagnosed with occupational musculoskeletal injuries. To the extent that the concept of rate-of-recovery can be operationally and meaningfully defined, a great window of opportunity will become available for empirically examining the special contributions psychological assessment can make in facilitating the recovery process from injury. Acknowledgements We are grateful to Dr. Jane Duckworth, Professor Emeritus, for her suggestion to examine MMPI-2 profile groupings; to John McKinney, ATC, Matt Ebert, OTR, and Lee Hines, ATC for their insightful discussions; to John Eddy who provided useful input regarding secondary gain issues; and to the late Karen Haney who assisted with the literature review.· References [1] Aronoff GM. The role of the pain center in the treat: ment for intractable suffering and disability resulting from chronic pain. In: Aronoff GM, ed. Evaluation and Treatment of Chronic Pain. Baltimore: Urban and Schwarzenberg, 1985. [2] Hazard RG, Fenwick JW, Kalisch SM, et al. Functional restoration with behavioral support: a one-year prospective study of patients with chronic low-back pain. Spine 1989;14(2):157-161. [3] Niemeyer LO, Jacobs K. Work-Hardening - State of the Art. Thorofare, New Jersey: Slack, Inc., 1989. [4] Sanders SH, Rucker KS, Anderson KO, et al. Clinical practice guidelines for chronic non-malignant pain syndrome patients. J Back Musculoskel Rehabil 1995;5:115-120. [5] Glueckauf RL. Use and misuse of assessment in rehabilitation: getting back to the basics. In: Glueckauf RL, Sechrest LB, Bond GR and McDonel EC, eds. Improving Assessment in Rehabilitation 'and Health. Newbury Park, California: Sage Publications, Inc., 1993. [6] Turk DC, Melzack R. Handbook of Pain Assessment. New York: Guilford Press, 1992.
WD. Alexy et al. / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 41-51
[7] [8] [9] [10] (11) [12]
Bernstein IH, Jaremko ME, Hinckley BS. On the utility of the SCL-90-R with low-back pain patients. Spine 1994; 19(1):42-48. Kerns RD, Turk DC, Rudy TE. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain 1985;23:345-356. Rosenstiel AK, Keefe FJ. The use of coping strategies in low-back pain patients: relationship to patient characteristics and current adjustment. Pain 1983;17:33-40. Greene RL. The MMPI-2/MMPI: An Interpretive Manual. Boston: Allyn and Bacon, 1991. Butcher IN, Dahlstrom WG, Graham JR, et al. MMPI-2 Manual for Administration and Scoring. Minneapolis: University of Minnesota Press, 1989. Graham JR. MMPI-2 - Assessing Personality and Psy-
[13]
[14] (15) [16]
51
chopathology (2nd edn.). New York: Oxford University Press, 1993. Duckworth JC, Anderson WP. MMPI and MMPI-2: Interpretive Manual for Counselors and Clinicians (4th edn.) Bristol, Pennsylvania: Accelerated Development, 1995. Dictionary of Occupational Titles (4th edn. revised). US Department of Labor, 1991. Matheson LN. 'How do you know that he tried his best?' - the reliability crisis in industrial rehabilitation. Ind Rehabil Q 1988;1(1):1-3. Thrift. RD. The use of the MMPI in identifying personality factors affecting maximum voluntary effort in a chronic low back pain rehabilitation program. Unpublished doctoral dissertation, 1989, University of Miami.
Journal of Back and Musculoskeletal Rehabilitation Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 41-51
Utilizing psychological assessment in rehabilitating patients with occupational musculoskeletal injuries William D. Alexy*a, Patrick M. Webb b , Laura A. Crismore c , Daniel 1. Mark d a Physiotherapy Associates, bPurdue
6110 N. Meridian, W,Dr., Indianapolis, IN 46208, USA University, School of Science at Indianapolis, Indianapolis, IN, USA cColumbus Regional Hospital, Columbus, IN, USA d Hillhaven Corporation, Columbus, IN, USA
Abstract Patients with occupational musculoskeletal injuries who participate in multidisciplinary rehabilitation programs will likely undergo psychological assessment as a part of the evaluation process. Although the importance of examining non-physical influences on the patient's recovery is widely recognized among clinicians, it is often unclear how findings from psychological assessment are being utilized to facilitate rate of recovery from injury. The purpose of this study was to encourage a re-examination of current psychological assessment practices among multidisciplinary rehabilitation programs and to describe how the Minnesota Multiphasic Personality Inventory (MMPI-2) was utilized with a work-hardening patient sample (n = 86). For the overall patient sample, the MMPI-2 depicted relatively high levels of somatic focus and low levels of psychological distress. To enhance clinical utility, a clustering method identified profile groupings that were distinguishable on the basis of known personality and behavioral correlates. Two profile groupings (Scale 1; Scales 1-3/3-1) were discussed with recommendations for how clinicians may facilitate rate of recovery from injury. The MMPI-2 appears to be particularly useful in identifying treatment conditions that may favorably influence rate of recovery from occupational musculoskeletal injuries.
Keywords: Psychological assessment; Work-hardening; MMPI-2; Rate of recovery
1. Introduction
Virtually all multidisciplinary rehabilitation programs that treat patients with occupational musculoskeletal injuries include standardized psychological assessment as an integral part of the
* Corresponding author, e-mail: [email protected] piu.edu
intake patient evaluation. There is general agreement among clinicians at pain centers [1], functional restoration [2], and work-hardening [3] programs that non-physical factors (e.g. presence of mood disorder, symptom magnification, secondary gain) are often significant negative influences on the recovery process from work-related injuries. It can be expected then that clinicians will look toward findings from psychological assessment for
1053-8127/96/$15.00 © 1996 Elsevier Science Ireland Ltd. All rights reserved. PII:SI053-8127(96)00188-1
42
W.D. Alexy et al./ Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 41-51
useful information having bearing on treatment intervention, therapy performance, and rehabilitation outcome. In keeping with the goal-directed focus of the recently published clinical practice guidelines for treating chronic non-malignant pain syndrome patients [4], concerted attention should be given to investigating how psychological assessment can be better utilized to facilitate rate-of-recovery from injury. If there is one source of agreement among present-day clinicians, employers, insurance carriers, and ostensibly patients themselves it is that a high premium is placed on recovery from work-related injury that occurs sooner rather than later. We define rate-of-recovery from injury as being the efficiency by which a patient proceeds through a course of treatment intervention, ranging from onset of injury to that point in time when maximum functional restoration or specified behavioral objectives have been achieved. The purpose of this study was (1) to encourage multidisciplinary rehabilitation programs to closely examine the basis for their current psychological assessment practices, and (2) to report on how the Minnesota Multiphasic Personality Inventory (MMPI-2) can be utilized to facilitate rate-of-recovery from injury with a work-hardening patient sample.
1.1. Psychological assessment Decisions regarding the selection of psychological assessment procedures ideally should be based on empirically-derived expectations for how the assessment findings will serve to guide rehabilitation programming and intervention. Given the substantial amount of time and expense involved with administering, scoring, and interpreting assessment information, a compelling clinical rationale ought to be evident linking assessment with intervention. Curiously, although predictive validity continues to be the gold standard, recent survey research has indicated that psychological assessment practices in rehabilitation settings provide relatively little guidance in formulating intervention strategies [5]. Part of the problem with psychological assess-
ment practices in rehabilitation stems from confusion that is created by the large number of competing standardized tests and scales. The literature does, however, offer some guidance in addressing this situation. Turk and Melzack [6], for example, reviewed numerous pain assessment instruments in an effort to identify their relative strengths and weaknesses. Another difficulty associated with assessment practices undoubtedly results from uncertainty in knowing which aspects of patients' psychological functioning should be formally assessed. Is it cost-effective to assess several dimensions of psychological status (i.e. 'the more we know about the patient, the better') or is there clinical rationale for limiting psychological assessment to areas such as symptom checklists (e.g., SCL-90-R) [7], pain inventories (e.g., Multidimensional Pain Inventory) [8], or coping strategies (e.g., Coping Strategies Questionnaire) [9]? Clinical staff are advised to closely examine the clinical rationale for their current assessment practices. Are findings from psychological assessment predictive of relevant outcome, such as return-to-work status, program compliance, and response to treatment? Can anything be inferred from the assessment about dimensions of the patient-clinician relationship that may have bearing on the recovery process? Will the patient's therapy performance be enhanced under conditions of relative high or low structure? Are there significant unresolving issues of a psychological nature (e.g., history of emotional trauma) that are impeding rate-of-recovery from injury? If so, how might these issues be effectively addressed in the context of treatment that is directed toward physical and functional restoration? Psychological assessment practices that are geared toward addressing such questions can make meaningful contributions to the clinician's efforts at facilitating rate-or-recovery from occupational musculoskeletal injuries.
1.2. Minnesota Multiphasic Personality Inventory The Minnesota Multiphasic Personality Inventory (MMPI) is currently the most widely used
WD. Alexy et at. / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 41-51
and highly researched objective psychological inventory [10]. First published over 50 years ago, the restandardized version (MMPI-2) [11] consists of 567 items to which the test taker marks (T) or (F). Raw scores are plotted on gender-appropriate T-score profile forms from which clinical interpretations are made, given scale elevations, codetypes, and configuration patterns. The Profile for Basic Scales consists of four validity scales and 10 clinical scales. Table 1 provides a brief identification and description of these scales. In-depth description of the MMPI-2, including its development, psychometric properties, scoring procedures, and interpretive strategies are available [10-13]. Most rehabilitation patients diagnosed with occupational musculoskeletal injuries can complete the MMPI-2 in 1-2 h. Item responses for the Basic Scales Profile can be either hand-scored (10-15 min) and interpreted or computer-scored and interpreted. The test is reasonably priced and
43
is not especially time-consuming for professional staff who are qualified to interpret the test [11]. Although the MMPI-2, like other standardized tests, has its relative strengths and limitations [6], we believe that some of the test's special properties warrant its use in rehabilitation settings with musculoskeletal injuries. For example, insights regarding a patient's psychological defenses, general level of adjustment, specific symptoms, major needs, coping strategies, and interpersonal relationships are obtainable through clinical profile interpretation. Inferences can also be made about the patient's relative receptiveness to treatment, which obviously is pertinent to rate-of-recovery. 2. Materials and methods 2.1. Patient sample
Participants in the study were 86 patients (61 males; 25 females) with occupational muscu-
Table 1 Identification and brief description of MMPI-2 Basic Scales' Validity scales L (Lie) ScaleF (Infrequency) Scale K (Correction) Scale ? (Cannot Say)-
._-_.__._--_.._ - - - - - - - - - - - - - - - - - - -
15 items reflecting common human faults to which most people are willing to admit. 60 items that are answered in the keyed direction by less than 10% of the standardization group for the original MMPI. 30 items designed to reveal the test taker who attempts to present himself in the best possible light. the number of items that have been left unanswered; reported as a raw score.
Clinical scales Scale 1 (Hypochondriasis) Scale 2 (Depression) Scale 3 (Hysteria) Scale 4 (Psychopathic Deviate) Scale 5 (Masculine-Feminine Interests) Scale 6 (Paranoia) Scale 7 (Psychasthenia) _.Scale 8 (Schizophrenia)Scale 9 (Mania) Scale 10 (Social IntroversionExtraversion) -
32 items that reflect a person's preoccupation with physical problems. 57 items concerned with feelings of depression and malaise. 60 items dealing with specific physical complaints along with a denial of concern about the physical problems. 50 items reflecting antisocial acts and feelings as well as hostility and/or anger. 56 items that measure stereo typic masculine or feminine interests. 40 items that indicate feelings of suspiciousness and wariness of other people's motives. 48 items concerned with feelings of anxiety and concern, and obsessive ruminations. 78 items that reflect feelings of alienation, differentness, confusion, and bizarre sensations. 46 items that show excessive energy, psychomotor accelerations, and imperturbability. 69 items measuring social shyness, the preference for solitary pursuits, and a lack of social assertiveness.
"Duckworth lC, Levitt, EE. Minnesota Multiphasic Personality Inventory Critiques, Vol. X. Austin, TX: PRO-ED, 1994;424-425.
2. In: Keyser DJ and Sweetland RC, eds. Test
44
WD. Alexy et at. / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 41-51
loskeletal injuries who were physician-referred to the Ergoplex Work-Hardening Center in Indianapolis, Indiana. Table 2 presents the patient demographic data. The majority of the patients met diagnostic criteria for chronic non-malignant pain syndrome [4]. Spine-related disorders comTable 2 Work-hardening patient demographics Characteristic
Value
Gender Male Female
71% (n 29% (n
Age
M = 39.6; SD = 9.4; (n = 86)
Ethnicity Caucasian African - American Hispanic Marital status Married Divorced Single Widowed Education High school and beyond Less than high school Diagnosis (site of injury) Back Shoulder Knee V-Extremity Neck Other Age of injury (months) Surgery Yes No Time since surgery (weeks)
=
61)
=
25)
83% (n
= 71)
16% (n 1% (n
= =
14) 1)
65% (n = 56) 20% (n = 17) 14% (n = 12) 1% (n = 1)
55% (n 45% (n
= =
47) 39)
48% (n = 41) 23% (n = 20) 12% (n
=
8% (n
=
7% (n 2% (n
= =
10) 7) 6) 2)
M = 7.1; Md = 5.0; SD = 6.1
63% (n 37% (n
= =
54) 32)
M = 20.2; Md = 16.0; SD = 18.3
Prior injury" Yes No
69% (n 31% (n
=
59)
=
27)
Litigation h Yes No
14% (n
=
12)
59% (n
=
50)
"Resulting in lost time from work. unavailable for 27% (n"" 24) of patient sample.
h Data
prised 55% (n = 47) of the sample; 45% (n = 39) were non-spine-related disorders. Recent injuries « 6 months) were represented by 58% (n = 50) of the sample; old injuries (6 months and greater) accounted for 42% (n = 36) of the sample. The length of time (months) that patients were employed at the job where the injury occurred ranged from 1 month to 35 years (M = 114.2 (9.5 years); Md = 40 (3.3 years); SD = 123.7). The majority of job categories held by patients were packaging and material-handling occupations; onjob physical demands were mostly medium and heavy [14]. Patients who were litigating reported that they were actively involved in a personal injury lawsuit at the time of admission to the program. Workers Compensation benefits were being received by 98% of the patient sample. 2.2. MMPI-2
The MMPI-2 was administered to all participants during the intake patient evaluation and within 2 days of beginning work-hardening rehabilitation. Information and instructions verbally given to patients for completing the MMPI-2 were as follows: (1) We are asking you to complete this personality inventory for the purpose of helping staff learn more about how they can best approach working with you while you are participating in the work-hardening program. (2) The results of the testing (feedback) will be discussed with you by our consulting psychologist within a few days. (3) We are asking you to read each of these items and to decide whether the statement is (T) or (F) for you. (4) You may come upon some items that do not seem to be clearly (T) or (F) for you; or you may conclude that an item is sometimes (T) and sometimes (F). Give it your best guess. We need an answer for every item. (5) Tell it like it is. Don't try to portray yourself in either a favorable or unfavorable light. Just respond to the items. Usually your first impression is the best answer.
45
W.D. Alexy et al.j Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 41-·51
(6) About mid-way through, you will probably want to stop and take a break. Feel free to do this; then come back and finish up the test. 3. Results
3.1. Basic scales profile Fig. 1 presents the MMPI-2 mean T-score elevations for the patient sample. The validity scale
T
l
F
K
,
Hs+.SK
D 2
Itt 3
configuration (Scales L,F,K) is suggestive of individuals who are conforming and who may tend to resort to denial mechanisms. Scale 1 (Hypochondriasis) and Scale 3 (Hysteria) are most highly elevated and a negative slope (left side high, right side low) characterizes the profile, suggesting the presence of internal conflicts and excessive somatic concerns. What is perhaps most noteworthy about this profile is the relatively low levels of psychological distress (F scale, Scale 7) and acting-out potential. One would not infer from this profile that these PtI+.4K 4
lit
5
PI 8
PI+1K 7
Sc+1K
8
1II+.2K
9
Si
o
120
::-120
liS
=-115
-
Work-Hardening Patient Sample (N=86)
II. 115
-=
Male (Q=61) Female (.u=25) - - - --
101
::-115
IS
-
::-15
:
-
75-=
15-=~--------------~--~--------------------__------------------------___ IS
.• 35 30
T
~I
~I
-=,
::"'30
L
F
,
Hs+.SK
o
2
Itt 3
PtI+.4K 4
lit
5
PI 8
PI+IK 7
Sc+IK
8
1Io+2K
9
Si
o
T
Fig.!. MMPI-2 mean T-score elevations for basic scales profile. Means, SD, and correlation matrix available from first author upon request.
W.D. Alexy et aLI JoumalofBack al," Musculoskeletal Rehabilitation 7 (1996) 41-51
46
patients, overall. are motivated. to recover 'ft~m injury, based on a need to reduce psychological discomfort. Male and female mean T~score differences' in Fig. 1 were found to be statistically insignificant.,
3.2. Profile groupings 01 ..
Table 4.. "., ElCamples.of perso~~I\ty andlx)havio,ral ,correlates· as&Qciated with high Scaje 1 profiles
1. 2. 3. 4.
Symptoms vague, non-specific, and difficult to isolate Symptoms used to manipulate and control others Strong element of secondary gain from symptom pattern Pattern represents stable chronic mode of adjustment that is difficult to modify 5. Pessimistic/defeatist/cynical outlook toward life 6. Make others miserable ' . 7. Demanding and critical of others 8.· ~pr-e.sses hostility indirectly 9. Fatigue; pain; r~uced efficiency in life 10. Medication use or abuSe is common 11. Resists psychological explanations 12. Expert 'doctor shoppers' - critical of treatment staff
. Although the Basic Sca~es Profile shown, i~ Fig. 1 may begin to suggest relevant clinical issues for the patient sample, it' clearly. is of,limi~~d va~ue. Experienced cliniCians are already aware that many patients with occupational musculoskeletal injuries are exceedingly focused on somatic complaints and are often seemingly 'resigned' to. their .... " Ipentified' inQ(een [10], .Graham [12], Duckworth and Anderson [13]. situatIon. In an effort to maximize the utility of the MMPI-2 profiles for the patient sample, individual profiles well~' .·groueeQ'i accordin~ to' known 'patients' included in this profile grouping, ml?an codetypes [10,12,13], profiles with assorted elevaT-score elevations and personality and behavioral tions;, and those that were within normal limits. . cOrrelates are not provided. ' Table 3 identifies the 5 profile groupings that .. The. 1-3/3-1 prople grouping comprised 17.4% emerged from this clustering method. (n ,;" '15) of the patient sample. Patient prQfiles Scales 1 (Hypochondriasis) profile grouping were included in this grouping when both Scale 1 comprised 14% (n = 12) of the patient sample. (Hypochondriasis) and Scale 3 (Hysteria) were Patient profiles were included in this grouping the only clinical scales at a level of clinical sigwhen Scale 1 was the only clinical scale at a level nificance (T ~ 65). Fig. 3 portrays the mean of clinical significant (T ;?; 65). Fig. 2 portrays the T-score elevations for the 1-3/3-1 profile groupmean T-score elevations for the Scale 1 profile ing. Personality and behavioral correlates of high grouping. Personality and behavioral correlates 1-3/3-1 profiles which may be useful to cllniassociated with high Scale 1 profiles which may be cians are listed in Table 5. useful to clinicians are listed in Table 4. The Assorted Elevated profile grouping comScale .3 (Hysteria) -profile grouping comprised· prised 23.2%.(~';'" 20)" of the patient sample. 2.3% (n = 2) of the patient sample. Patient proP~tie~t p~dfiles were included in this grouping files were included in the grouping when Scale 3 .'when ~ne or more clinical scales were at a level was the only scale at a level of clinical signifi- ,. .: of clinical significante (T ~ 65), other than Scale cance (T :
4.2.1-3/3-1 (Hypochondriasis/Hysteria) patients As much as high Scale 1 patients present a major challenge to clinicians, high 1-3/3-1
50
W.D. Alexy et at. / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 41-51
patients bring another set of complications to the recovery process. These patients convert psychological problems into somatic complaints (Table 5). Classic conversion symptoms may be present where the somatic complaints are of psychological origin, or the somatic complaints may be based in organic pathology. In either case, these patients are using somatic symptoms to avoid thinking about or dealing with sources of psychological distress and conflict, and in so doing, rate-of-recovery is impeded. Clinicians who treat high 1-3/3-1 patients typically find that they are reasonably compliant and responsive during therapy. Circumstances, however, tend to 'come up' resulting in missed therapy sessions, and these patients don't seem to make as much progress as would be clinically expected. The primary psychological objectives with these patients are to identify sources of major distress that might be at the root of their somatic preoccupations, lessen resistances to recognizing how physical symptoms and psychological distress are related, and provide psychological intervention as needed. Psychological assessment should carefully examine potential sources of distress (present and past) with high 1-3/3-1 patients. For most of these patients, the source of distress that is linked with somatic symptoms seems to reside within a significant-other relationship where the impact of hurt and unfulfilled needs, emotional trauma, and/or major loss remains active. It is highly desirable that multidisciplinary staff are present when these patients are given feedback from the MMPI-2, since the symbolic pairing of the physical and psychological may be advantageous in helping patients merge these two domains. We also recommend that over the course of the patient's rehabilitation program multidisciplinary staff actively and frequently engage these patients in open discussion about progress being made with their identified source of psychological distress. Understandably, the clinician's demonstrated sensitivity to the patient's situation, along with the timing of this type of patient-clinician interaction will likely influence the patient's rateof-recovery.
5. Conclusion Psychological assessment practices in multidisciplinary rehabilitation programs should be developed around the theme of utilizing findings to assist clinicians in facilitating rate-of-recovery from injury. The MMPI-2 is particularly useful in working with patien.ts diagnosed with occupational musculoskeletal injuries. To the extent that the concept of rate-of-recovery can be operationally and meaningfully defined, a great window of opportunity will become available for empirically examining the special contributions psychological assessment can make in facilitating the recovery process from injury. Acknowledgements We are grateful to Dr. Jane Duckworth, Professor Emeritus, for her suggestion to examine MMPI-2 profile groupings; to John McKinney, ATC, Matt Ebert, OTR, and Lee Hines, ATC for their insightful discussions; to John Eddy who provided useful input regarding secondary gain issues; and to the late Karen Haney who assisted with the literature review.· References [1] Aronoff GM. The role of the pain center in the treat: ment for intractable suffering and disability resulting from chronic pain. In: Aronoff GM, ed. Evaluation and Treatment of Chronic Pain. Baltimore: Urban and Schwarzenberg, 1985. [2] Hazard RG, Fenwick JW, Kalisch SM, et al. Functional restoration with behavioral support: a one-year prospective study of patients with chronic low-back pain. Spine 1989;14(2):157-161. [3] Niemeyer LO, Jacobs K. Work-Hardening - State of the Art. Thorofare, New Jersey: Slack, Inc., 1989. [4] Sanders SH, Rucker KS, Anderson KO, et al. Clinical practice guidelines for chronic non-malignant pain syndrome patients. J Back Musculoskel Rehabil 1995;5:115-120. [5] Glueckauf RL. Use and misuse of assessment in rehabilitation: getting back to the basics. In: Glueckauf RL, Sechrest LB, Bond GR and McDonel EC, eds. Improving Assessment in Rehabilitation 'and Health. Newbury Park, California: Sage Publications, Inc., 1993. [6] Turk DC, Melzack R. Handbook of Pain Assessment. New York: Guilford Press, 1992.
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[7] [8] [9] [10] (11) [12]
Bernstein IH, Jaremko ME, Hinckley BS. On the utility of the SCL-90-R with low-back pain patients. Spine 1994; 19(1):42-48. Kerns RD, Turk DC, Rudy TE. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain 1985;23:345-356. Rosenstiel AK, Keefe FJ. The use of coping strategies in low-back pain patients: relationship to patient characteristics and current adjustment. Pain 1983;17:33-40. Greene RL. The MMPI-2/MMPI: An Interpretive Manual. Boston: Allyn and Bacon, 1991. Butcher IN, Dahlstrom WG, Graham JR, et al. MMPI-2 Manual for Administration and Scoring. Minneapolis: University of Minnesota Press, 1989. Graham JR. MMPI-2 - Assessing Personality and Psy-
[13]
[14] (15) [16]
51
chopathology (2nd edn.). New York: Oxford University Press, 1993. Duckworth JC, Anderson WP. MMPI and MMPI-2: Interpretive Manual for Counselors and Clinicians (4th edn.) Bristol, Pennsylvania: Accelerated Development, 1995. Dictionary of Occupational Titles (4th edn. revised). US Department of Labor, 1991. Matheson LN. 'How do you know that he tried his best?' - the reliability crisis in industrial rehabilitation. Ind Rehabil Q 1988;1(1):1-3. Thrift. RD. The use of the MMPI in identifying personality factors affecting maximum voluntary effort in a chronic low back pain rehabilitation program. Unpublished doctoral dissertation, 1989, University of Miami.
