Who needs Spine Surgery?
Selecting appropriate surgical patients poses a challenge for spine surgeons. Research has concentrated on psychological factors for outcome prediction. Initially, screening profiles were employed to identify personality traits linked to low back pain.
The Minnesota Multiphasic Personality Inventory (MMPI) revealed traits such as hypochondriasis and hysteria in patients with functional low back pain. However, this method encountered challenges in outcome prediction.
A more refined approach emerged with the biopsychosocial theory of pain, which considers factors like worker’s compensation and social support. Patient-centered outcomes encompass pain, disability, and work capacity.
Significant attempts are underway to create a screening tool that can predict the success of spine surgery, but a widely accepted measure is still lacking. Current research is focused on investigating the resilience and grit of orthopedic surgical candidates, with the potential for improvement through therapy and positive impact on surgical outcomes.
This review delves into the development of screening tools, defines psychological concepts, explores their relevance to clinical outcomes, and investigates their implications for preoperative assessments conducted by spine surgeons.
Previous Attempts In Patient Selection For Spine Surgery
The complex interplay of psychology, societal factors, and underlying pathology poses a challenge in developing a reliable tool for patient selection in spine surgery. Various presurgical psychological screening (PPS) scorecards have been tested, taking into account personality, cognitive, behavioral, and environmental factors.
However, the long-term predictive abilities and practical applicability of these scorecards in clinical practice are still uncertain. Ongoing research focuses on refining the PPS by potentially integrating parameters such as grit and resilience. Successful implementation will require further investigation and the use of objective outcome measures.
Psychosocial Metrics
The response of individuals to surgery is influenced by complex psychological concepts such as resilience, self-efficacy, and grit, which are shaped by social, cultural, and biological factors. However, there is variation in how these concepts are defined and utilized, underscoring the importance of exploring the latest understanding in this field.
Resilience
Resilience refers to the capacity to adjust and exhibit flexibility in the face of challenging life circumstances. It is connected to positive interpersonal connections, social proficiency, decreased healthcare utilization, and enhanced self-assessed health.
Resilience can be strengthened through therapeutic interventions and targeted approaches, and it has the ability to adapt in response to stress. Its definition may be impacted by its relationship with other psychological aspects, including positive mental well-being. In individuals with spinal cord injuries, high self-efficacy is associated with an increased display of resilient behaviors.
Measuring resilience is a complex task, and researchers employ a variety of scales for this purpose. Among the highly regarded scales are the Brief Resilience Scale (BRS), Connor-Davidson Resilience Scale (CD-RISC), and Resilience Scale for adults (RSA). However, these scales are considered to have a moderate level of quality.
The BRS focuses on personal agency, while the CD-RISC assesses factors such as competence and relationships. The RSA examines both interpersonal and intrapersonal factors. Some criticism has been raised regarding the overemphasis on individual factors at the expense of environmental factors in these scales. Nonetheless, these scales have been applied in studies involving orthopedic patients.
Patient Activation
In recognizing the essential role patients play in managing their health, Hibbard et al developed the concept of patient activation, closely linked to resilience.
This concept comprises four domains: understanding the significance of the patient’s role, possessing the necessary confidence and knowledge to take action, actively participating in maintaining and enhancing health, and persisting in the face of challenges.
Patient activation is widely regarded as a strong predictor of health outcomes, especially in chronic illnesses, and exhibits particular potential within the realm of spinal surgery.
The assessment of patient activation, which examines the level of patient engagement and self-assurance in healthcare, bears resemblance to the concept of resilience.
It evaluates the extent to which a patient is willing to collaborate with healthcare providers and adhere to treatment plans, even in challenging situations. The 22-item patient activation measure (PAM-22) and its subsequent version, the PAM-13, are established and trustworthy instruments for gauging this attribute.
Grit
Defined as the unwavering determination and passion to achieve long-term goals despite obstacles, grit is a personality trait. It has been linked to success among high-achieving individuals, irrespective of their talent and intelligence levels. Grit is associated with deriving happiness from engagement and meaningful pursuits, rather than pursuing instant gratification.
However, recent studies challenge the notion of grit as an entirely independent trait, suggesting that perseverance plays a more significant role in predicting success. Furthermore, there is some overlap between grit and the trait of self-control.
The measurement of grit commonly involves the use of either the 12-item Grit Scale or the revised 8-item Short Grit Scale (Grit-S), both of which exhibit satisfactory psychometric properties.
However, there is ongoing debate regarding the extent of overlap between grit and concepts such as perseverance and self-control. Recent evaluation of the Grit-S revealed a greater emphasis on consistency of interest rather than perseverance, prompting the development of a 5-item Grit Scale that specifically targets perseverance. This adapted scale demonstrates robust predictive capabilities for academic and career outcomes.
Self-Efficacy
An individual’s self-efficacy refers to their personal belief in their capacity to effectively perform in a specific situation or attain desired outcomes.
It involves the subjective perception of one’s own ability to carry out specific behaviors under particular circumstances. Self-efficacy has the potential to shape behaviors, activity levels, and achievements.
The pain self-efficacy questionnaire (PSEQ) is commonly used in the context of spinal surgery. It consists of 10 items and measures individuals’ confidence in performing activities despite ongoing pain.
Several metrics are available for assessing self-efficacy across various conditions, but a systematic review found that none of them were suitable for musculoskeletal rehabilitation.
Spine Surgery
Limited research has been conducted on resilience, patient activation, grit, and self-efficacy in the context of spinal surgery. Evidence suggests that low resilience and pain self-efficacy scores are associated with higher levels of functional disability in individuals with back and neck pain.
On the other hand, higher levels of patient activation are related to improved functional outcomes and increased participation in physical therapy. However, further research is needed to understand the role of grit in spinal surgery outcomes and the impact of self-efficacy.
The psychological factors of resilience, patient activation, grit, and self-efficacy show potential in predicting success in spine surgery. Resilience and patient activation are particularly strong metrics for assessing patients before surgery.
However, more research and standardized data collection are necessary to fully comprehend their impact on patient outcomes. Interventions targeting resilience improvement are an important area of focus. Continued study in this field has the potential to enhance preoperative risk assessment and ultimately improve patient outcomes.
Do you have more questions?
What is the biopsychosocial model of pain?
The biopsychosocial model of pain considers pain as a complex experience influenced by biological, psychological, and social factors. It recognizes that pain is not just a physical sensation but also affected by emotional and social contexts.
How does resilience affect surgical outcomes?
Resilience can positively impact surgical outcomes by helping patients cope better with stress, adhere to rehabilitation protocols, and maintain a positive outlook, which collectively contribute to faster and more successful recovery.
What are the main components of patient activation?
The main components of patient activation include understanding the importance of one’s role in health management, having the confidence and knowledge to take action, actively participating in maintaining and improving health, and persisting through challenges.
How is grit different from self-efficacy?
Grit refers to the perseverance and passion for long-term goals, focusing on sustained effort over time. Self-efficacy is the belief in one’s ability to perform specific tasks or achieve goals. While grit is about long-term commitment, self-efficacy is about confidence in handling specific situations.
What tools are used to measure resilience?
Common tools to measure resilience include the Brief Resilience Scale (BRS), the Connor-Davidson Resilience Scale (CD-RISC), and the Resilience Scale for Adults (RSA).
Can psychological interventions improve surgical outcomes?
Yes, psychological interventions can improve surgical outcomes by enhancing factors like resilience and self-efficacy, reducing preoperative anxiety, and promoting better adherence to postoperative care plans.
What role does patient activation play in recovery from spine surgery?
Patient activation plays a crucial role in recovery by ensuring patients are engaged in their care, adhere to treatment protocols, and proactively manage their health, leading to better functional outcomes and faster recover
Are there any criticisms of the current resilience scales?
Yes, criticisms include an overemphasis on individual factors at the expense of environmental factors, which can influence resilience. These scales may not fully capture the complexity of resilience.
How does low resilience affect patients with chronic pain?
Low resilience can lead to poorer coping strategies, higher levels of distress, and reduced adherence to treatment plans, resulting in worse functional outcomes and prolonged recovery.
What is the Pain Self-Efficacy Questionnaire (PSEQ)?
The PSEQ is a tool that measures a patient’s confidence in performing activities despite pain. It consists of 10 items and is widely used to assess self-efficacy in the context of chronic pain management.
Can grit be developed or improved through interventions?
While grit has a strong personality component, aspects like perseverance and resilience can be enhanced through targeted interventions, which can indirectly improve grit.
What are the implications of high patient activation levels?
High patient activation levels are associated with better health outcomes, increased adherence to treatment, and greater engagement in preventive health behaviors, leading to improved recovery and quality of life.
Why is there a need for standardized screening tools in spine surgery?
Standardized screening tools are needed to consistently assess and predict patient outcomes, identify patients who may benefit from additional psychological support, and tailor interventions to improve surgical success rates.
How is self-efficacy measured in patients undergoing spine surgery?
Self-efficacy in spine surgery patients is often measured using the Pain Self-Efficacy Questionnaire (PSEQ) or other condition-specific self-efficacy scales that assess confidence in managing pain and performing daily activities.
What challenges exist in integrating psychological factors into surgical assessments?
Challenges include the variability in how psychological factors are defined and measured, the need for validated and reliable screening tools, and the integration of these assessments into routine clinical practice.
How does worker’s compensation influence pain perception and recovery?
Worker’s compensation can affect pain perception and recovery by creating additional stress and possibly influencing patients’ motivation and engagement in recovery due to financial or occupational concerns.
What is the difference between the Grit Scale and the Short Grit Scale (Grit-S)?
The Grit Scale has 12 items and measures perseverance and passion for long-term goals. The Short Grit Scale (Grit-S) is a more concise version with 8 items, designed to measure the same traits with similar reliability.
Can resilience training be part of preoperative preparation?
Yes, resilience training can be part of preoperative preparation, helping patients develop better coping strategies, reduce stress, and improve their overall readiness for surgery.
How do social support systems influence surgical outcomes?
Strong social support systems can positively influence surgical outcomes by providing emotional support, practical assistance during recovery, and encouraging adherence to rehabilitation protocols.
What is the significance of the Connor-Davidson Resilience Scale (CD-RISC)?
The CD-RISC is significant for its comprehensive assessment of resilience, including personal competence, coping strategies, and adaptability, making it a valuable tool in evaluating patients’ resilience in various contexts.
How does self-control relate to grit?
Self-control is a component of grit, particularly in terms of maintaining focus and effort over time. However, recent studies suggest that perseverance, rather than self-control, plays a more critical role in long-term success.
What future research is needed in this field?
Future research should focus on refining psychological screening tools, understanding the interplay between different psychological factors, and developing standardized protocols for integrating these assessments into clinical practice.
How can surgeons use psychological assessments in preoperative evaluations?
Surgeons can use psychological assessments to identify patients at risk of poor outcomes, tailor preoperative counseling, design personalized intervention plans, and set realistic expectations for recovery.
What impact do resilience and self-efficacy have on adherence to postoperative care?
Higher resilience and self-efficacy are associated with better adherence to postoperative care, as patients are more likely to engage in rehabilitation, follow medical advice, and maintain a positive attitude toward recovery.
Are there any existing protocols for incorporating psychological assessments in spine surgery?
While there are no universally accepted protocols, some institutions have developed their own guidelines incorporating psychological assessments into preoperative evaluations. Standardization and wider adoption of these protocols are needed.
I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.
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