Effect of spirituality on successful recovery from spinal surgery.

ABSTRACT

Background. Many patients believe prayer helps them recover from health problems. Benefits of spirituality on other illnesses and surgical procedures have been reported. It is unknown whether patients with strong spiritual beliefs have a greater propensity for successful recovery from spinal surgery.

Methods. In this study, 188 patients having spinal surgery completed the visual analog pain scale (VAS) and the Oswestry functional capacity questionnaire (OSW) before and after operation, and the scores were used to assess surgical outcome. Degree of spirituality was assessed using the INSPIRIT survey.

Results Paired test revealed significant improvements in both the VAS and OSW outcome measures. Linear regression analysis revealed no correlation between change in either VAS or OSW.

Conclusions. These results suggest that recovery from spinal surgery may be more dependent on proper patient selection and surgical technique than on patient spiritual beliefs.

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PHYSICIANS are routinely instructed on how to care for their patients' medical needs and how to relieve health-related concerns, but they are rarely encouraged to inquire about their patients' spiritual beliefs. (1) The term spirituality can have many meanings, but it generally contains the following elements: meaning and purpose in life, transcendence, connection with others, and spiritual energy. (2) The areas of religion and spirituality are often ignored in the doctor-patient relationship either to avoid any potential conflict or because the physician or patient believes the subject is not relevant to the patient's medical care. The omission of these discussions of religious faith is not the result of a lack of belief among physicians. A recent national survey of family physicians revealed that 79% had a strong religious or spiritual orientation. (3) In another survey, 96% of physicians considered spiritual well-being an important health consideration, but most reported infrequent discussions of faith or referrals to chaplains either because of lack of time or training in this area. (4)

Although it might not be expected in light of the increasing levels of violence in our society, belief in God has remained relatively stable over the past 40 years, and two thirds of respondents to a recent Gallup Poll believed religion could answer all or most contemporary problems. (5) Additionally, 90% of Americans responded that they pray, and 97% of those respondents believe their prayers are heard. Because of their strong spiritual beliefs, many patients have expressed a desire for their physicians to include elements of spirituality in their treatment. (6-8)

A recent study examined patients' acceptance of spirituality-based questions during the medical history. (9) It was reported that 51% of patients considered themselves religious, and 90% believed recovery from an illness could be influenced by prayer. Two thirds of patients indicated they would welcome questions regarding spirituality during the medical history.

Previous studies have investigated the effects of patients' spirituality on their health and recovery from disease. Patients with higher levels of spirituality have the following reported benefits: less burdened by illness, (10) less depressed, (11) greater life satisfaction, (12) lower blood pressure, (13,14) fewer strokes, (15) lower mortality rates from coronary artery disease and cardiac surgery, (16,17) improved obstetric outcomes, (8) and utilization of fewer health services in general. (18) The positive results reported in many of these studies may be attributed to a positive patient attitude. The positive effects of intercessory prayer have also been documented in a double-blind study of patients in a cardiac care unit. (19)

Outcomes of spinal surgery have been previously shown to be influenced by various patient factors, including age, sex, muscle strength, psychologic profile, work environment, workers' compensation, educational status, and litigation. (20-25) The purpose of this study was to investigate the effect of patients' level of spirituality on the outcome of spinal surgery.

METHODS

Patients having spinal surgery during 1998 were asked to participate in this study. All patients were eligible regardless of surgical indications, procedure, workers' compensation, age, sex, or other patient factors. Of the 188 patients who participated in the study, 78 (41%) were male and 110 (59%) were female. The mean age was 52 years (range, 16 to 84 years). Fifty-four patients (29%) were smokers, 43 (23%) were drinkers, and 28 (15%) were involved with workers' compensation.

Outcomes were evaluated using the visual analog pain scale (VAS) and the Oswestry functional capacity questionnaire (OSW). Patients completed these forms preoperatively and postoperatively, and the data were analyzed using a paired t test to reveal any significant changes in pain or functional capacity after surgery.

Patients' level of spirituality was quantified using the Index of Core Spiritual Experiences (INSPIRIT). (26) This questionnaire provided a score for each patient's spirituality on a scale of 1 to 4, with 4 representing the highest level of spirituality. Data were analyzed to determine whether any correlation existed between the INSPIRIT score and improvements in the VAS and OSW scores.

Patients were then categorized into three levels of spirituality based on the INSPIRIT scores. High spirituality was defined as a score above 3.0, moderate was a score from 2.0 to 2.9, and low was a score from 1.0 to 1.9. Changes in VAS and OSW were compared among these three groups of patients, and ANOVA was used to identify any significant differences.

RESULTS

Paired t tests revealed significant improvements in both VAS and OSW after surgery (P < .001). The mean improvement in VAS was 38% and in OSW, 26%. Linear regression analysis revealed no correlation between either the change in VAS (r = .006) or 08W (r = .017) and the INSPIRIT score. Graphs were done to plot the changes in VAS (Fig 1) and OSW (Fig 2) as a function of INSPIRIT, with a best fit linear approximation through the data.

Patients were categorized as having high, moderate, or low levels of spirituality, and their outcome measures were analyzed using ANOVA to compare these three groups of patients (Table). A large proportion of the patients (79%) had a high level of spirituality. These categorical data showed no significant differences in outcome data.

DISCUSSION

Previous reports have documented a correlation between degree of spirituality and chance of successful recovery from various illnesses or surgical procedures. (13-17) No studies have investigated the effects of spirituality on the recovery from spinal surgery.

As in previous studies, the INSPIRIT form was used in this study to quantify patients' level of spirituality. (27) This questionnaire focuses on experiences that the patient interprets as spiritual, as opposed to some other surveys that focus on the patient's cognitive beliefs. It has been independently evaluated and found to reflect intrinsic religiosity. (28)

In contrast to previous reports from other medical fields, we were unable to correlate a patient's level of spirituality with outcome of spinal surgery. Significant improvements in outcome measurements were obtained in the study population without regard to spirituality, but no greater improvements were seen with increasing levels of spirituality.

Although it is not possible to definitively determine why no correlation was found, there are several possibilities. The first of these is the level of morbidity and mortality associated with our patient population as compared with those in previous studies. Many of the previous studies were investigating much more debilitated patient populations, including burn victims, cancer patients, and cardiac and transplant surgery patients. (17,29,30) It is likely that the improvement of these patients is much more dependent on a positive outlook and a strong desire to recover than is found in patients undergoing spinal surgery. While patient factors do play a role in spinal surgery, a good result is likely to be more dependent on proper patient selection, good surgical technique, and adequate postoperative rehabilitation. A key difference is that in spinal surgery there is often a specific mechanical problem that is responsible for the patient's disorder. If this mechanical problem is appropriately identified and cor rected, the patient's condition should improve. As a result, there is less influence on outside factors as compared with patients in previous studies who were affected by more systemic disorders without a single identifiable and treatable cause.

A second explanation is that the high overall success rate of the study's patient population left little room for additional improvement due to spirituality. Significant improvements in Outcome measurements were obtained in this study without regard to spirituality. It is possible that if the study population had not had such positive outcomes, there may have been more of an identifiable influence of spirituality.

The results of this study do not intend to dispute that a patient's strong spiritual belief is beneficial to his medical care. A positive attitude and strong spirituality can provide the patient with the necessary emotional stability and determination to fight to recover from many illnesses. These beliefs should be supported and encouraged by physicians, since they can only be beneficial to a patient's recovery.

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TABLE

Outcomes Data Categorized by Spirituality Level

                             Mean VAS         Mean OSW
Spirituality  INSPIRIT        Change     P     Change     P
   Level       Range    No.    (%)     Value    (%)     Value

High          3.0-4.0   148     38      .85      30      .47
Moderate      2.0-2.9    25     35      .24      22      .36
Low           1.0-1.9     9     53              -27 *

INSPIRIT = Index of Core Spiritual Experiences, VAS = visual analog pain
scale, OSW = Oswestry function capacity questionnaire.

* Negative % represents a worse postoperative value.

References

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KEY POINTS

* Previous studies have found that patient spirituality has a positive influence on medical illness and recovery from surgery.

* Postoperative changes in pain and functional capacity were assessed in 188 spinal surgery patients.

* Patient spirituality was assessed using INSPIRIT, which focuses on the patient's experiences that the patient interprets as spiritual, as opposed to some other surveys that focus on the patient's cognitive beliefs.

* Significant improvements in outcome measurements were obtained in the study population without regard to spirituality, but there were no greater improvements seen with increasing levels of spirituality.

* In spinal surgery, often a specific mechanical problem is responsible for the patient's disorder. If this problem is identified and corrected, the patient should improve, thus limiting the effect of factors such as spirituality

From the center for Sports Medicine and Orthopaedics, Foundation for Research, Chattanooga, Tenn.

Reprint requests to Jason C. Eck, MS. 916 Cherrywood Apts, 1200 Little Gloucester Rd, Clementon, NJ 08021.