The SPADE Symptom Cluster in Primary Care Patients With Chronic Pain

Abstract

Objectives Sleep disturbance, pain, anxiety, depression and low energy/fatigue, the SPADE pentad, are the most prevalent and co-occurring symptoms in the general population and clinical practice. Co-occurrence of SPADE symptoms may produce additive impairment and negatively affect treatment response, potentially undermining patients' health and functioning. The purpose of this paper is to determine: (1) prevalence and comorbidity (i.e., clustering) of SPADE symptoms; (2) internal reliability and construct validity of a composite SPADE symptom score derived from the Patient-Reported Outcomes Measurement Information System (PROMIS) measures; and (3) whether improvement in somatic symptom burden represented by a composite score predicted subsequent measures of functional status at 3 and 12 months follow-up. Methods Secondary analysis of data from the Stepped Care to Optimize Pain care Effectiveness study, a randomized trial of a collaborative care intervention for Veterans with chronic pain. Results Most patients had multiple SPADE symptoms; only 9.6% of patients were monosymptomatic. The composite PROMIS symptom score had good internal reliability (Cronbach's alpha = 0.86) and construct validity and strongly correlated with multiple measures of functional status; improvement in the composite score significantly correlated with higher scores for five of six functional status outcomes. The standardized error of measurement for the raw composite score was 2.84, suggesting a 3-point difference in an individual's composite score may be clinically meaningful. Discussion Brief PROMIS measures may be useful in evaluating SPADE symptoms and overall symptom burden. Because symptom burden may predict functional status outcomes, better identification and management of comorbid symptoms may be warranted.

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“…Such an observation has given rise to the study of symptom clusters (Miaskowski, Dodd, & Lee, 2004) A common symptom cluster observed within the context of primary care is composed of sleep disturbance, pain, anxiety, depression, and low energy/fatigue (SPADE) (Davis, Kroenke, Monahan, Kean, & Stump, 2016). In this study of 250 patients with musculoskeletal pain, only 9.6% were monosymptomatic while 20% of the sample had all 5 symptoms in the SPADE cluster.…”

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“…For example, the co‐occurrence of pain and depression ranges from 30% to 50%, and several prospective studies have shown bidirectional relationships between pain, insomnia, fatigue, and emotional distress . Although treatment of an individual symptom can be complicated by co‐occurrence of other symptoms (eg, pain modifying the response to depression treatment), interventions that improve overall symptom burden are associated with subsequent improvement in patient‐reported functioning . Taken together, optimal patient‐centered care requires the assessment and management of multiple co‐occurring symptoms.…”

“…[5][6][7][8] Although treatment of an individual symptom can be complicated by co-occurrence of other symptoms (eg, pain modifying the response to depression treatment 9 ), interventions that improve overall symptom burden are associated with subsequent improvement in patient-reported functioning. 10,11 Taken together, optimal patient-centered care requires the assessment and management of multiple cooccurring symptoms.…”