Chronic Pain Problems Research Articles

Chronic pain: The case for prevention

Although behavioral methods can produce clinically and statistically significant improvements for patients with chronic musculoskeletal pain, there is a need for preventive interventions. This paper examines current statistics concerning the development of chronic pain and the need for prevention. Considerable resources and suffering might be saved if effective preventive methods are developed, and there are advantages in intitiating early intervention. Behavioral methods for prevention are not well developed, but knowledge concerning the development of chronic pain problems as well as the treatment of chronic pain patients forms a base from which preventive measures might be built. Some examples of behavioral programs for the secondary and primary prevention of chronic pain are presented. The results from these first attempts have been positive and merit further exploration.

Impact of chronic pain on the spouse: Marital, emotional and physical consequences

The effects of chronic illness on marital relationships and the spouses' emotional and physical health were examined in chronic pain patients, their spouses, and a control sample of spouses of diabetic patients. Results indicated that pain patients and their spouses experienced considerable change in marital and sexual satisfaction. Patients with better marital adjustment also reported higher overall pain levels and had more solicitous and maritally satisfied spouses. Spouses' marital adjustment was positively associated with patients' marital satisfaction and spouses' own mood. Spouses' dysphoric mood was related to patients' negative appraisal of the pain experience, spouses' perceived lack of life control, and spouses' marital dissatisfaction. Although spouses of chronic pain patients showed no more physical symptoms than spouses of diabetics, they reported significantly more pain symptoms that were related to elevated levels of depressed mood. The results indicate that not only is chronic pain associated with problems in the marital relationship but heightened distress and physical symptoms is spouses as well. These effects are related less to the existence of a chronic pain problem per se but rather to patients' and spouses' manner of coping with the situation.

Mediating factors in non-medical treatment for migraine headache: Toward an interactional model

The inadequacy of traditional (i.e. pharmacological) treatment for migraine headache has led to the development of numerous non-medical interventions (e.g. biofeedback, relaxation, cognitive-behavioral programs). All of these non-medical interventions have produced at least some success in reducing migraine headache parameters. However the mechanism of treatment efficacy is unclear, with a number of not mutually exclusive relationships proposed. Purported mediators of successful outcome in these treatments include specific control of vascular activity, general reduction of automatic arousal, biochemical changes, cognitive, affective, and behavioral change, therapist contact and support, and credibility and placebo expectancy. The present paper attempts to discuss and evaluate the mechanisms of change that have been proposed as mediators of successful treatment of migraine headache. An interactional model of adaptive change as a function of treatment is presented. The implications of the model for assessment and treatment are discussed. It is suggested that the interactional model may be applicable to the treatment of a range of chronic pain problems.

New directions in the understanding and management of pain

Control of pain and the suffering that it causes still eludes us. Despite impressive progress in the prevention and cure of disease and in care of the trauma victim, pain is still a frontier in medical research. It accompanies surgery, various diagnostic procedures and dental care as well as acute injury and disease. For a significant number of patients it persists after injury or illness into a chronic state. Chronic pain is recognized to be the most frequent cause of disability in the United States and many industrialized nations today, and is a major cost to society in both work hours lost and medical expenses. In addition to its social importance, pain is an intimate cause of personal concern for every human being throughout life. The progress, or lack of progress, achieved by medical research in pain control is of interest to us all. Pain disorders may be usefully classified in two categories: acute and chronic. The etiology, physiopathology, symptomatology, diagnosis and therapy of these two types of pain are quite different and require separate consideration. Acute pain is that which arises from an acute injury or disease process and persists only as long as the tissue pathology itself. If acute pain problems are not effectively treated, they may progress to chronic states. Chronic pain is that: (1) associated with chronic tissue pathology; or (2) which persists beyond the normal healing period for an acute injury or disease. There are unique challenges for health care providers associated with each of these two categories of problems, and failure to distinguish between these types of pain has led to a widespread, ongoing mismanagement of patients that can be prevented if strong efforts are made to better educate health care professionals about pain and its therapy. This paper presents an overview of current understanding about the nature of pain and its management. The physiology and psychology of pain are reviewed against a background of the concepts and information taught 25 years ago. Some common acute and chronic pain problems are reviewed and discussed. Finally, several new directions in pain control are described.

Chronic Pain

A complex problem of vast dimensions, chronic pain is receiving increasing attention due to the expansion of knowledge of the neurophysiology, neurochemistry and psychology of pain. Chronic pain presents a challenge to many disciplines in the health professions, and one that is more recently being presented to the psychiatrist.This paper will attempt to define the problem of chronic pain, to explore the concept of organic versus psychogenic pain, to describe the psychodynamics and other characteristics seen in the chronic pain patient and to discuss the importance of the psychiatristin evaluation and treatment of chronic pain .

Psychologic assessment technology for geriatric practice.

Psychologic assessment is an integral aspect of the comprehensive functional assessment of geriatric patients. Medical areas in which psychologic testing and evaluation can be of significant service in the diagnosis and formulation of treatment plans include psychiatric and neurologic disturbances, psychosomatic disorders, circulatory diseases (especially hypertension), diabetes, chronic pain, sexual dysfunctions, and gastrointestinal problems. In the effort to gain an understanding of the total patient, it is important to clarify the effect of physical condition on a person's psychologic reactions as well as the impact of psychologic states on his/her biologic status. This orientation is particularly important in dealing with elderly patients because the interaction between the physical and the psychologic in this age group is exceedingly strong and significant. Despite the fact that research in the psychology of the aged is of long standing, the attention given by clinical psychologists to the provision of services to geriatric patients has been quite limited until recently. Many psychologic tests have been developed during the past 70 years, but relatively few of them have been standardized for use with the aged. Of late, however, this has been changing. Several tests have been adapted, and some new ones have been organized with the needs and characteristics of the aged in mind. Closer attention has been paid to psychometric principles in the development of the tests, leading to the organization of useful norms and the demonstration of proper levels of reliability and validity. Accordingly, the state of the art of psychologic assessment of the aged is currently rather limited, but the outlook for the near future appears encouraging. In evaluating the condition of a geriatric patient, the clinical psychologist normally generates data through observations, testing, and interviewing. The resulting report covers the following areas: 1) adaptation to the examination and behavioral characteristics during the procedure, 2) cognitive functioning, 3) visual motor coordination and perception of spatial relationships, and 4) personality characteristics and mental health status. Data for the first area are normally derived by the examiner from observations and subjective impressions of the patient's behavior. For each of the other areas the information is obtained through standardized tests. In this discussion, some of the principal assessments that are currently available are reviewed and evaluated for their usefulness with the aged.

A review of follow-up studies of multidisciplinary pain units

Chronic pain is a major public health problem in the United States. Estimates from the National Institutes of Health put the cost of chronic pain at 40 billion dollars a year. They estimate that as many as 15 million adults suffer from low back pain with a minimum cost of 5 billion dollars in direct medical costs and 93 million work days lost every year. In an attempt to cope with this massive problem, multidisciplinary pain units have arisen which attempt to address the complex, multi-faceted aspects of a chronic pain problem. The importance of this new treatment approach is made evident by the 1981 overview of multidisciplinary pain centers published by the National Institutes of Health. In this publication, the history and success of these units since their first development by Bonica are evidenced. The purpose of the present paper is to briefly, critically summarize one small aspect of these programs, specifically follow-up analysis of the patients after discharge.

The Modified Somatic Perception Questionnaire (MSPQ).

The development of a new scale to measure somatic and autonomic perception, the Modified Somatic Perception Questionnaire or MSPQ is described. It has been derived specifically for use with chronic backache patients, although its utility with other chronic pain problems is currently under investigation. Following pilot studies on anxious patients and normal controls a pool of items was subjected to reliability checks and parallel-form analysis. The final 13 item scale was derived from a pilot study of 102 chronic backache patients and its construct validity confirmed on a further study of 200 backache patients. Sex differences in the use of the scale were integrated into the final version. The scale was compared with the Zung Depression Inventory and the first three clinical scales of the M.M.P.I. Individual items were compared with clinical symptomatology rated independently by an orthopaedic surgeon. In a small experimental study the MSPQ was compared with electromyographic readings from the erector spinae muscles and biceps, with the rating of pain using the McGill Pain Questionnaire, and with experimental ischaemic pain using the submaximum effort tourniquet test. In other studies the scale has been shown to be of importance in the understanding of functional disability. Its predictive validity in response to treatment is currently under investigation in studies of spinal fusion, chemonucleosis and multidisciplinary pain programmes. The simple 13 item four-point self-report scale is easy to administer, has high patient compliance and, in conjunction with measures of depressive symptomatology and inappropriate signs and symptoms would seem to be of considerable promise in the understanding of the sequelae of backache and much more sensitive than traditional measures of personality structure.

Outline of a fear-avoidance model of exaggerated pain perception—I

The present paper describes a theoretical model for exaggerated pain perception which has been generated from a multidisciplinary team approach to the problem of chronic low-back pain. The model is an attempt to explain how and why some individuals develop a more substantial psychological overlay to their pain problem than do others. Central to the model is the concept of ‘fear of pain’ which, it is suggested, leads to differing responses in different individuals. The two extreme responses are those of ‘confrontation’ and ‘avoidance’, although most individuals probably exhibit a mixture of the two. The former, it is argued, leads the individual to resume an increasing range of physical and social activities as the organic basis for the pain resolves and, as a consequence, ensures minimal psychological overlay. By contrast, an avoidance strategy is thought to produce a number of physical and psychological consequences which promote the development of the invalid status and the phenomenon of exaggerated pain perception. The model suggests that the type of strategy adopted (i.e. confrontation or avoidance) is influenced by a number of psychosocial factors.

A review of cognitive-behavioural methods for the treatment of chronic pain

Cognitive-behavioural methods for the treatment of chronic pain are described. They are divided into two categories. Firstly, those directly concerned with modifying pain related cognitions. These include distraction or relabelling techniques derived largely from analogue studies on experimental pain which show that various cognitive strategies can increase pain tolerance levels. Secondly, those concerned with modifying cognitive responses to stress. These include stress management techniques derived from the research on anxiety management. Outcome studies for both categories of cognitive methods and for a range of chronic pain problems are reviewed. It is concluded that although outcome studies report favourable results for cognitive methods there is a paucity of well controlled and evaluated studies.

Role of the Psychiatrist in Personal Injury Litigation

Psychiatry has been insufficiently attendant to the demands being placed on it by an ever-growing volume of personal injury or tort litigation. Increasing attention to chronic pain problems and the subtle behavioral sequelae of closed head injuries often challenge the diagnostic skills of psychiatrists. This article reviews additional diagnostic approaches that are perhaps insufficiently utilized. It is suggested that increasing attention be paid in both training and the quality of services in this area.

A standardized evaluation of psychosocial factors in chronic pain

A number of psychosocial factors are generally considered to be important in exacerbating and maintaining chronic pain problems. However, standardized and reliable methods of evaluating these factors are needed. We have developed such an evaluation system, called the Psychosocial Pain Inventory (PSPI), and have obtained normative data from a large sample of chronic pain patients. Scores on the PSPI were approximately normally distributed and had good inter-rater reliability. Patients with high PSPI scores were more likely to be considered exaggerating their symptoms during their physical examinations, but they did not show less evidence of an organic basis for pain. Significant correlations were obtained between PSPI scores and some measures from the McGill Pain Questionnaire, but scores on the PSPI were essentially unrelated to personality disturbance as measured by the Minnesota Multiphasic Personality Inventory (MMPI). The PSPI and MMPI appear to provide different types of information that can be used in a complementary way in evaluating pain patients. Results of a small pilot study suggest that high scores on the PSPI predict poor response to medical treatment for pain.

New insights into the old problem of chronic pelvic pain

Between July, 1974 and February, 1979, 109 adolescent girls, ranging in age from 10 1/2 to 19 yr. with unexplained chronic pelvic pain, underwent diagnostic laparoscopy. Endometriosis was the most common finding occurring in 49 patients (45%), followed by postoperative adhesions in 17 patients (16%) and congenital abnormalities of the uterus in 10 patients (9%). Other important causes were chronic pelvic inflammatory disease with peritubal and periovarian adhesions in 9%, chronic hemoperitoneum in 5%, functional ovarian cysts in 5%, and uterine serositis in 2%. No pathology could be seen in 10 patients (9%). Analysis of the presenting symptoms and physical findings revealed in most instances that the presence of significant pelvic pathology as a cause of the chronic pelvic pain was predictable and had been previously misdiagnosed. Intraoperative and postoperative management of the major problems encountered stress the importance of conservative surgery and the need for long-term follow-up.

On attempting selective blockade of dorsal root C fibers in the treatment of chronic pain problems

Twelve patients with intractable pain due to metastatic cancer were treated with either one or two subarachnoid infusions of sterile distilled water. All patients experienced some pain relief lasting from 9 to 90 days. Clinical testing of six patients suggested that dorsal root C fibers may have been preferentially blocked by the infusions, as would be predicted from previous animal experiments.

Acupuncture in chronic pain.

A course of 10 daily acupuncture treatments was given to 200 patients who suffered from chronic pain syndromes of at least one year duration and the result assessed at the end of the course of treatment and after an interval of at least 2 months. Treatments were individualized using needling of body loci distally and near the site of pain, and ear acupuncture. In 38 patients suffering from chronic headaches, including 13 cases of migraine-type headache, 81% reported an improvement in their condition, but only one patient was pain free for the 2-month observation period. In 162 patients with other chronic pain problems, 99 or 61% were improved or pain free at the end of treatment; in 69 of these a worthwhile degree of improvement persisted over the observation period of 2 months. Thirteen percent of all patients did not respond to acupuncture and in 26% the response was considered as transient only. Daily treatments are not more effective than weekly or biweekly treatments. Pain in the neck and shoulder region, in the knee and low back pain responded to acupuncture with prolonged improvement in over 50% of the patients treated. Facial pain syndromes and pain in the region of the trunk were least responsive and only 3 of 11 patients with post-herpetic neuralgia reported still having less pain after 2 months. Needling of effective loci and particularly ear needling often causes an instantaneous reduction or disappearance of pain; the speed of this response can only be explained by a mechanism within the nervous system. Based on our experience acupuncture represents a useful therapeutic modality in the management of pain.

Percutaneous trial of stimulation for patient selection for implantable stimulating devices.

The author describes a flexible electrode which can be inserted percutaneously for a period of several days in candidates for an implantable electrical stimulating device for pain relief. This allows the patient a trial of stimulation which closely mimics that of the intended implantable system. If this trial does not give adequate pain relief in a variety of situations, the patient is not considered to be a suitable candidate for an implantable device. The trial of stimulation in no way obviates the need for careful scrutiny of the social and psychological factors accompanying chronic pain problems.

Naloxone Reversal of Pentazocine-Induced Respiratory Depression

To Editor:— Pentazocine lactate (Talwin Injectable) can produce respiratory depression when given in large doses or when given to susceptible patients. Naloxone hydrochloride (Narcan) is an antagonist for pentazocine, as well as narcotic analgesics. Pentazocine lactate has recently been introduced for relief of pain in surgical, neurologic, obstetric, and medical disorders and as a supplement to surgical anesthesia. It is a member of benzomorphan series and differs from other narcotic analgesics principally and importantly because of absence of addiction liability. 1 It is consequently exempt from narcotic control regulations; thus it is likely to find widespread use for chronic pain problems. It is capable of producing respiratory depression when administered in large doses or to certain susceptible patients. The manufacturer's drug description 2 states that the usual narcotic antagonists, such as nalorphine, are not effective respiratory stimulants for depression due to pentazocine lactate. Methylphenidate (Ritalin) is

Some implications of learning in problems of chronic pain

Some implications of learning in problems of chronic pain

An application of behavior modification technique to a problem of chronic pain

An application of behavior modification technique to a problem of chronic pain

CHRONIC GASTRIC ULCER ASSOCIATED WITH ASPIRIN INGESTION. A REPORT OF 5 CASES AND REVIEW OF THE LITERATURE.

Five cases of chronic gastric ulcer, each associated with the ingestion of a large amount of salicylates prior to the onset of symptomatology and discovery of the ulcer, are presented. Each of these individuals had a benign, chronic pain problem. It appeared that the gastric ulceration occurred through some local action of the salicylate on the stomach as a result of the long-term salicylate ingestion. Healing of the ulcer took place only after discontinuation of the salicylates. It is apparent from a review of the clinical and experimental studies of various authors that aspirin, other salicylates, and aspirin-containing compounds, can produce a local irritative and destructive lesion in the human gastric mucosa. This has been demonstrated in different studies by direct visualization following ingestion of the compound, both gastroscopically and in surgical specimens. Isotopic blood-loss studies have consistently demonstrated occult blood loss in the stools of individuals taking salicylates. Control of these studies using other compounds known to produce gastroduodenal ulceration on a long-term basis did not produce similar bleeding. The triad of chronic pain, aspirin ingestion, and chronic gastric ulcer has been commented upon by several foreign authors.