Subjective Pain Scale Research Articles

Spinal Rehabilitation by Work Tolerance Based on Objective Physical Capacity Assessment of Dysfunction

A work tolerance program was used for rehabilitation treatment of 45 patients with spinal dysfunction. Patients entering the treatment group were prospectively evaluated by objective physical capacity assessment (PCA). Treatment patients averaged 4 weeks of three, one half day sessions per week. These patients were compared with a control group of 33 patients who did not participate in the rehabilitation program but were evaluated by PCA. A telephone review of all patients in each group was carried out at 6- and 12-month follow-up. Results demonstrated that 78% of the rehabilitation treatment group were discharged with an improved functional work capacity. Most importantly, at 6-month follow-up, 73.0% of patients in the treatment group were productively working while only 38% of control group patients were actively employed. In addition, 84.4% showed an improvement in spinal range of motion. The subjective pain scale ratings of these treatment patients demonstrated only 44.4% decreased pain, while 51.1% stayed the same, and two patients increased discomfort. Further medical diagnostics or intervention was required in 24.4% of treatment patients. These findings definitely show that a spinal rehabilitation work-tolerance program based on objective measurement will enhance an increased rate of return to productive employment activity. There is poor correlation of subjective pain assessment when compared to objective PCAs. Therefore, recommendations of patients for return-to-productive work should be based pain ratings. When adjusted for nonselection patients, the authors community-based hospital program showed similar results to other programs. The work tolerance and rehabilitation program in Concord, New Hampshire, demonstrated a significant cost-effective approach; being less expensive, less time-consuming, and less psychologically oriented.

Use of an Orthotic Device in the Treatment of Posterior Heel Pain

Research Funded by the Lexington Clinic Foundation for Research and Education. Posterior heel pain (PHP) presents a difficult clinical challenge. The causes of PHP include Haglund syndrome (pump bump deformity), Achilles tendinitis, and Sever's disease (retrocalcaneal bursitis, traction apophysitis). The purposes of this study were to 1) describe a new orthotic device used in the treatment of PHP and 2) evaluate the effectiveness of this device. The orthotic device consisted of a neoprene sleeve holding 1/4 inch PPT foam rubber horseshoe (Sports Supports, Inc., Dallas, TX). The horseshoe was placed directly over the injury to protect and relieve pressure or was inverted and used as a counterforce brace to reduce the tensile stress to the Achilles tendon. Eight patients (6 children, 2 adults) were evaluated at the time of application and after 1 month of use. Three criteria were considered: 1) subjective pain scale, 2) active goniometric measurements, and 3) toe raise test. The statistical analysis indicated a significant improvement in pain during activity from initial to follow-up and in pain after activity from initial to follow-up. All patients demonstrated improved strength and flexibility. It was concluded that this device may be an effective adjunct to the treatment of PHP. J Orthop Sports Phys Ther 1990;11(9):410-413.

Senior Author's Response

I wish to thank Dr. Deusinger for his thoughtful comments on our study, specifically those relating to the use of parametric statistics for our pain data and the validity and reliability of our pain and activity self-rating scales. To my knowledge, the activity self-rating we used is not an established assessment and has not been studied. Objections to its use are justified. I would, however, like to respond to points raised about measurement and data analysis of pain. Pain is subjective, highly personal, and influenced by psychological, cultural, ethnic, and social factors.1 It is difficult to measure. Concerns about the validity and reliability of subjective pain scales have been raised by others, as well as by Dr. Deusinger.1–3 Excellent reviews of pain assessments, including strengths and limitations of various scales, are found in articles by Keefe and colleagues1 and by Syrjala and Chapman.2

Cortical power spectral analysis of acute pathophysiological pain.

In the past decade, advances in quantitative EEG methods, such as the analysis of cortical power spectrum, have proven a useful tool for observing changes in brain activity as a function of physiological and behavioral states. The cortical power spectrum (CPS) is a computer-derived analysis of brain electrical activity using mathematical principles of Fast Fourier Transform function. The total energy output of specific cortical areas can be estimated over time, as a function of EEG spectral frequencies. This report describes the study of CPS in pathophysiological pain patients, using acute dental pain as a model. Seven "walk-in" acute pain patients in an emergency dental clinic were recorded during 10 min of pain, before treatment. Approximately one week later, 10 min recordings during nonpain states were obtained as control. Subjective pain scales and other psychological measures were administered to all subjects before and after recording on each visit. Each 10 min stage of continuous CPS recording consisted of 10 spectra per stage, 6 epochs/spectrum, and 10.24 sec/epoch; each spectrum was stored, averaged, transformed, displayed, printed, and plotted by the Pain Microcomputer System. Results show significant cortical power reduction along all frequency bands (0.5-50 Hz) when pain-states are compared to nonpain states. The magnitude of reduction also appears to correspond to subjective pain report. Analysis for rank order may be inversely related to subjective painfulness, indicating that pain and alpha-desynchronization are closely associated. This study demonstrates that the brain activity of clinical pain patients can be measured. The feasibility of developing a pathophysiological objective pain measuring system is discussed.

Tryptophan loading may reverse tolerance to opiate analgesics in humans: A preliminary report

Five patients on chronic opiate medication to treat low-back and leg pain were determined to have developed opiate tolerance on the basis of their failure to obtain significant relief (rated on a subjective pain scale and by the degree of straight leg-raising they were able to endure) after receiving 30 mg of morphine administered i.v. in divided doses over 35 min. After these patients' diets had been supplemented with 4 g/day of l-tryptophan for 2–9 weeks, they achieved significant relief from pain when the opiate tolerance test was re-administered, and were able to lead more active lives while reducing their daily opiate intake. Chronic opiate administration probably reduces the serotonin turnover rate in the central nervous system; it may be that this is reversed by loading with the serotonin precursor, l-tryptophan.