The prevention of chronic pain and disability: a preliminary investigation.

A preliminary investigation was undertaken on 117 acute back pain cases, to assess the utility of counseling at the acute stage upon the course of recovery over the subsequent 6 months. In addition, the extent to which psychological reactions to acute injury would allow the 'tagging' of individuals at risk for chronic pain problems, was studied. The minimal rehabilitation counseling proved inadequate to effect the course of recovery, but remarkably accurate predictions were possible at the sub-chronic point (3 months) as to who would make complete recoveries.     

A high-risk method for studying psychosocial antecedents of chronic pain: the prospective investigation of herpes zoster.

Although patients with chronic pain are often psychologically distressed, it has been difficult to determine whether this distress is an antecedent of chronic pain or whether it is caused by the experience of living with chronic pain. The aim of this investigation was to develop a method that would allow individuals who are at risk for the development of chronic pain to be studied before their pain has become chronic. Patients with acute herpes zoster were assessed with demographic, medical, pain, and psychosocial measures. Pain was assessed in follow-up interviews at 6 weeks and 3, 5, 8, and 12 months after these initial assessments. There were no significant differences between patients who developed short-term herpes zoster pain and patients who did not develop short-term pain for any of the measures at the initial assessment, except for one measure of pain intensity. Patients who developed chronic herpes zoster pain, however, had significantly greater pain intensity, higher state and trait anxiety, greater depression, lower life satisfaction, and greater disease conviction at the initial assessment than patients who did not develop chronic pain. In discriminant analyses, disease conviction, pain intensity, and state anxiety each made a unique contribution to discriminating patients who did and who did not develop chronic pain. This study demonstrates the feasibility of investigating psychosocial antecedents of the development of chronic pain by prospectively examining the longitudinal course of herpes zoster.     

Entstehung und Aufrechterhaltung von chronischen Schmerzen

Chronic pain has previously been defined as lasting longer than 3 or 6 months. This criterion, however, does not adequately describe the process of pain becoming chronic. Consequently, pain chronicity is not only assessed by pain duration but by consideration of other factors, such as disability or intensity. A number of learning processes affect pain chronicity as they mediate changes in neural networks involved in pain processing. Furthermore, a number of psychosocial risk factors have been identified that affect not only the transition from acute to chronic pain but also the maintenance of chronic pain. The fear-avoidance model takes into account many of these risk factors to explain the development and maintenance of chronic musculoskeletal pain.     

Chronic pain, meaning, and spirituality: A qualitative study of the healing process in relation to the role of meaning and spirituality

This qualitative study explores experiences of individuals with chronic pain in their attempt to find meaning in the presence of continual pain. Fifteen participants at Loma Linda University Behavioral Medicine Center were interviewed. Emerging themes from this study show that (1) meaning is initially defined as the ability to engage in productive activities and positive relationships; (2) chronic pain is perceived as the factor that removes meaning from the lives of sufferers; (3) medication is used to cope with pain, leading to addiction; (4) addiction results in greater loss of meaning; and (5) rediscovery of meaning takes place through a more complex understanding of the self that embraces suffering and thus is able to explain the interrelation of pain, emotions, and addiction. A change in self-understanding makes the reintegration of meaning possible.     

A 1-year follow-up of an experimental study of a self-management arthritis programme with an added exercise component of clients with osteoarthritis of the knee

The aim was to assess the self-efficacy and health outcomes of an adopted Arthritis Self-Management Programme (ASMP) among osteoarthritic knee sufferers in Hong Kong at 1 year. An experimental study with 95 participants assigned randomly to the intervention (n=45) or control group (n=50). Seventy-seven (81.1%) participants joined at least one out of three follow-ups in the 12 month period. Participants in the intervention group received a 6-week ASMP with an added exercise component in two general clinics. Outcome measures included arthritis self-efficacy (ASE) and health outcomes including pain and fatigue rating, self-rated health, daily activities limitation and number of unplanned arthritis-related medical consultations. Mean change (12 months minus baseline) and the effect size of the outcome measures were calculated by Mann-Whitney U test and nQuery Advisor 4.0. At 12 months, there were significant reductions of current pain (p=0.0001), pain at night (p=0.001), pain during walking (p=0.01) and number of unplanned arthritis-related medical consultations (p=0.03) and a significant increase in ASE for pain (p=0.01) and other symptoms (p=0.02) and self-rated health (p=0.04) among the intervention group but not for the control group. However, there were similarities in outcome measures of pain while switching from a sitting to a standing position, fatigue rating and physical functional limitation (p=0.15; p=0.22 and p=0.91, respectively) for both groups. Our findings add to the evidence that the modified arthritis empowering programme improved perception of control of osteoarthritis and three health outcomes after 12 months of treatment.     

A controlled evaluation of paraspinal EMG biofeedback in the treatment of chronic low back pain

Sixty-six chronic low back pain sufferers were randomly divided into three groups. Following individual assessments consisting of psychological questionnaires, pain monitoring, and measurement of paraspinal electromyogram (EMG), one group received paraspinal EMG biofeedback and another a placebo treatment. The third group received no intervention. Two further assessments were carried out on all groups immediately after treatment and at a 3-month follow-up. All groups showed significant reduction in pain, anxiety, depression, and paraspinal EMG following treatment and at follow-up, but there were no differences between groups. A regression analysis failed to identify subjects' characteristics that predicted positive outcome in the biofeedback group. However, high scores on the Evaluative scale of the McGill Pain Questionnaire and high hypnotizability were significant predictors of positive outcome for the placebo group. It is concluded that paraspinal EMG biofeedback is not a specific treatment for chronic low back pain in a nonhospitalized population.     

Nature of marital relations among chronic pain patients

Fifty-two chronic pain patients and their spouses were evaluated for their marital relations utilizing the FACES III. In most areas of family functioning the couples provided evidence of difficulties and demonstrated a significant level of agreement about the nature of the problems. On the circumplex model the couples were functioning at the mid-to extreme-range. This study suggests that marital difficulties among chronic pain sufferers may indeed be pervasive.     

The effects of age and musculoskeletal pain on force variability among manual workers

The present study investigated the influence of age and musculoskeletal pain on force variability during a continuous isometric handgrip force task performed at 30% of maximal voluntary contraction carried out until failure. We recruited 96 male manual workers aged 51–72 years. The participants were stratified according to their age (50–59 and 60+ years) and by pain status (no pain, acute pain and chronic pain). The amplitude and structure of variability expressed as respectively standard deviation (SD) and coefficient of variation (CV), and sample entropy (SaEn) were calculated from the endurance task. The oldest group had an approximately 18% longer endurance time than the youngest group. No between-group differences were found in SD or CV, whereas a significant interaction between age and pain stage was found for SaEn. The youngest group showed lower SaEn than the oldest for both those with chronic pain and those without pain, indicating less force complexity, whereas a tendency for the opposite was found in the acute pain group. Within the pain stage groups, workers with acute pain had higher SaEn compared with both the no pain and chronic pain groups. These findings suggest that age and musculoskeletal pain differentially affects the structure of force variability in manual workers.     

Information processing in chronic pain disorder: A preliminary analysis

Researchers have alternately suggested selective attention, impaired stimulus filtering, and affective language deficiency models as accounting for multiple somatic complaints in persons with chronic pain disorder. The purpose of the present study was to establish the comparative usefulness of these three models for explaining somatic focus in a chronic pain population. Nine chronic pain patients evidencing high somatic focus (somatizing chronic pain patients), 10 chronic pain patients evidencing low somatic focus (nonsomatizing chronic pain patients), and 10 healthy control subjects were administered a computerized version of the emotional Stroop test as a test of these models. A total of 105 pain-, depression-, and neutral-content words were used as Stroop test stimuli. Stroop test color-naming response latencies were submitted to a two-way Group × Word Type mixed-model ANOVA, with Word Type as the repeated measure. Results reveal that neither the selective attention model nor the affective language deficiency model adequately explain Stroop test performance in somatizing chronic pain patients. Findings provide tentative support for the impaired stimulus filtering model, with somatizing chronic pain patients evidencing similar Stroop test response delays across all words. These results suggest that chronic pain sufferers misinterpret bodily sensations. Findings are discussed in terms of a bilevel approach for treatment of somatizing chronic pain patients that would include assisting the patient in accurate appraisal and interpretation of physical symptoms.     

A Cognitive-Behavioral Approach to Chronic Pain Management

More than one third of Americans suffer from recurring or persistent pain. Because this condition can result in depression, social isolation, disruption of intimate relationships, and prolonged disability, chronic pain sufferers may seek counseling. This article provides counselors with an introduction to the role of psychosocial processes in the experience of pain and offers assessment and intervention recommendations based on a cognitive-behavioral therapy approach to pain management.     

Trauma symptoms,temperament traits,social support and the intensity of pain in a Polish sample of patients suffering from chronic pain

The aim of the current study was to investigate the relationship between the intensity of pain, treated as the explained variable, and the level of trauma symptoms, as appear in posttraumatic stress disorder (PTSD), temperament traits postulated by the Regulative Theory of Temperament and aspects of social support among patients suffering from chronic pain (arthritis and low-back pain). To assess the intensity of pain among participants we used the Numerical Rating Scale (NRS-11). The level of trauma symptoms was assessed with the PTSD Factorial Version inventory (PTSD-F). Temperament was measured with the Formal Characteristics of Behaviour – Temperament Inventory (FCB-TI). Social support was tested with the Berlin Social Support Scales (BSSS). The results of our study suggest that significant predictors of pain intensity among chronic pain sufferers were trauma symptoms. We also noticed that some temperament traits (i.e., emotional reactivity) increased the level of global trauma symptoms, which, in turn, intensified the level of pain. In addition, we showed that global trauma symptoms decreased the support participants actually received.     

The refractory headache patient--II. High medication consumption (analgesic rebound) headache

'Analgesic rebound headache' is identified by habituation of an individual to pain reducing medication, the exacerbation of headache pain a few hours after medication consumption and a marked increase in headache frequency and intensity for several weeks after medication is discontinued. We describe three studies undertaken to clarify the existence and characteristics of this proposed headache syndrome. In Study 1 we compared a group of headache sufferers who consume large amounts of analgesic medications to headache sufferers who did not consume excessive analgesics. It was found that the two groups did not differ on age, duration of headache problem or gender. However, the groups did differ on subjective headache pain (with the high medicators experiencing more headache pain than low medicators) and diagnosis (with high medicators being more likely to have a muscle contraction component to their headaches). In an analysis of drug use within the high medication group, it was found that 91% were taking some kind of analgesic and that a majority (84%) were taking more than one type of medication. In Study 2 we found that the group of high medicators were not as successful in reducing headache activity as a result of a self-regulatory behavioral treatment as the matched controls. Furthermore, there was a direct relationship between reduction and treatment success in the high medication consuming population. Lastly, in Study 3 we examined the current psychological functioning of the two groups; no differences were found between the two groups indicating the lack of 'addictive' personality characteristics as an explanation for the high medicating population. These findings all support the existence of a sub-population of headache sufferers who consume excessive amounts of analgesic medication and who are relatively refractory to behavioral treatment.     

Momentary mood and coping processes in TMD pain.

Temporomandibular dysfunction (TMD) pain, like many chronic pain problems, appears to be multiply determined. Patients with TMD pain of at least 6 months duration (N = 30) were administered questionnaires measuring dispositional coping styles and appraisals to explore the dynamic interactions of the pain and coping process. Patients were then issued handheld computers that prompted them to record their momentary pain and coping processes 4 times per day for 7 days. Hierarchical linear regression models using both the dispositional and momentary predictors indicated that momentary pain was a function both of dispositional tendency to catastrophize and of momentary measures of catastrophization, self-efficacy, and mood states. Results were seen as supporting a situational model of intervention for chronic TMD pain.     

A randomized clinical trial of a population- and transtheoretical model-based stress-management intervention.

Stress has been associated with a variety of chronic and acute conditions and with higher use of health care services. This research reports on 18-month outcomes of a randomized clinical trial of a stress-management program based on the transtheoretical model (TTM; J. O. Prochaska & C. C. DiClemente, 1986). A national sample of 1,085 individuals participated (age range = 18-91 years, M = 55.33; 68.9% female, 31.1% male; 84.8% Caucasian; 15.2% non-Caucasian). Both the treatment and control groups received assessments at 0, 6, 12, and 18 months. In addition to the assessments, the treatment group received 3 individualized reports (0, 3, 6 months) and a manual. The 18-month assessment was completed by 778 individuals (72%). A random effects model indicated that participants completing the study in the treatment group had significantly more individuals reporting effective stress management at follow-up time points than did completers in the control group. Results also indicate that the intervention had significant effects on stress, depression, and specific stress-management behaviors. Results provide evidence for the effectiveness of this TTM population-based stress-management intervention.     

Cognitive predictors of posttraumatic stress disorder in children: results of a prospective longitudinal study

The present study explored whether cognitive factors specified in the Ehlers and Clark model (Behav. Res. Ther. 38 (2000) 319) of posttraumatic stress disorder (PTSD) predict chronic PTSD in children who had experienced a road traffic accident. Children were assessed at 2 weeks, 3 months, and 6 months after the accident. Data-driven processing during the accident, negative interpretation of intrusive memories, alienation from other people, anger, rumination, thought suppression and persistent dissociation at initial assessment predicted PTSD symptom severity at 3 and 6 months. On the basis of sex and stressor severity variables, 14% of the variance of PTSD symptoms at 6 months could be explained. The accuracy of the prediction increased to 49% or 53% when the cognitive variables measured at initial assessment or 3 months, respectively, were taken into account.     

急性疼痛与慢性疼痛对奖赏加工的影响及神经机制

疼痛和奖赏能够为个体提供不同的行为动机和主观价值体验,寻求奖赏和避免疼痛对于生存都很重要。疼痛可划分为急性疼痛和慢性疼痛,奖赏可区分为预期阶段的动机成分和体验阶段的享乐成分。奖赏对疼痛的抑制作用已经被广泛证实,但关于疼痛对奖赏的影响,目前的研究结果并不一致。因此需要进一步区分并探究急性疼痛与慢性疼痛对奖赏加工不同阶段的影响,分析两种疼痛对奖赏加工产生不一致影响的现象。这种现象出现的原因可能与急性疼痛向慢性疼痛转变过程中出现的奖赏加工能力缺陷有关。未来可以考虑从改善奖赏加工能力缺陷的角度进行检测和治疗,提前预防急性疼痛向慢性疼痛转变。     

Chronic pain as a posture towards the world

This article discusses what chronic pain is “about”, what the intentional object is of pain, and what is the intentional relation like? My approach is based on Maurice Merleau‐Ponty’s phenomenology, with an aim is to understand a two‐way relationship: how the sufferers bestow meaning on chronic pain, and how pain, on the other hand, signifies peoples’ life. In contrast to biomedical and cognitive‐behavioral theories, chronic pain is not only meaningful, but as an intentional emotion as well; it does not simply “happen” in the nervous system. I analyzed meanings assigned to pain through the narratives of three patients with chronic pain. Pain is described as creating a discontinuity in the patient’s Lebenswelt at the narrative level. When attempting to find meaning to their pain, patients point both to everyday life and biomedical referents. The structure of bestowing meaning is, metaphorically, like a necklace with everyday world and biomedical interpretations strung like beads, one after the other. The intentional object of pain, on the contrary, is constituted of the patients’ world in its wholeness. My results don’t confirm Drew Leder’s idea of disrupted intentionality, but underline directness as the basic relation of human experience also in case of pain and disease. Pain in itself is an e‐movere, an intense passionate movement, an intentional relation with and a bodily posture taken towards the world.     

Comparing the role of psychological flexibility and traditional pain management coping strategies in chronic pain treatment outcomes

Psychologically-based interventions for chronic pain traditionally include a mix of methods, including physical conditioning, training in relaxation or attention control, strategies to decrease irrational or dysfunctional thinking patterns, and activity management training. Recent developments suggest additional methods to promote acceptance, mindfulness, values-based action, and cognitive defusion (a cognitive process entailing change in the influences exerted by thoughts without necessarily changing their form or frequency). Collectively, these processes entail what is referred to as psychological flexibility. This study examined how changes in traditionally conceived methods of coping compare to changes in psychological flexibility in relation to improvements in functioning over the course of an interdisciplinary treatment program. Participants were 114 chronic pain sufferers. Results indicated that changes in the traditionally conceived methods were essentially unrelated to treatment improvements, while changes in psychological flexibility were consistently and significantly related to these improvements. We suggest that psychological flexibility appears highly relevant to the study of chronic pain and to future treatment developments. The utility of more traditionally conceived pain management strategies, on the other hand, may require a reappraisal.     

Der neuropathische Schmerz in der medizinischen Praxis

Patients with pain symptoms probably represent one of the most frequent treatment indications in clinical practice. This is regardless of medical specialty, as pain is interdisciplinary and occurs in all fields, and is thus also treatable and should be treated, as long as the pain is chronic, i.e. lasting for more than 3 up to a maximum of 6 months. The exception is purely organ-related or postoperative pain that is induced by an attributable previous incident. The pain as such, as long as it is not trauma- or surgery-induced, is invariably a neurological disease or a neurological symptom.     

Quetiapine augmentation of selective serotonin reuptake inhibitors in treatment-resistant obsessive-compulsive disorder: a six-month follow-up case series

Obsessive-compulsive disorder (OCD) is a relatively common, often chronic and disabling disorder with high rates of partial and/or absent response to standard, recommended treatments, such as selective serotonin reuptake inhibitors (SSRIs) and psychotherapy. This article presents the cases of four patients suffering from OCD and comorbid mood or anxiety disorders, who were treated with SSRIs at adequate doses for at least 12 weeks, showing a partial response. Quetiapine treatment was added to SSRIs at a dose of 25 mg/day and titrated up to 200 mg/day. Patients were followed up for 6 months. After 12 weeks, all the patients were classified as "much improved" on the Clinical Global Impression-Improvement scale and showed a Yale-Brown Obsessive-Compulsive Scale score reduction > or =35%. After 6 months of follow-up, all the patients maintained the same level of improvement. Although quetiapine augmentation to SSRIs has shown mixed results in published controlled trials in the acute treatment (12 weeks) of patients with treatment-resistant OCD, this case series indicates that patients who benefit from this pharmacologic regimen in the acute phase tend to maintain such an improvement. Larger follow-up studies are warranted to confirm our findings.