Follow-up results of a cognitive-behavioural treatment for chronic pain in a primary care setting

Abstract

An outpatient cognitive-behavioural treatment programme for pain control was administered to chronic pain patients in three primary care practices with a medical psychologist as a group therapist. The patients suffered from headaches, migraines, cervical pain, shoulder-arm pain, and low back pain. A matched sample of patients with the same disorders served as a waiting-list control group. The programme consisted of training in progressive muscle relaxation, several attention related techniques, and cognitive restructuring as well as reinforcing non-pain behaviour, and aimed at an improvement of self-control strategies. At the six month follow-up, the treated subjects showed improvements in their average scores of anxiety, depression and bodily symptoms compared with the untreated controls. Pain intensity was reduced by 34% in those subjects (9 out of 25) who were most adherent to the treatment regimen. Our results indicate a long-term improvement in well-being as a consequence of the treatment. This was confirmed by the ratings of the physicians and by the reduced number of patient-physician contacts three months post treatment as compared to the controls. Treatment adherence seems to be a most important agent in maintaining long-term reductions of pain intensity.     

Developmental trajectories of multisite musculoskeletal pain and depressive symptoms: The effects of job demands and resources and individual factors

Objective: To investigate developmental paths in multisite musculoskeletal pain (MPS) and depressive symptoms (DPS) and the effects of job demands (JD), job resources (JR), optimism and health-related lifestyle on these paths. We expected to find four trajectories – Low Symptoms, High Pain, High Depression and High Symptoms – and hypothesised that high JDs, low JRs, low optimism and adverse lifestyle predict belonging to trajectories with high symptom levels.

Design: Data on Finnish firefighters (N = 360) were collected in 1996, 1999 and 2009. The effects of JDs (mental and physical workload), JRs (supervisory relations, interpersonal relations, task resources), optimism and lifestyle (alcohol consumption, smoking, physical exercise, sleeping) on MPS and DPS were assessed. Latent class growth modelling and multinomial logistic regression were applied.

Results: Three trajectories emerged: Low Symptoms; High Pain; and High Depression. In a multivariable model, high mental workload (OR 2.9, 95% CI 1.5–5.5), poor interpersonal relations (2.6, 1.4–5.0), sleeping problems (2.7, 1.4–5.2) and low optimism (2.0, 1.0–3.7) predicted belonging to High Depression. Alcohol consumption (2.4, 1.4–4.1) and sleeping problems (2.1, 1.3–3.6) were related to High Pain.

Conclusions: Different developmental paths in MPS and DPS are possible. Partly different factors predict the development of pain and depressive symptoms.     

Effects of different psychological interventions on neck,shoulder and low back pain in female hospital staff

Abstract

One hundred and eleven females volunteered to take part in this intervention study of musculoskeletal pain. They all completed a survey of pain among five hundred and eighty-six female hospital staff and presented mild to severe pain in the neck, shoulder and/or low back. They were randomly assigned to one of the following groups; Focus on job-stress and psychosocial coping (Cognitive), relaxation training (Relaxation), the combination of the two (Combined) or to a control group (Control). Musculoskeletal pain (intensity and duration) was assessed by self-report prior to interventions, immediately after interventions, and at a four months follow-up. Results from multivariate analyses of variance as well as covariance (pre-intervention levels of pain as covariate) showed that magnitude of pain reduction was dependent upon the interaction between area of the back and type of intervention. These trends were more significant for intensity than for duration scores. They were due to reductions of pain in (1) neck and shoulders for the Cognitive and Combined groups and (2) in the low back and shoulders for the Relaxation group. The four month follow-up assessment revealed a significant risk of relapse only for duration of low back pain among subjects in the Combined group. Results from the Cognitive approach to intervention may reflect a causal role for ability to cope with psychosocial job stress in the development of neck and shoulder pain in female hospital staff.     

Adherence to pharmacological treatment of non-malignant chronic pain: The role of illness perceptions and medication beliefs

The objective was to identify the degree to which illness perceptions and medication beliefs explain variations in reported adherence to medication prescribed for the treatment of non-malignant chronic pain and to test the applicability of an extended version of the self-regulatory model to the chronic pain population. A cross-sectional design included 217 clinic patients completing validated questionnaires assessing their illness perceptions, medication beliefs and reported adherence to medication. Perceptions of illness (pain) as chronic, uncontrollable and unremitting were associated with greater adherence, fewer medication concerns and a belief that treatment was necessary. Structural equation modelling supports an extended SRM for chronic pain. It suggests that patients holding perceptions of serious consequences of pain and high emotion levels have more concerns about medication and are less adherent. Perceptions of serious illness consequences are also associated with stronger beliefs about the necessity of medicines and greater adherence. Beliefs about illness and medication are associated with adherence to treatment in chronic pain and this can be explained by an extended SRM. Results are preliminary and require replication. Further studies should explore the role that emotion has on coping strategies in chronic pain. Interventions should focus on altering unhelpful beliefs that reduce adherence.     

Medical help-seeking by different types of chronic pain patients

Abstract

This paper reports on a study of the use of health services by different types of patients with chronic benign pain. The purpose of the study was to identify differences in medical consumption between different types of pain patients. In the course of one year 586 patients were selected by 45 general practitioners: they included patients who had had almost daily chronic pain symptoms for at least six months, without a medical diagnosis (such as cancer or arthritis) to explain the pain. Patients were categorized according to the Multidimensional Pain Inventory which distinguishes four categories: the dysfunctional, who perceive severe pain and gain social support; the interpersonally distressed, who combine pain with affective and relational distress; adaptive copers, who cope with their pain in a number of ways; the average type, with characteristics of all three other types. It was hypothesised that adaptive copers would make less use of health services and would be more involved in self-help activities than dysfunctional or interpersonally distressed patients. Frequent use of psychological services by the interpersonally distressed group was expected. It was predicted that difference in health services use would continue during the subsequent year.

No differences were found between the four groups in location, temporal characteristics, or possible medical causes of the pain symptoms. Dysfunctional patients used more services than the others. Adaptive copers used the least. The four groups did not differ in self-care activities. Group-membership as well as pain severity are related to the use of health services. None of the groups showed a significant decline in the use of health services during the year. It is concluded that chronic pain is invalidating, but that not all patients are equally excessive in their use of medical services.     

The role of the patient in the management of post surgical pain

Abstract

An experiment was conducted to test the idea that patients do not have the necessary knowledge about pain relief to contribute effectively to their own pain management through such strategies as being more assertive in requesting analgesia. When patients were provided with video-taped information about available pain control techniques, together with a rationale for the minimisation of pain and encouragement to request analgesia as required, they did not achieve significantly less pain than control groups. Since patients were well satisfied with pain levels substantially greater than zero, it is argued that the conventional wisdom that high pain scores indicate that post surgical pain is badly treated should be re-assessed.     

Is laughter the best medicine?

Abstract

One hundred patients with chronic arthritis were interviewed and completed questionnaires about coping, well-being and their use of humour. A comparison of patients scoring high or low on each of 3 measures of humour showed that those who reported they used humour least, had most difficulty recognising it and valued it least. They also reported more depressive symptoms and lower personal self-esteem. Regressions showed that depression was best predicted by the inactive use of humour in coping. and to a lesser extent, pain intensity. Cluster analysis of data on general coping strategies showed that valuing humour distinguished two-thirds of patients who were relatively normal and cautiously optimistic, from the other third, where the outlook was negative and hopeless. Those with a more positive view tended to be younger, less disabled, in less pain and with several social advantages on a number of indicators. However they also had a longer duration of disease. Two-thirds of patients said they were able to laugh when in pain but those most able to do this had less intense pain during the previous week. Furthermore the most disabled arthritis patients found laughter to be a most effective strategy. The research has implications for preventing depression and coping with disability.     

Investigation of the association between mobbing and musculoskeletal discomfort in academicians

This study aimed to identify the association between exposure to mobbing and musculoskeletal discomfort in academicians. One hundred academicians working at a university were included in the study. Permission was granted by the Rector prior to the study and questionnaires were delivered to the academicians. The Turkish version of the Leymann Inventory of Psychological Terror (LIPT) was used to evaluate mobbing and the Turkish version of the Cornell Musculoskeletal Discomfort Questionnaire (CMDQ) was used to assess musculoskeletal discomfort. When the data were analyzed, a moderate association was found between mobbing perceived by the academic staff and musculoskeletal discomfort. In conclusion, this study showed that mobbing is a risk factor for musculoskeletal discomfort.     

Impasse and the interpretation of perversion

This article presents a case study of a year of psychotherapeutic work by a female and male therapist with a 14-year-old boy born with ambiguous genitalia. His mother was also present in the sessions at the request of Zak. We describe the early trauma surrounding Zak's birth and the subsequent desertion of a violent father. We present the catalogue of medical interventions he received to re-construct his genitals. Now at the age of 14 years Zak is entering into a chemically induced puberty. His mother had a version of an internal couple at war, where the male was viewed as useless and with suspicion. This view served to distort her capacity to bear Zak's condition and dovetailed with his phantasy of a monstrously violent and destructive male. Thus the artificial shove into manhood for Zak was filled with terror. The induced puberty was felt more like an attack and he acted out through resistance to intervention and non-compliance. This organisation created in him a state of thoughtlessness and despair, which we propose parades itself as a ‘secondary handicap’ (Sinason, Mental Handicap and the Human Condition, Free Association, London, 1992). Our joint work as a couple with Zak and his mother stood in opposition to their internal structures and provided an experience of a different kind of coupling: an opportunity to observe a cooperatively working couple who helped give words to the anxieties they brought. We trace Zak's attachment to and internalisation of a thinking couple, which paralleled both his ability to become more expressive and a reduction in acting out his aggression. The work aimed to promote in Zak a level of emotional development that was commensurate with his physical development. The construction of genitals and a lifetime of testosterone injections alone will not allow Zak to grow into the man he can be. We will attempt to explore the basis of these structures to demonstrate that the work provided the opportunity for Zak to reflect upon and express his terror, and to turn to other people to seek support, help and advice.