Douglas E. DeGood

Patterns of postoperative analgesic use with adults and children following cardiac surgery

Abstract The postoperative prescription and administration of analgesics following cardiac surgery for 50 children were compared with those of 50 adults. Six children were the only patients in the sample who were prescribed no postoperative analgesics. Overall, children were prescribed significantly fewer potent narcotics. The administration data revealed even more pronounced group differences. During the observation period, children received 30% of all analgesic administrations while adults received 70%. Some possible reasons for these age differences in analgesic usage are presented and implications regarding the adequacy of postoperative pain control in children are discussed.

Perception of fault in patients with chronic pain

&NA; The beliefs and expectancies of chronic pain patients have been shown to be critical cognitive facilitators or impediments to the recovery process. In the present study patients presenting to an outpatient pain center were classified according to their response to the questionnaire item “Who do you think is at fault for your pain?”. Patients were then grouped according to the responses ‘employer’, ‘other’, or ‘no one’. The resulting 3 groups of patients did riot differ in current pain intensity or activity limitation, but the fault conditions, relative to the no‐fault patients, reported greater concurrent mood distress and behavioral disturbance, as well as poorer response to past treatments, and lessor expectations of future benefits. The negative effects were more pronounced in the Employer‐Fault group, than for the Other‐Fault group (primarily ‘doctors’ and ‘other drivers’). On balance, the present data suggest: that attribution of blame may be an under‐recognized cognitive correlate of pain behavior, mood disturbance, and poor response to treatment.

A comparison of low back pain patients in the United States and New Zealand: Psychosocial and economic factors affecting severity of disability☆

&NA; One hundred and ninety‐eight patients suffering from chronic low back pain seen at the University of Virginia (U.S.) Pain Center and 117 similar patients seen at the Auckland Hospital, Auckland, New Zealand (N.Z.) Pain Clinic completed a self‐report questionnaire prior to beginning comparable outpatient treatment programs. Approximately 55% of the sample from each country returned a follow‐up questionnaire 1 year later. Analyses of the results indicated that despite nearly similar between‐country reports of pain frequency and intensity, the U.S. patients, both at pre‐ and post‐testing, reported greater emotional and behavioral disruption as a correlate of their pain. U.S. patients consistently used more medication, experienced more disphoric mood states, and were more hampered in social‐sexual, recreational, and vocational functioning. Patients from both countries demonstrated a nearly equal degree of pre‐ to post‐improvement; however, the relative initial differences favoring the New Zealanders remained constant across both questionnaire administrations. At the onset of treatment, 49% of the U.S. sample and only 17% of the N.Z. patients were receiving pain‐related financial compensation. At follow‐up, patients from both countries receiving pretreatment compensation were less likely to report a return to full activity, although the relationship appeared more pronounced in U.S. patients. Seemingly, compared to the U.S., the N.Z. compensation‐disability system is used less, or for shorter durations of time, resulting in less severe life‐style disruption than appears to be the case in the U.S. patients. Seemingly, compared to the U.S., the N.Z. compensation‐disability system is used less, or for shorter durations of time. resulting in less severe life‐style disruption than appears to be the case in the U.S.

A psychosocial and behavioral comparison of reflex sympathetic dystrophy, low back pain and headache patients

&NA; Based primarily on anecdotal evidence, patients with reflex sympathetic dystrophy (RSD) have often been suspected of having a high degree of psychosocial disturbance prior to the onset of symptoms as well as in reaction to the disorder. In the present study, patients presenting to a pain center with RSD were compared to patients with low back (LBP) and headache pain (HAP) on a variety of self‐reported demographic, behavioral, pain and mood measures. Typical of most patients experiencing chronic pain, all three groups demonstrated elevations indicative of pain, emotional distress and behavioral disturbance. However, although the RSD patient group reported the highest level of pain intensity, the most employment disruption and contained the highest percentage of patients receiving financial compensation, this same group paradoxically reported less emotional distress on the Symptom Checklist‐90R than did LBP and HAP patients. This paradox may be due to the lesser chronicity of the RSD patients as well as to their apparently experiencing a more sympathetic response from doctors, employers and insurance carriers than their LBP and HAP counterparts. On balance, the present data do not support the hypothesis the RSD patients, relative to other pain patients, are uniquely disturbed in psychosocial functioning.

Pain complaint and the weather: weather sensitivity and symptom complaints in chronic pain patients

&NA; Chronic pain patients frequently report that weather conditions affect their pain; however, no standardized measures of weather sensitivity have been developed. We describe the development and use of the Weather and Pain Questionnaire (WPQ) which assesses patient sensitivity to meteorologic variables defined by the National Weather Service (e.g., temperature, precipitation). Seventy chronic pain patients (59% females) with an average age of 43 years completed the WPQ. The instrument was revised using factor analysis to produce a Weather Sensitivity Index (WSI) (48% of variance) with high internal consistency (0.93) and test‐retest reliability (r = 0.89). Reporting patterns suggested that patients could reliably identify which meteorologic variables influenced their pain but could not reliably determine which physical symptoms were consistently affected. The most frequently reported meteorologic variables which affect pain complaint were temperature (87%) and humidity (77%). The most frequently reported physical complaints associated with the weather were joint and muscle aches (82% and 79%, respectively). Patients labeled as being ‘weather sensitive’, defined by greater than median scores on the WPQ, reported significantly greater pain intensity, greater chronicity of pain problems, and more difficulties sleeping than patients with low scores on the WPQ. No differences in gender, education level, disability status, or global psychological distress were found. Results are discussed with respect to physiological and psychological mediating variables.

Effects of Humorous Stimuli and Sense of Humor on Discomfort

The effects of humor on increasing discomfort thresholds were tested with Transcutaneous End Nerve Stimulation (TENS). Undergraduate students (n = 31) with high or low scores on Martin and Lefcourts Situational Humor Questionnaire were randomly assigned to a humor or nonhumor condition. Discomfort thresholds for TENS were assessed before and during treatment. There was a significant increase in discomfort thresholds in the humorous treatment compared to the nonhumorous condition. Evidence was found for subjects to smile “wryly” (an increase in zygomatic and corrugator tensions) more during humorous stimuli than nonhumorous stimuli when they were waiting to be stimulated with the TENS.

Global appropriateness of pain drawings: Blind ratings predict patterns of psychological distress and litigation status

&NA; Previous studies examining pain drawings of low back pain patients have shown conflicting results in predicting elevations of MMPI scores. A study of 82 patients whose drawings were rated only for overall, anatomical appropriateness was conducted using the SCL‐90 rather than the MMPI as the psychological assessment instrument. Significant differences were found between appropriate and inappropriate drawings; however, these differences seem to reflect differences in cognitive style of coping with pain as opposed to psychopathology. The implications and limitations of the study are discussed.

Interactive effects of the affect quality and directional focus of mental imagery on pain analgesia.

College students (25 men and 25 women) were randomly assigned (within sex) to each of the 4 factorial groups, based on manipulation of affect quality (positive vs. negative) and directional focus (internal vs. external) of mental imagery, and to a control group receiving no manipulation. Both imagery variables had a significant impact on pain tolerance and ratings during a cold-pressor test with positive affect and external imagery producing greater analgesia than their counterpart conditions. Positive affect imagery combined with external imagery resulted in the lowest reported pain amongst the groups. However, self-reported mood descriptors did not consistently parallel the pain tolerance and rating data. Likewise, although heart rate and skin potential responses increased during the cold pressor for the group as a whole, the only significant difference amongst the experimental groups was the relatively higher skin potential reactivity of the positive affect-external imagery group—possibly reflecting greater task engagement for this group. Seemingly, imagery in this situation operates primarily via cognitive, rather than via physiological mediators of the pain experience.

Cognitive Deficits in Chronic Pain Patients With and Without History of Head/Neck Injury: Development of a Brief Screening Battery

The incidence of cognitive deficits in chronic pain patients with a history of major or minor head/neck injury (HI) and without a history of major or minor head/neck injury (NHI) was examined. As an alternative to more costly and time-consuming assessment instruments, a brief screening battery was employed which tested for problems in concentration and attention. Based on a limited subsample, 100% accuracy was obtained in predicting deficits later confirmed by full neuropsychological testing. Results indicated significantly higher incidence of difficulties in sustained attention and rapid problemsolving ability in the HI group than in the NHI group. These difficulties are discussed in the context of recent evidence that the incidence of subtle but possibly lasting cognitive deficits is greater than had been earlier recognized with minor head trauma. Implications of the type of deficits noted, their clinical presentation, and suggestions for their detection and clinical management in chronic pain patients are discussed.

The Balans chair and its semi-kneeling position: an ergonomic comparison with the conventional sitting position.

Recently, the Balans chair has been introduced with claims that, because of its semi-kneeling position, individuals will experience decreased low-back pain (LBP) as well as improvement in circulation. This study investigated the validity of these claims. Twenty healthy subjects were randomly assigned to one of two groups. Group 1 subjects sat in the Balans chair for a 30-minute study period and then sat in a conventional office chair for an additional 30-minute period. Group 2 subjects were studied in the reverse seating order. Parameters studied were cervical and lumbar paraspinous surface EMG, and pedal cutaneous blood flow measured by laser-Doppler flowimetry. In addition, a questionnaire comparing the comfort of the two chairs was completed at the end of the study session. Comfort ratings showed an overall preference for the conventional chair. Increased cervical (P = .004) and lumbar muscle EMG measurements were noted after sitting in the Balans chair. Pedal cutaneous blood flow was increased by 15% in the Balans chair (P = .001). The data do not support the manufacturers claim that the Balans chair is likely to decrease complaints of LBP.