Francis J. Keefe

Grading the severity of chronic pain.

&NA; This research develops and evaluates a simple method of grading the severity of chronic pain for use in general population surveys and studies of primary care pain patients. Measures of pain intensity, disability, persistence and recency of onset were tested for their ability to grade chronic pain severity in a longitudinal study of primary care back pain (n = 1213), headache (n = 779) and temporomandibular disorder pain (n = 397) patients. A Guttman scale analysis showed that pain intensity and disability measures formed a reliable hierarchical scale. Pain intensity measures appeared to scale the lower range of global severity while disability measures appeared to scale the upper range of global severity. Recency of onset and days in pain in the prior 6 months did not scale with pain intensity or disability. Using simple scoring rules, pain severity was graded into 4 hierarchical classes: Grade I, low disability‐low intensity; Grade II, low disability‐high intensity; Grade III, high disability‐moderately limiting; and Grade IV, high disability‐severely limiting. For each pain site, Chronic Pain Grade measured at baseline showed a highly statistically significant and monotonically increasing relationship with unemployment rate, pain‐related functional limitations, depression, fair to poor self‐rated health, frequent use of opioid analgesics, and frequent pain‐related doctor visits both at baseline and at 1‐year follow‐up. Days in Pain was related to these variables, but not as strongly as Chronic Pain Grade. Recent onset cases (first onset within the prior 3 months) did not show differences in psychological and behavioral dysfunction when compared to persons with less recent onset. Using longitudinal data from a population‐based study (n = 803), Chronic Pain Grade at baseline predicted the presence of pain in the prior 2 weeks, Chronic Pain Grade and pain‐related functional limitations at 3‐year follow‐up. Grading chronic pain as a function of pain intensity and pain‐related disability may be useful when a brief ordinal measure of global pain severity is required. Pain persistence, measured by days in pain in a fixed time period, provides useful additional information.

The use of coping strategies in chronic low back pain patients: Relationship to patient characteristics and current adjustment

Abstract Cognitive and behavioral pain coping strategies were assessed by means of questionnaire in a sample of 61 chronic low back pain patients. Data analysis indicated that the questionnaire was internally reliable. While patients reported using a variety of coping strategies, certain strategies were used frequently whereas others were rarely used. Three factors: (a) Cognitive Coping and Suppression, (b) Helplessness and (c) Diverting Attention or Praying, accounted for a large proportion of variance in questionnaire responses. These 3 factors were found to be predictive of measures of behavioral and emotional adjustment to chronic pain above and beyond what may be predicted on the basis of patient history variables (length of continuous pain, disability status and number of pain surgeries) and the tendency of patients to somaticize. Each of the 3 coping factors was related to specific measures of adjustment to chronic pain.

Mood Disorders in the Medically Ill: Scientific Review and Recommendations

OBJECTIVE The purpose of this review is to assess the relationship between mood disorders and development, course, and associated morbidity and mortality of selected medical illnesses, review evidence for treatment, and determine needs in clinical practice and research. DATA SOURCES Data were culled from the 2002 Depression and Bipolar Support Alliance Conference proceedings and a literature review addressing prevalence, risk factors, diagnosis, and treatment. This review also considered the experience of primary and specialty care providers, policy analysts, and patient advocates. The review and recommendations reflect the expert opinion of the authors. STUDY SELECTION/DATA EXTRACTION Reviews of epidemiology and mechanistic studies were included, as were open-label and randomized, controlled trials on treatment of depression in patients with medical comorbidities. Data on study design, population, and results were extracted for review of evidence that includes tables of prevalence and pharmacological treatment. The effect of depression and bipolar disorder on selected medical comorbidities was assessed, and recommendations for practice, research, and policy were developed. CONCLUSIONS A growing body of evidence suggests that biological mechanisms underlie a bidirectional link between mood disorders and many medical illnesses. In addition, there is evidence to suggest that mood disorders affect the course of medical illnesses. Further prospective studies are warranted.

The management of persistent pain in older persons

Pain is an unpleasant sensory and emotional experience. 1 Pain is a complex phenomenon derived from sensory stimuli or neurologic injury and modified by individual memory, expectations, and emotions. 2 Pain is usually associated with injury or a pathophysiologic process that causes an uncomfortable experience and is usually described in such terms. Although there are no objective biologic markers of pain, an individual’s description and selfreport usually provides accurate, reliable, and sufficient evidence for the presence and intensity of pain. 3 Persistent pain can be defined as a painful experience that continues for a prolonged period of time that may or may not be associated with a recognizable disease process. The terms persistent and chronic are often used interchangeably in the medical literature. Unfortunately for many elderly persons, chronic pain has become a label associated with negative images and stereotypes often associated with longstanding psychiatric problems, futility in treatment, malingering, or drug-seeking behavior. The term persistent pain may foster a more positive attitude by patients and professionals for the many effective treatments that are available to help alleviate suffering. 4 The clinical manifestations of persistent pain are commonly multifactorial. Because of the complex interplay among these factors across several domains (physiologic, psychologic, and social), discriminating which factors are most important for the purpose of treatment can be very challenging. Further complicating this task is the fact that pain expression and hence the importance of specific factors commonly vary, not only across individuals but also over time in one individual. Elderly persons have been defined by demographers, insurers, and employers as those aged 65 years and over. In healthcare discussions, the elderly persons often described are those who are most frail, with health and disability problems typically encountered in the older population. By age 75 many persons exhibit some frailty and chronic illness. In the population above age 75, morbidity, mortality, and social problems rise rapidly, resulting in substantial strains on the healthcare system and societal safety nets. This group represents the fastest growing segment of the total population. 5 The greatest challenges in geriatric medicine are represented by the oldest, sickest, and most frail patients with multiple medical problems and few social supports. The guideline panel focused its attention on this group as it prepared this update. Persistent pain is common in older people. 6 A Louis Harris telephone survey found that one in five older Americans (18%) are taking analgesic medications regularly (several times a week or more), and 63% of those had taken prescription pain medications for more than 6 months. 7 Older people are more likely to suffer from arthritis, bone and joint disorders, back problems, and other chronic conditions. This survey also found that 45% of patients who take pain medications regularly had seen three or more doctors for pain in the past 5 years, 79% of whom were primary care physicians. Previous studies have suggested that 25% to 50% of community-dwelling older people suffer important pain problems. 6,8,9 Pain is also common among nursing home residents. 10,11 It has been estimated that 45% to 80% of them have substantial pain that is undertreated. Studies of both the community-dwelling and nursing home populations have found that older people commonly have several sources of pain, which is not surprising, as older patients commonly have multiple medical problems. A high prevalence of dementia, sensory impairments, and disability in this population make assessment and management more difficult. The consequences of persistent pain among older people are numerous. Depression, anxiety, decreased socialization, sleep disturbance, impaired ambulation, and increased healthcare utilization and costs have all been found to be associated with the presence of pain in older people. Although less thoroughly described, many other conditions are known to be worsened potentially by the presence of pain, including gait disturbances, slow rehabilitation, and adverse effects from multiple drug prescriptions. 12 Psychosocial factors affect and are affected by pain in older patients. It has been shown that older adults with good coping strategies have significantly lower pain and This guideline was developed and written under the auspices of the American Geriatrics Society (AGS) Panel on Persistent Pain in Older Persons and approved by the AGS Board of Directors on April 8, 2002.

Coping with rheumatoid arthritis pain: catastrophizing as a maladaptive strategy

&NA; The present study examined catastrophizing in rheumatoid arthritis (RA) patients. Subjects were 223 RA patients who were participants in a longitudinal study. Each patient completed the Catastrophizing scale of the Coping Strategies Questionnaire (CSQ) on 2 occasions separated by 6 months (time 1, time 2). The Catastrophizing scale is designed to measure negative self‐statements, castastrophizing thoughts and ideation (sample items = ‘I worry all the time about whether it will end,’ ‘It is awful and I feel that it overwhelms me’). Data analysis revealed that the Catastrophizing scale was internally reliable (alpha = 0.91) and had high test‐retest reliability (r = 0.81) over a 6 month period. Correlational analyses revealed that catastrophizing recorded at time 1 was related to pain intensity ratings, functional impairment on the Arthritis Impact Measurement scale (AIMS), and depression at time 2. Predictive findings regarding catastrophizing while modest were obtained after controlling for initial scores on the dependent variables, demographic variables (age, sex, socioeconomic status), duration of pain, and disability support status. Taken together, these findings suggest that catastrophizing is a maladaptive coping strategy in RA patients. Further research is needed to determine whether cognitive‐behavioral interventions designed to decrease catastrophizing can reduce pain and improve the physical and psychological functioning of RA patients.

The relationship of gender to pain, pain behavior, and disability in osteoarthritis patients: the role of catastrophizing

&NA; One hundred and sixty‐eight patients with osteoarthritis (OA) of the knees participated in this study. Of the participants, 72 were men and 96 were women. All participants completed the Arthritis Impact Measurement Scales (AIMS), underwent a 10 min standardized observation session to assess their pain behavior, and completed the Catastrophizing Scale of the Coping Strategies Questionnaire (CSQ) and the Depression Scale of the Symptom Checklist 90 Revised (SCL‐90R). The study found that there were significant differences in pain, pain behavior, and physical disability in men and women having OA. Women had significantly higher levels of pain and physical disability, and exhibited more pain behavior during an observation session than men. Further analyses revealed that catastrophizing mediated the relationship between gender and pain‐related outcomes. Once catastrophizing was entered into the analyses, the previously significant effects of gender were no longer found. Interestingly, catastrophizing still mediated the gender–pain relationship even after controlling for depression. These findings underscore the importance of both gender and catastrophizing in understanding the OA pain experience and may have important implications for pain assessment and treatment.

An interdisciplinary expert consensus statement on assessment of pain in older persons

This paper represents an expert-based consensus statement on pain assessment among older adults. It is intended to provide recommendations that will be useful for both researchers and clinicians. Contributors were identified based on literature prominence and with the aim of achieving a broad representation of disciplines. Recommendations are provided regarding the physical examination and the assessment of pain using self-report and observational methods (suitable for seniors with dementia). In addition, recommendations are provided regarding the assessment of the physical and emotional functioning of older adults experiencing pain. The literature underlying the consensus recommendations is reviewed. Multiple revisions led to final reviews of 2 complete drafts before consensus was reached.

Race, ethnicity and pain

The current paper provides a brief overview of research on the effects of race and ethnicity on pain. More specifically, the article reviews the utility of the concepts of race and ethnicity for pain research, suggests operational definitions of race and ethnicity, reviews the literature on the effects of race and ethnicity on laboratory and clinical pain, and provides suggestions for future research.

Pain coping skills training in the management of osteoarthritic knee pain: A comparative study

The purpose of this study was to determine whether a cognitive-behavioral intervention designed to improve pain coping skills could reduce pain, physical disability, psychological disability, and pain behavior in osteoarthritic knee pain patients. Patients in this study were older adults (mean age=64 years) having persistent pain (mean duration=12 years), who were diagnosed as having osteoarthritis of the knee on the basis of medical evaluation and x-rays. Patients were randomly assigned to one of three conditions: pain coping skills training, arthritis education, or a standard care control condition. Patients in the pain coping skills training condition (n=32) attended 10 weekly group sessions training them to recognize and reduce irrational cognitions and to use attention diversion and changes in activity patterns to control and decrease pain. Arthritis education subjects (n=36) attended 10 weekly group sessions providing them with detailed information on osteoarthritis. Standard care control subjects (n=31) continued with their routine care. Measures of coping strategies, pain, psychological disability, physical disability, medication use, and pain behavior were collected from all subjects before and after treatment. Results indicated that patients receiving pain coping skills training had significantly lower levels of pain and psychological disability post-treatment than patients receiving arthritis education or standard care. Correlational analyses revealed that patients in the pain coping skills training group who reported increases in the perceived effectiveness of their coping strategies were more likely to have lower levels of physical disability post-treatment. Taken together, these findings indicate that pain coping skills training can reduce pain and psychological disability in osteoarthritis patients. Future studies should examine whether behavioral rehearsal or spouse training can strengthen the effects of pain coping skills training in order to reduce physical disability and pain behavior as well as pain and psychological disability.

Persistent pain and depression: a biopsychosocial perspective

This review highlights recent research findings on the relationship between persistent pain and depression and discusses the implications of these findings for future research in persons who suffer from both pain and depression. First, we briefly discuss advances in theories of pain that underscore the important role that depression can play in the chronic pain experience. Second, we discuss depression in persons suffering from chronic pain from a biopsychosocial perspective that takes into account both biological and psychosocial mechanisms linking pain and depression. Third, we address biomedical, psychosocial, and combined medical-psychosocial approaches to treatment in persons with persistent pain and depression. We conclude by highlighting future directions for research related to screening and diagnosis of depression in persons having persistent pain, treatment of comorbid pain and depression, and individual and subgroup differences in the experience of persistent pain and depression.