Frank Leavitt

Affective and sensory dimensions of back pain.

&NA; Pain words used to communicate suffering were analyzed to identify specific dimensions of back pain. The words were obtained from a group of 131 patients suffering from back pain who described their discomfort on a standardized 87‐item pain questionnaire. The results indicate that words descriptive of back pain are not associated in completely random ways. When patients complain of back pain, their report falls into 7 distinguishable patterns. The major pattern accounts for 38% of the variance and refers almost entirely to emotional discomfort. The second pattern accounts for 9% of the variance and is a mixed emotional and sensory factor. The remaining 5 patterns account for 29% of the variance and constitute an entirely sensory class of factors.

The prevalence and clinical impact of reported cognitive difficulties (fibrofog) in patients with rheumatic disease with and without fibromyalgia.

Cognitive dysfunction in patients with rheumatic disease encompasses a range of impairment. Their prevalence, co-occurrence, and impact on symptom severity were assessed in 57 patients with fibromyalgia (FMS) and 57 patients with rheumatic disease without FMS. Information pertaining to memory decline, mental confusion, and speech difficulty was extracted from questions embedded in a health questionnaire and a blind retrospective chart review. Pain, morning stiffness, fatigue, and sleep difficulty were established on a 0- to 100-mm visual analog scale. Variables of mental confusion, fatigue, tension, depression, anger, and vigor were assessed using the Profile of Mood States. Compared with the non-FMS sample, patients with FMS complained more often of memory decline (70.2–24.6%), mental confusion (56.1–12.3%), and speech difficulty (40.4–3.5%). Memory decline and mental confusion were coupled more often in patients with FMS (50.9–8.8%). Patients with FMS with this combination of cognitive problems reported more pain (76.0–45.4%), stiffness (79.7–43.7%), fatigue (79.6–52.6%), and disturbed sleep (59.2–36.6%) compared with patients with FMS with memory problems alone. Patients with rheumatic disease substantially differ in cognitive vulnerability, with patients with FMS at considerably higher risk for cognitive difficulty. More importantly, the prevalence of a combined disturbance in memory and mental clarity is high and closely associated with the perception of increased illness severity and diminished mental health in FMS. That this linkage has the possibility of having a great deal to do with an important clinical variant of FMS underscores the need for greater clinical recognition of this underrecognized pattern and for further research. Patients with fibromyalgia frequently report memory and concentration problems, especially if asked about them. Clinicians could judge these complaints as similar to adult attention deficit syndrome and reassure the patient. Trying medication to improve attention and concentration is sensible but untested in fibromyalgia.

The detection of psychological disturbance in patients with low back pain.

Abstract The feasibility of developing a pain scale for detecting psychological disturbance in patients with low back pain was investigated in two studies. In the first study, stepwise discriminant analysis was used to identify the best combination of pain terms that would discriminate the functional group from the organic group. Thirteen pain variables were identified which correctly identified 93.6% of the cases of low back pain. These pain terms were used to categorize 159 new cases in the second. Cross-validation shrinkage was only 10.6%. One hundred and thirty-two out of 159 cases in the new sample were correctly classified. The advantages of this pain scale over existing methods are discussed, along with implications for clinical orthopedic practice.

Psychological disturbance and pain report differences in both organic and non-organic low back pain patients

&NA; Patients with undiagnosable low back pain have been observed to differ from patients with proven low back pain in their clinical description of pain and in their psychological status. More variable and diffuse pain qualities are emphasized in their clinical reports and more psychological disturbance characterizes them as a group, suggesting an association between pain expression and psychological disturbance. One hundred and two patients with low back pain were administered a standardized pain questionnaire to determine more systematically the association between pain expression and psychological disturbance in patients with and without demonstrable organic disease. Patients with psychological disturbance differed significantly from patients without psychological disturbance in the following ways. They used more words in their description of pain, distributed these words over more pain factors, and endorsed significantly more pain of the affective and skin pressure variety. The results underscore previous clinical impressions and suggest that patients without either organic or psychological findings may be cases of undiagnosed organic disease.

Organic status, psychological disturbance, and pain report characteristics in low-back-pain patients on compensation.

The relationship between compensation and three variables—psychologic disturbance, organic status, and pain report characteristics— was assessed. Patients on compensation were clinically similar to patients not on compensation in the relative frequency of cases of psychologic disturbance and nonorganic findings in each group. Patients on compensation differed only when objective evidence of organic disease and psychologic stability was present. Under these circumstances, the compensation group used 43% more words to describe their pain and endorsed more pain qualities on five independent dimensions of pain. These results indicate that compensation primarily affects the description of low-back pain in cases where objective evidence of injury is present and leads to an intensification of sensory discomfort. Little justification was found for the atmosphere of suspicion that surrounds patients on compensation who have no evidence of organic disease.

Demographic and affective covariates of pain.

&NA; Relationships of four demographic variables and five affective variables to eight attributes of low back pain were investigated in 251 patients by stepwise, multivariate analysis. The demographic variables are age, sex, race, and education. The affective variables are state anxiety, trait anxiety anxiety, hostility, and depression. Seven of the pain variables are from the factorially derived Low Back Pain Questionnaire. The eighth pain variable is a self‐estimate of intensity. Relationships among demographic and pain variables are small and unsystematic. Hostility has a small, systematically inverse relation to pain variables, supporting theories relating low back pain to inhibition of anger. Anxiety has a small positive relationship, and depression has no relationship to pain variables. In general, the small relationships indicate that the Low Back Pain Questionnaire provides descriptions of pain that are not confounded by social characteristics or current emotional states of patients.

Chronic low back pain and depression

It is not clear whether the psychological disturbances associated with chronic low back pain are the cause or the result of the chronicity. It is also not clear whether increasing duration of low back pain is associated with depression. Three groups of patients (N = 148), with recent (0-6 months), relatively longstanding (6-24 months) and chronic (more than 24 months) low back pain were given the MMPI, Multiple Affect Adjective Check List (MAACL), State Trait Anxiety Inventory (STAI) and Low Back Pain Questionnaire (LBPQ). Increasing chronicity is associated with significant increases on MMPI Hs, D, HY, PT and MA scales, and on STAI Trait Anxiety scale. These results suggest that chronicity leads to the development of psychopathological characteristics and that these characteristics include a heightened awareness of somatic functioning and the vegetative aspects of the depressive syndrome, but that there is no increase in depressive mood or in the perception of the pain itself.

The physical exertion factor in compensable work injuries : a hidden flaw in previous research

Studies of the industrially injured worker invariably suggest that compensation reinforces pain and prolongs disability. These claims may be spurious. Researchers have historically failed to take into account the fact that return to work is partly contingent on the amount of physical labor involved in the job, and that compensation and noncompensation groups differ on this variable in important ways. Patients on compensation are more likely involved in heavy physical exertion on their jobs. In this study, 1,191 workers with low-back pain who were injured on the job were compared with 389 workers who were injured away from work on variables of disability time and pain intensity. To disentangle the effects of physical exertion, four levels ranging from none to heavy were examined. The results suggest that injury on the job operates both independent of level of physical exertion, as well as in interaction with it, to extend the period of disability. Injury on the job is associated with prolonged disability time, irrespective of the type of job performed.

Cognitive and dissociative manifestations in fibromyalgia.

Memory decline and mental confusion frequently complicate the clinical presentation of fibromyalgia; however, formal cognitive examination often does not support deterioration. This paradox was examined in the context of dissociation, a condition with many cognitive similarities. Dissociation refers to the separation of parts of experience from the mainstream of consciousness. A common example is highway hypnosis. Eighty-nine fibromyalgia (FM) patients and 64 other rheumatic disease patients were screened for memory decline and mental confusion using a questionnaire format. Pain, dissociation, affective distress, fatigue, sleep difficulty, and mental confusion were also assessed.Cognitive complaints (76.4%–43.8%) and dissociative symptoms (37.1%–1.9%) were overrepresented in patients with FM. Among FM patients with high dissociation, cognitive difficulties were reported by 95%; 100% of these cases reported that both memory and mental clarity were affected, a condition referred to as fibrofog. Dissociation in combination with fibrofog was associated with higher levels of FM symptom intensity and decreased mental well being. These findings suggest that dissociation may play a role in FM symptom amplification and may aid in comprehending the regularity of cognitive symptoms. Separating cases of fibrofog from cognitive conditions with actual brain damage is important. It may be prudent to add a test of dissociation as an adjunct to the evaluation of FM patients in cases of suspected fibrofog. Otherwise, test results may prove normal even in patients with disabling cognitive symptoms.

Low back pain in patients with and without demonstrable organic disease.

&NA; Pain descriptors of patients with low back pain were analyzed to determine their usefulness in identifying patients without demonstrable organic disease. Using a standardized back pain questionnaire which scales qualities of pain along 7 independent factors, it was possible to make clear distinctions between the subjective reports of patients with and without demonstrable organic disease of the lower back. Pain described by patients with demonstrable organic disease tends to be consistent and specific; whereas pain described by patients without demonstrable organic disease tends to be more variable and diffuse. Pain reported by the latter group was also more intense. Factors which may underlie these findings were discussed.