Robert G. Large

Epidemiology of pain in New Zealand

&NA; Information on the prevalence of pain in the general population has relevance for the allocation of health services and for understanding of chronic pain. In 1986 a sample of 1498 adults were interviewed using the Diagnostic Interview Schedule. Questions on pain were taken from the somatisation section of the interview schedule. These responses were used to determine the lifetime prevalence of pain in the urban population of New Zealand. The majority of subjects reported more than one life disrupting experience of pain. Pain was most common in the joints, back, head and abdomen. Women reported more pain than men. In general the prevalence of pain increased with age, however this was not true for headaches and abdominal pain. Most subjects related their pain symptoms to a physical cause.

Follow-up results from a randomised controlled trial evaluating in- and outpatient pain management programmes

&NA; This study reports a 9–18 month follow‐up of a randomised controlled trial of pain management programmes for chronic, non‐malignant pain. Twenty‐two inpatients, 18 outpatients and 12 control subjects completed the follow‐up assessments. Significant treatment effects were demonstrated by the inpatient group on pain ratings, the Pain Behaviour Checklist, and General Health Questionnaire, with similar effects demonstrated by the outpatient group on the former 2 measures. The findings were confounded by higher inpatient scores at pretreatment, in comparison with the 2 other conditions. There was a high drop‐out rate of subjects, particularly from the control condition which illustrates the limitations of controlled group designs in this area. Analgesic use, activity levels and pain ratings were also evaluated using the criteria for ‘success’ described by Malec et al. (1981). Results indicated that 68% of inpatients, 61% of outpatients and 21% of control subjects met all 3 criteria. Both treatment programmes were effective in returning patients to paid employment, whilst 3 control group patients gave up work. The cost‐benefit implications of these changes are discussed. We conclude that pain management programmes contribute substantially to the rehabilitation of chronic pain sufferers.

Function and the patient with chronic low back pain.

OBJECTIVE To undertake a comparative examination of the reliability and validity of two frequently used self-report measures of functional disability, the Pain Disability Index (PDI) and the Oswestry Low Back Pain Disability Questionnaire (OLBPDQ). DESIGN A descriptive ex-post facto design was used in the study. SETTING Pain clinics and neurosurgical units at three metropolitan hospitals. SUBJECTS One hundred patients with chronic low back pain of noncancer origin were administered the two questionnaires as part of a larger questionnaire battery. RESULTS Acceptable internal consistency values of 0.76 for the PDI and 0.71 for the OLBPDQ were obtained. A correlation of r = 0.63 was found between the PDI and the OLBPDQ, supporting the concurrent validity of the two scales. Both the scales were found to be correlated to the Beck Depression Inventory scores (PDI, r = 0.42; OLBPDQ, r = 0.39), with higher disability associated with greater depression. Only the total PDI score was found to be sensitive to functional status differences within the patient sample. CONCLUSIONS These findings support other recent work in favor of the PDI. The PDI had a slightly higher internal consistency and was more sensitive than the OLBPDQ.

The psychiatrist and the chronic pain patient: 172 anecdotes

&NA; The clinical experience of a psychiatrist working in a pain clinic is described. One hundred and seventy two patients were assessed over a 4‐year period. The modal age was 45–54 years with a male : female ratio of 7 : 10. The modal duration of pain was 1–5 years, the back being the commonest site. Depression was diagnosed in 30% of cases. Personality disorder, traumatic neurosis, anxiety, hysteria and drug dependence were the next most common diagnoses. Treatment was instituted in half of the patients seen and half of the treated patients improved or recovered. Drug withdrawal, EMG feedback and brief psychotherapy were associated with more improvement than pharmacotherapy or treatment at a psychiatric unit. The response to antidepressant medication was particularly disappointing and possible reasons for this are discussed.

A randomised control trial evaluating in- and outpatient pain management programmes

&NA; This study investigated the clinical efficacy of in‐ and outpatient pain management programmes in comparison with a control group. Following physical examination and psychosocial assessments, and after obtaining informed consent, patients were randomly assigned to 1 of 3 groups: (1) a 4 week multidisciplinary inpatient pain management programme; (2) a 9 week (2 h/week) multidisciplinary outpatient programme; or (3) a control group. Self‐report, behavioural and physiological measures were taken pre and post treatment. Patients in the treatment groups demonstrated significant improvement at posttreatment on measures of psychological distress, pain behaviour, health‐related disability and pain intensity (following physical exertion) when compared with the control group. Little difference was demonstrated on the remaining measures. Difficulties encountered in conducting clinical research with this population and utilising a control group design are discussed.

REDUCTION IN SKIN REACTIONS TO HISTAMINE AFTER A HYPNOTIC PROCEDURE

This study sought to test whether a cognitive-hypnotic intervention could be used to decrease skin reactivity to histamine and whether hypnotizability, physiological variables, attitudes, and mood would influence the size of the skin weals. Thirty eight subjects undertook three individual laboratory sessions: a pretest session to determine sensitivity to histamine, a control session, and an intervention session during which the subject experienced a cognitive-hypnotic procedure involving imagination and visualization. Compared with the control session, most subjects (32 of 38) decreased the size of their weals measured during the intervention session, and the differences between the weal sizes produced in the two sessions were highly significant (N = 38; t = 4.90; p <.0001). Mood and physiological variables but not hypnotizability scores proved to be effective in explaining the skin test variance and in predicting weal size change. Feelings of irritability and tension and higher blood pressure readings were associated with less change in weal size (i.e., a continuation of reactivity similar to that found in the control session without the cognitive-hypnotic intervention), and peacefulness and a lower blood pressure were associated with less skin reactivity during the intervention. This study has shown highly significant results in reducing skin sensitivity to histamine using a cognitive-hypnotic technique, which indicates some promise for extending this work into the clinical area.

Opioids for chronic pain of non-malignant origin--caring or crippling.

Pain management has improved in the past few decades. Opioid analgesics have become the mainstay in the treatment of cancer pain whilst inter-disciplinary pain management programmes are the generally accepted approach to chronic pain of non-malignant origin. Recently some pain specialists have advocated the use of opioids in the long-term management of non-cancer pain. This has raised some fundamental questions about the purpose of pain management. Is it best to opt for maximum pain relief and comfort, or should one emphasise function and activity as higher priorities? Will the use of opioids create more autonomy for pain sufferers or will this add handicaps to lives which are already limited? Until more clinical outcome data are available we advocate caution in the use of opioid analgesia. Such caution can, and does, raise questions about the rights of the patient and the rights of the prescriber in a context where the facts do not point to a clear course of action.

The personal constructs of coping with chronic low back pain: is coping a necessary evil?

&NA; The construct of coping is explored in this paper utilising repertory grid technique with a small group of non‐patients with chronic pain. Nineteen volunteers with low back pain completed a repertory grid with eight given elements signifying various self and illness‐related roles. Two constructs were given and the remainder elicited using the triad method. The 19 participants rated themselves as being in less pain than those they typified as ill or disabled and considered themselves to be coping with their pain. The constructs elicited emphasised authenticity, the limitations of being a coper, mastery, active stoicism, cheerfulness, acceptance and maintaining acceptable social interactions and appearances. Copers were considered to not be in constant pain. Self, ideal‐self and social‐self constructs were closely related. The participants rated themselves more like copers than ill, pain‐suffering, invalid or hypochondriacal persons. Being a coper, however, was less desirable than being pain free. In essence, these volunteers with low back pain see coping as a necessary evil. This ambivalent and ambiguous construing of coping needs to be further explored in community and patient groups if we are to improve the collaboration between patients and therapists in achieving good pain management.

Economic Considerations in Pain Management

Pain is usually thought of as a symptom requiring examination, investigation and diagnosis, and clinicians have focused their efforts on detecting the cause of the pain and directing treatment to any purported underlying cause , When a patient is suffering acute pain , this is a logical way to proceed, although symptomatic management of the pain itself is accepted as being necessary to humane medical care , For chronic pain, find ing the cause does not always lead to a resolution of the problem. When the cause of the pain is found , it is sometimes a condition which is chronic or relapsing and for which current medical treatments are inadequate to effect a cure . Many musculoskeletal pains, some headaches and neuropathic pains fall into this latter category, Sometimes no cause can be discovered and speculation runs rife as to whether the patient is depressed, hysterical, malingering or has a low pain threshold. However, in the past 20 years a new paradigm has emerged and we have begun to think of pain , particularly chronic pain , as a disease or syndrome in its own right The consequence of this new view of pain has been the burgeoning of pain clinics and pain management programmes for chronic pain, whilst acute pain management involves time, increasingly sophisticated equipment and staff training, This commitment of staff, equipment and other resources to pain management raises questions about the cost-benefit versus efficacy of the enterprise, This article focuses on the current status of pain management and the ongoing debate on its efficacy and economic efficiency.

Coping with chronic low back pain: an idiographic exploration through focus groups.

Objective: This article explores the coping construct held by individuals with chronic low back pain. The research addresses two criteria identified as important for coping research: it looks at peoples appraisals and responses to the specific stressor of living with chronic low back pain, and it seeks to identify what these individuals actually think and do in response to the ongoing stressor of living with chronic pain. Method: Fifteen people with chronic low back pain who responded to a media release participated in focus group discussions on coping with chronic pain. Results: Analysis indicated the desirability, if not need, for a somatic focus, the reliance on higher order cognitive strategies for planful action, and the use of a varied repertoire of coping strategies. Conclusions: These findings are discussed both in terms of adjustment to chronic illness and in relation to current pain management practices.