Steven F. Brena

Chronic back pain: Electromyographic, motion and behavioral assessments following sympathetic nerve blocks and placebos

&NA; Twenty patients with chronic low back pain received 12 lumbar sympathetic injections, in a series of 6 with bupivacaine and a series of 6 with saline. Changes in subjective pain intensity, EMG from paravertebral muscles, joint ranges of mobility, and daily activity levels were measured at multiple intervals throughout treatment and at 3 monthly follow‐up intervals. The MMPI was administered before treatment, after treatment and at 3‐month follow‐up. Results revealed significant reductions in subjective pain intensity lasting 1 month after treatment which were not significantly different during bupivacaine and saline injection periods. Patients MMPI profiles were indicative of reduced depression and an increase in ability to manage their lives. No significant changes were recorded with respect to EMG, joint range of mobility, or daily activity levels. Results were discussed in terms of a massive placebo effect and analgesia obtained through hyperstimulation of various tissue structures. They are consistent with the hypothesis that central postsynaptic mechanisms were predominant in these patients chronic back pain states. Because subjective pain relief did not independently produce increasing function, it was recommended that deep analgesic injections or other pain relieving techniques be matched with behavior modification leading to functional rehabilitation.

Treatment outcome in a chronic pain rehabilitation program

One hundred patients were selected who had completed an outpatient rehabilitation program designed to teach competent coping with chronic pain. Data at follow-up periods averaging 21 months posttreatment indicated statistically significant decreases in subjective pain intensity and increases in activities of daily living with substantial reductions in use of medications for pain. Changes from pretreatment to follow-up were not significantly different among groups of patients with pending, current, or no disability. Eight of 19 unemployed persons who had pending disability claims had returned to work at follow-up. It was concluded that considerable changes in function can occur with relatively brief outpatient pain rehabilitation and that pending or current disability is not necessarily an indication of likely treatment failure.

Differential utility of medical procedures in the assessment of chronic pain patients

&NA; Physicians are frequently called upon to evaluate patients with chronic pain toestablish the etiology,determine the extent of impairment and disability, andprescribe treatment. In many cases, there is little agreement as to what evaluation procedures should be used or how to weight and integrate these findings. Two studies were conducted to determine the domain of procedures pain specialists believe are most important in evaluation and the clinical utility of each. A survey of 75 physicians specializing in the treatment of chronic pain was conducted. Coefficients of concordance indicated that physicians displayed substantial agreement as to the differential utility of 18 physical examination and diagnostic procedures. The relevance of each of these procedures in the assessment of 100 pain patients was evaluated. Differential weights for each procedure derived from the survey were highly correlated with clinical practice. The results of the present studies provide a basis for development of a standardized assessment procedure that incorporates statistically derived weights to quantify medical findings.

Management of patients with chronic pain

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Empirically derived chronic pain patient subgroups: the utility of multidimensional clustering to identify differential treatment effects

&NA; The current study used multidimensional clustering to delineate empirically subgroups of chronic pain patients and to compare their responses to interdisciplinary pain rehabilitation. A total of 180 chronic pain patients were used as subjects. They were administered the Sickness Impact Profile (SIP), Medical Examination and Diagnostic Information Coding System (MEDICS) and treatment outcome measures including subjective pain intensity, hours standing and walking, medication usage and work status. All subjects then participated in an outpatient interdisciplinary pain rehabilitation program, with 120 being randomly selected and 90 available for follow‐up assessment. Multidimensional cluster analyses using SIP and MEDICS data identified 4 replicable subgroups: cluster A — highly dysfunctional with moderate levels of physical pathology; cluster B — moderately dysfunctional with moderate levels of physical pathology; cluster C — highly functional with low levels of physical pathology; and cluster D — highly dysfunctional with low levels of physical pathology. Cluster‐A and ‐D patients showed significantly higher levels of depression, more medication usage, less activity and were less likely to be working at pretreatment. These 2 clusters also showed the largest improvement in subjective pain intensity, medication usage, activity level, and return to work post‐treatment. Patients in cluster B exhibited the least amount of improvement across outcome measures and, unlike the other 3 clusters, failed to show any significant improvement in work status at post‐treatment. Cluster differences were not primarily a function of age, sex, pain intensity, pain location, pain duration, or depression. It was concluded that useful subgroups of chronic pain patients could be reliably identified through multidimensional clustering. More importantly, these subgroups exhibited differential response to treatment that could be used to guide treatment application and maximize efficiency and effectiveness.

Learned helplessness and responses to nerve blocks in chronic low back pain patients.

Abstract In a double‐blind study, 67 chronic low back pain patients received 4 lumbar sympathetic nerve blocks, two given with bupivacaine and two given with saline. It was hypothesized that patients showing evidence of ‘learned helplessness,’ as measured by dependence on habit‐forming medications for the pain, low activity levels, and elevated MMFI scores on Hypochondriasis, Depression and Hysteria would show the least reduction in subjective pain intensity following injections with both bupivacaine and saline. It also was hypothesized that placebo responses would be greatest in patients who had a high educational level, were divorced, and had no pending disability claims. Responses 30 min following nerve blocks failed to correlate with these variables. However, decreases in subjective pain intensity 24 h following both types of nerve blocks were greater in patients who showed low levels of pain behavior, who were divorced, and who had no pending disability claims. Decreased pain 24 h following saline injections was significantly related to low scores on the Lie, Defensiveness, Hypochondriasis, and Hysteria scales of the MMPI and to reduced subjective pain intensity following a 6 week comprehensive outpatient pain rehabilitation program. It was concluded that chronic pain patients who are fixed in their focus on pain, high in pain‐related behaviors, and low in responsibilities are less likely to respond favorably to nerve blocks and that medical treatment for them needs to be paired with therapies designed to reduce their helplessness.

Phantom urinary bladder pain — case report

Phantom urinary phenomena are a relatively rare disease entity. Literature search has revealed only one case following cystectomy, seven cases following spinal cord injury and several other cases in hemodialysis patients. This report presents a case of painful phantom bladder following cystectomy for chronic kidney and urinary tract infection. Treatment was directed toward sensory hyperstimulation for suppression of the subjective experience of the painful phantom. Lumbar sympathetic blocks and transcutaneous electrical stimulation were used. Competent coping mechanisms were increased through relaxation training and assertiveness training to deal with a medical problem which has no standard solution. The patients response to the Comprehensive Pain Control Program was excellent with an estimated 75% reduction in painful phantom perceptions. A brief discussion of the medical literature on the subject is presented.

Patterns of conscious failure to provide accurate self-report data in patients with low back pain.

Assessment and treatment responses were compared in 17 subjects with chronic low back pain assessed as showing at least one clear consciously produced inconsistency in statements and/or behaviors during their participation in an interdisciplinary treatment program and 143 subjects assessed as showing no such inconsistency. Numerous statistically significant differences emerged: Inconsistent subjects were more likely to have pending litigation and to be assessed by staff as showing a higher degree of focus on pain and more dramatized complaints, lower levels of medical findings and attention and interest in treatment, and poor compliance with treatment and assessment procedures. In addition, these subjects reported lower levels of physical activity and generally more inconsistent or negative responses to lumbar sympathetic injections with fewer expected changes in physical sensations. Though not definitive, these results suggested a syndrome of characteristics among such subjects which are similar to those proposed as likely characterizing malingerers. The need for a particularly careful validation of self-report data in patients showing many of these characteristics was emphasized.

The "learned pain syndrome": decoding a patient's pain signals.

Learned pain is a distinct entity with its own set of symptoms, diagnostic criteria, and treatment methods. Recognition of the condition by health professionals is necessary for proper patient management and will facilitate further research and appropriate training.

Nerve blocks and chronic pain states--an update. 2. Clinical indications.

With the unfortunate exception of the differential spinal block, diagnostic nerve blocking has become somewhat obsolete with the development of newer, more sophisticated diagnostic technology. Therapeutic nerve blocks remain useful in treating patients with various terminal cancers, some forms of back pain, tic douloreux, causalgia, reflex sympathetic dystrophy, and many trigger point syndromes. For dysfunctional and pain-disabled patients (rated as class 1 or 3 on Emory Pain Estimate Model), block therapy must be structured in comprehensive pain rehabilitation programs.