Thomas E. Rudy

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.

Chronic pain and depression: toward a cognitive-behavioral mediation model

Although considerable attention has recently been devoted to explaining why depression is a frequent concomitant of chronic pain, little empirical work has been conducted to test predictions based on these models. The present study was designed to test a cognitive-behavioral mediation model of pain and depression that proposes perceived reduction in instrumental activities along with a decline in perceptions of control and personal mastery are necessary prerequisites for the development of depressive symptomatology in pain patients. According to this model, in contrast to alternative models, the presence of pain is not sufficient condition for the subsequent development of depression. This model was tested and confirmed through the application of structural modeling with latent variables. Specifically, the direct link between pain and depression was found to be non-significant, however, measures of perceived life interference and self-control were found to be significant intervening variables between pain and depression. These results provide the first empirical demonstration that psychological mediators may be involved in the development of depression secondary to chronic pain. The findings of this study are contrasted with single-factor models that postulate both chronic pain and depression as resulting from a common cause.

The robustness of an empirically derived taxonomy of chronic pain patients

There is currently no classification system for chronic pain patients that has achieved consensus. The lack of a classification that is used consistently across settings has impaired advance of knowledge and treatment of chronic pain patients. Recently, an empirically derived multivariate classification system, the Multiaxial Assessment of Pain (MAP) patients, has been developed. In this paper, the generalizability of the MAP system was evaluated by contrasting the MAP classification of 3 common but diverse chronic pain syndromes, namely, low back pain, headache, and temporomandibular disorders. The results indicate that although the proportion of patients classified into the 3 subgroups of the MAP taxonomy differ, the profiles based on the pattern of interrelationship among the assessment scales were remarkably similar. These data suggest that the psychosocial and behavioral responses associated with chronic pain are common to diverse samples of pain patients despite differences in demographic characteristics and medical diagnosis. The implications of these results for research and clinical practice are discussed. The potential utility of a polydiagnostic approach using more traditional medically based classifications such as proposed by the IASP (Merskey, H., Pain, Suppl. 3 (1986) S1-S225) complemented by classification based on the MAP psychosocial-behaviorally based taxonomy are examined.

The McGill Pain Questionnaire reconsidered: confirming the factor structure and examining appropriate uses.

&NA; A major problem in the understanding and psychological treatment of chronic pain patients is the inadequacy of available assessment procedures. Currently, the most frequently used instrument is the Pain Rating Index (PRI) of the McGill Pain Questionnaire, designed to assess 3 components of pain (i.e., sensory, affective and evaluative) postulated by the Gate Control Theory. The PRI has been used in many studies to make differential diagnoses, to describe different groups of pain patients and to identify the factor composition of the instrument itself. To date, however, no study has appropriately tested the a priori structure of the PRI or cross‐validated it. Confirmatory factor analytic procedures employed in the present study supported Melzacks postulated tri‐component structure of the PRI in 2 diverse samples of pain patients from different hospitals. However, the 3 components were found to be highly intercorrelated. Subsequent analyses revealed that the 3 components of the PRI do not display adequate discriminant validity. The current use of 3 subscales to establish differential diagnoses or patterns of different pain syndromes may lead to inappropriate classification and treatment decisions. The major conclusion of these findings is that use of only the total score of the PRI is appropriate for pain assessment.

Neglected topics in chronic pain treatment outcome studies: determination of success.

&NA; Although literature on chronic pain treatment outcome has made substantial strides in improving the quality of the studies reported, there remain a number of factors that lead to qualification of the generally positive results. In the two previous papers in this series a set of mitigating factors was discussed, namely, representativeness of the samples treated in these outcome studies, relapse, and non‐compliance with therapeutic recommendations. Additional limitations include the lack of agreement on the criteria on which to base evaluation of the success of treatment outcome and the percentage of treated patients included in follow‐up data. In this paper, the most common methods for determining success are described (group effects based on standard and quasi‐standard outcome measures). The limitations of this approach are discussed and alternative strategies are presented that focus not only on traditional criteria based on group means but on additional criteria including: (a) importance of change (i.e., clinical vs. statistical significance), (b) proportion of patients who improve, (c) cost, (d) efficiency in treatment delivery, (e) and consumer acceptance and satisfaction.

Towards a comprehensive assessment of chronic pain patients

Abstract The evaluation and treatment of individuals suffering from chronic pain is frequently aligned with how pain is conceptualized. Unidimensional models of pain are reviewed and the inadequacies of conducting assessments from these perspectives are highlighted. Several preliminary attempts at integrating medical and psychological data are discussed. A triarchic. Multiaxial Assessment of Pain (MAP) approach, based on sound taxometric and multivariate classification procedures, is proposed. It is concluded that a comprehensive evaluation of chronic pain patients should include the assessment and integration of physical, psychosocial, and behavioral information.

Differential treatment responses of TMD patients as a function of psychological characteristics

&NA; A number of studies have reported that psychological factors play a significant role in TMD. Several studies have identified subgroups of patients based on their responses to psychological assessments; however, none of these studies have reported on the clinical utility of classifications of TMD patients on these various measures. In this study, the differential response of 133 TMD patients classified within 3 psychosocial‐behaviorally based subgroups to a conservative, standardized treatment was examined. The treatment consisted of the combination of an intra‐oral appliance, biofeedback, and stress management. Follow‐up assessments were conducted 6 months after treatment termination. The results demonstrated that overall as a group patients significantly improved and maintained improvements on physical, psychosocial, and behavioral measures (P < 0.0001). Comparisons across patient subgroups, however, revealed differential patterns of improvement on the outcome measures. Most notably, reliable change indices demonstrated that the patients classified into a subgroup characterized by the greatest degree of psychological distress (Dysfunctional) demonstrated significantly greater improvements on measures of pain intensity (P < 0.001), perceived impact of TMD symptoms on their lives (P < 0.001), depression (P < 0.01), and negative thoughts (P < 0.001), compared with groups characterized by greater interpersonal problems (Interpersonally Distressed) and those patients who appeared to be the least disabled by TMD (Adaptive Copers). These data provide support for the clinical utility of a psychosocial‐behavioral classification system and suggest that in future research individualizing treatments and outcome measures based on patient characteristics may improve treatment efficacy and outcome evaluation.

Neglected factors in chronic pain treatment outcome studies - referral patterns, failure to enter treatment, and attrition

&NA; An increasing number of chronic pain treatment outcome studies have appeared in the literature. In general, these studies support the efficacy of multidisciplinary pain programs, as well as specific treatment modalities such as biofeedback and relaxation. Reviews of this literature have tended to be cautiously optimistic. Some concerns, however, have been raised about the methodological adequacy of these studies, particularly in terms of the lack of control groups, the brief duration of follow‐up periods, and the vague criteria used for establishing the success of the therapeutic interventions. Other factors that mitigate conclusions regarding the generalizability of the favorable results reported need to be considered. In this paper 3 rarely discussed topics that are implicit within most treatment outcome studies and that need to be given greater attention are examined. These topics include:referral patterns to pain clinics (who are referred to pain clinics, when, and how representative is the referred sample?);failure to enter treatment (e.g., exclusion criteria, lack of available financial support to cover the cost of treatment, patients refusal to accept recommendations), and consequently, the representativeness of the treated sample;patients attrition. In this paper we discuss each of these factors as they underscore important qualifications that have to be made in evaluating treatment outcome studies.

Effects of intraoral appliance and biofeedback/stress management alone and in combination in treating pain and depression in patients with temporomandibular disorders

To assess the differential efficacy of two commonly used treatments for temporomandibular disorders (TMD), intraoral appliances (IAs) and biofeedback (BF), separately and in combination, two studies were conducted. The first study directly compared IA treatment, a combination of biofeedback and stress management (BF/SM), and a waiting list control group in a sample of 80 TMD patients. Both treatments were determined to be equally credible to patients, ruling out this potential threat to the validity of the results obtained. The results demonstrated that the IA treatment was more effective than the BF/SM treatment in reducing pain after treatment, but at a 6-month follow-up the IA group significantly relapsed, especially in depression, whereas the BF/SM maintained improvements on both pain and depression and continued to improve. The second study examined the combination of IA and BF/SM in a sample of 30 TMD patients. The results of this study demonstrated that the combined treatment approach was more effective than either of the single treatments alone, particularly in pain reduction, at the 6-month follow-up. These results support the importance of using both dental and psychologic treatments to successfully treat TMD patients if treatment gains are to be maintained.

The impact of chronic low back pain on older adults: A comparative study of patients and controls

Abstract Chronic low back pain (CLBP) is one of the most common, poorly understood, and potentially disabling chronic pain conditions from which older adults suffer. Many older adults remain quite functional despite CLBP, and because age‐related comorbidities often exist independently of pain (e.g., medical illnesses, sleep disturbance, mobility difficulty), the unique impact of CLBP is unknown. We conducted this research to identify the multidimensional factors that distinguish independent community dwelling older adults with CLBP from those that are pain‐free. Three hundred twenty cognitively intact participants (162 with ⩾moderate pain for ⩾3 months, and 158 pain‐free) underwent comprehensive assessment of pain severity, medical comorbidity (illnesses, body mass index, medications), severity of degenerative disc and facet disease, lumbar flexion, psychological constructs (self‐efficacy, mood, overall mental health), and self‐reported as well as performance‐based physical function. Significant differences were ascertained for all 22 measures. Discriminant function analysis revealed that eight measures uniquely maximized the separation between the two groups (self‐reported function with the Functional Status Index and the SF‐36, performance‐based function with repetitive trunk rotation and functional reach, mood with the Geriatric Depression Scale, comorbidity with the Cumulative Illness Rating Scale and BMI, and severity of degenerative disc disease). These results should help to guide investigators that perform studies of CLBP in older adults and practitioners that want an easily adaptable battery for use in clinical settings.