Wilbert E. Fordyce

A prospective study of work perceptions and psychosocial factors affecting the report of back injury

A longitudinal, prospective study was conducted on 3,020 aircraft employees to identify risk factors for reporting acute back pain at work. The premorbid data included individual physical, psychosocial, and workplace factors. During slightly more than 4 years of follow-up, 279 subjects reported back problems. Other than a history of current or recent back problems, the factors found to be most predictive of subsequent reports in a multivariate model were work perceptions and certain psychosocial responses identified on the Minnesota Multiphasic Personality Inventory (MMPI). Subjects who stated that they “hardly ever” enjoyed their job tasks were 2.5 times more likely to report a back injury (P = 0.0001) than subjects who “almost always” enjoyed their job tasks. The quintile of subjects scoring highest on Scale-3 (Hy) of the MMPI were 2.0 times more likely to report a back injury (P = 0.0001) than subjects with the lowest scores. The multivariate model, including job task enjoyment, MMPI Scale-3, and history of back treatment, revealed that subjects in the highest risk group had 3.3 times the number of reports in the lowest risk group. These findings emphasize the importance of adopting a broader approach to the multifaceted problem of back complaints in industry and help explain why past prevention efforts focusing on purely physical factors have been unsuccessful.

Acute back pain: A control-group comparison of behavioral vs traditional management methods

Back-pain patients with onset in the preceding 1–10 days and comparable on a back examination were randomly assigned to traditional management (A regimen) and behavioral treatment methods (B regimen). Patients were compared at 6 weeks and 9–12 months on a set of “Sick/Well” scores derived from patient reported vocational status (V), health-care utilization (HCU), claimed impairment (CI), and pain drawings (D) and on two measures of activity level. No differences were found at 6 weeks, but at 9–12 months, A-group Ss were more “sick.” No A/B differences were found on activity-level measures. Group A Ss showed significant increases in claimed impairment from preonset to follow-up, whereas Group B Ss had returned at follow-up to preonset levels

The behavioral management of chronic pain: A response to critics

&NA; Common criticisms of behavioral treatment programs for chronic pain are summarized. Some criticisms are based on conceptual misunderstandings; therefore, basic concepts and goals of behavioral programs are presented. Other criticisms question the effectiveness of these programs; therefore, the role of social reinforcers in maintaining or reducing pain behaviors is reviewed. The failure to isolate specific treatment variables is alleged; this is acknowledged, along with the practical and ethical questions making this virtually impossible. Finally we describe the need to change the thinking about ‘pain’ from the pathological or disease model, appropriate to acute pain, to a learning model when discussing the excess disability and suffering of chronic pain patients.

Drug utilization patterns in chronic pain patients

Abstract In the population of chronic pain patients seen at multidisciplinary pain clinics, excessive and/or inappropriate medication use is a frequent problem. This study examined differences between chronic pain patients who used no addicting medication (30% of the sample of 131 patients), those who used narcotic but not sedative medications (33%) and those who used both narcotic and sedative medications (37%). Patients in the narcotic and narcotic‐sedative groups had undergone significantly more pain‐related hospitalizations and surgeries than those in the no addicting drugs group. Narcotic‐sedative patients spent significantly more money on pain medication per month, reported significantly greater physical impairment, and had higher MMPI hypochondriasis and hysteria scores when compared to the other patients. The findings are interpreted in light of the hypothesis that certain patients show greater readiness to complain of and seek help for physical symptoms.

The modification of avoidance learning pain behaviors.

This study demonstrates a procedural innovation designed to modify chronic pain behaviors which have been acquired through avoidance learning. Discussion focuses on avoidance learning as a seldom-investigated factor in the acquisition and maintenance of chronic pain behaviors.

Pain complaint-exercise performance relationship in chronic pain☆

Abstract Chronic pain patients typically display reduced activity level attributed to pain and implying a positive correlation between exercise or activity and pain complaints. This study correlated observed pain complaints with amount of prescribed exercise performed by chronic pain patients when exercising to tolerance. Patients were in evaluation of earliest stages of multi‐modal treatment. Exercises were physician prescribed to assess use of involved body parts and to promote general activity level. Patients were instructed to do exercise repetitions until pain, weakness of fatigue caused them to stop. Patients decided when to stop. Observations of amount of exercise performed were correlated with observed visible or audible indications of pain or suffering (pain behaviors). Results indicate a consistent negative relationship, i.e., the more exercise performed, the fewer the pain behaviors. This finding is contrary to the frequently observed physician prescription with chronic pain to limit exercise when pain increases.

A standardized evaluation of psychosocial factors in chronic pain

Abstract A number of psychosocial factors are generally considered to be important in exacerbating and maintaining chronic pain problems. However, standardized and reliable methods of evaluating these factors are needed. We have developed such an evaluation system, called the Psychosocial Pain Inventory (PSPI), and have obtained normative data from a large sample of chronic pain patients. Scores on the PSPI were approximately normally distributed and had good inter‐rater reliability. Patients with high PSPI scores were more likely to be considered exaggerating their symptoms during their physical examinations, but they did not show less evidence of an organic basis for pain. Significant correlations were obtained between PSPI scores and some measures from the McGill Pain Questionnaire, but scores on the PSPI were essentially unrelated to personality disturbance as measured by the Minnesota Multiphasic Personality Inventory (MMPI). The PSPI and MMPI appear to provide different types of information that can be used in a complementary way in evaluating pain patients. Results of a small pilot study suggest that high scores on the PSPI predict poor response to medical treatment for pain.

The Quota System in Burn Rehabilitation

This article describes the quota system as a treatment for the helplessness behaviors and depressive symptoms that develop in some patients with burn injuries. With an A-B single-case design, the quota system was implemented for a patient who had sustained a particularly severe burn injury. A series of baseline behaviors were measured for 3 days, and then 80% of the patients average performance on each of the targeted behaviors was computed and used as the initial quota value. The behavioral quotas were increased systematically and gradually by approximately 5% to 10% every day. The results suggest that the quota system may have been effective in decreasing an overall trend toward passivity, in increasing 3 of 4 targeted rehabilitation behaviors, and in reducing depressive symptoms in a patient with a particularly devastating injury.

On the nature of illness and disability: an editorial.

Issues underlying the rapid increase in assignment of disability to nonspecific low back pain are addressed. The central point of the discussion is that the healthcare system relies too exclusively on a biomedical perspective on pain and illness while failing to consider adequately environmental influences on symptom behavior and care seeking. Specific medical conditions with pathoanatomic findings observed are distinguished from nonspecific conditions in which those are lacking or only inferred. A biomedical model often suffices with specific conditions but, inherently, nonspecific conditions implicate the environment and social feedback. Impairment usually is defined in terms of biomedical issues. Disability, however, although often originating with impairment, is subject to major influence by patient effort and other considerations implicating the environment. In light of these issues in addition to reconsidering disability policy, attention also is directed to implications for the physicians role in implicitly encouraging patient perceptions of suffering as related inevitably to assumed underlying pathoanatomic factors.

Opioids, pain, and behavioral outcomes

U se of opioid analgesics in management of chronic nonmalignant pain, as in any other intervention, must ultimately be viewed in terms of effects on patient performance. Proponents of opioid use under appropriate safeguards1-4 take the position that the choice is an option to consider under certain circumstances. These circumstances include careful weighing of psychological and social factors in the patient’s context. The focus of their position is that opioid usage does not necessarily impair patient ability to function, or does so only to a degree that is “cost effective,” in terms of suffering and the meeting of life’s obligations, when weighed against what is anticipated were they not used. The factor to weigh is maximum function versus minimal suffering. They have also argued that opponents of opioid use draw on “nonmedical considerations,” including reluctance to use on the basis of morality issues. Portenoy3 for example, mentions “stigma attached to these drugs by their potential for abuse.” Their position also seems to imply that opponents may tend to an “all-or-none” perspective in which such moral or ethical issues, when invoked, fail to consider whether patient performance is enhanced or, at the least, not compromised. These are valid points. There are social and political factors influencing the use of opioids. Legal criteria may fail to differentiate medically prescribed usage dictated by professionals from drug usage on a nonprescribed basis. This may result in excessive constraints on their use. Resort may also be made to law or to agency policy to restrain prescription of prescribed opioids.