69. the Management of Chronic Pain

8/12/2019 69. the Management of Chronic Pain

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T h e M a n a g e m e n t of C hron i c Pain 389BIBLIOGRAPHY

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Brody DS, Hahn SR , Spitzer RL, et al: Identifying patients with d epression in the primary care setting : Amore efficient method. Arch Intern Med 158(22):2469-2975, 1998.Katon W J, Walker EA: Medically unexplained symptoms in primary care. J Clin Psychiatry 59 Suppl20:15-21, 1998.Kessler RC, McGonagle KA, Zhao S, et al: Lifetime and 12-mo nth prevalence of DSM-111-R psychiatric dis-orders in the Un ited States: Results from the National Comorhidity Survey . Arch G en Psych iatry 5 1:8-19,1994.Kessler LG, Cleaty PD, Burke JD: Psychiatric disorders in primary care. Arch Gen Psychiahy 42583-587, 1985.Lustman PJ: Anxiety disorders in adults with diabetes m ellitus. Psychiatr C lin North Am 11(2):419-431,1988.Von Korff M , Shapiro S, Burke JD: Anxiety and depression in a primary care clinic. Arch G en Psych iatry44152-156, 1987.Walker EA, Katon WJ, Jemelka RP: Psychiatric disorders and medical care utilization among people in thegeneral population wh o report fatigue. J Gen Intern Med 8:436-440, 1993.Yingling KW, Wulsin LR , Arnold LM, Rouan GW: Estimated prevalences of panic disorder and depressionamo ng consecutive patients seen in an emergency dep artmen t with acute chest pain. J Gen Intern Med8:231-235, 1993.

69. TH E MANAGEMENT OF CHRONIC PAINRo6evt N am i s o n Ph.D.

1. What is the difference between acute and chronic pain?Acute pain g enerally is associated with tissue damag e and represents a warning of injury to theindividual. It is expected to be directly proportional to the sensory input of the tissue damage and tocontinue until the damaged tissue and/or afferent pathways have returned to normal functioning.Chronic noncancer pain, in contrast, is a persistent condition o ften associated w ith an initial episodeof acute pain but continuing long past the time when healing would normally take place. Chronicnoncancer pain serves no beneficial purpose and is resistant to medical intervention .2. What are the different categoriesof pain?Pain syndro mes may be categorized according to the character and history of the symptom:

Acute pain is self-limiting, usually of less than 6-month duration, and generally adaptive innature (e.g., postsurgical pain, dental pain, pain following injury).Recurrent acute pain consists of a series of intermittent episodes of pain that are acute incharacter but chronic insofar as the condition persists fo r more than 6 m onths (e.g., migraineheadaches, trigeminal neuralgia, temporomandibular disorder).Chronic nonmalignant pain persists beyond 6 months and is intractable. Pain severityvaries over time and may or may not have a known relationship to active pathophysiologicor pathoanatomic process (e.g., chronic mechanical low back pain, diffuse myofascial painsyndrome).Chronic progressive pain increases in severity over time and often is associated with malig-nancies and degenerative disorders (e.g., skeletal metastatic disease, rheumatoid arthritis).

3. How do psychogenic and organic pain differ?Chronic pain represents a comp lex interaction of factors. The pain typically is related toan initial som atic event but, over time, is increasingly influenced by the patients personality,bel iefs , and environment . Attempts to re liably d ist inguish between organic and psycho genicpain have been largely unsuccessful. Many practitioners incorrectly believe that chronic painreflects either organic pathology or psycho genic symp toms. If physical findings are inadequate


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390 T h e Management of Chronic Painto accou nt fo r a patients report of chro nic pain, then the pain often is perceived to be mostlypsychological. It generally is unwarranted, however, to assum e that psychological factors are theprimary ca use of pain.

4. Which measures are useful in assessing pain intensity?Pain intensity can be m easured by subjective num erical pain ratings (scales from 0-10 or0-loo), visual an alogue scales, verbal rating scales, pain drawings, and com bined standardizedquestionnaires.5. What is a visual analogue scale?A popular means of measuring pain intensity is the visual analogue scale (VAS), which uses astraight line, usually 10cm long, with the extreme limits of pain on either en d of the line. Th e patientis instructed to place a mark o n the line to best indicate pain severity. Scores are obtained by m ea-suring the distance from the end labeled no pain to the mark made by the patient. Although fre-quently used to m easure chron ic pain, the VAS is time-consum ing to score and has questionablevalidity for older patients.6. What are verbal ratings of pain?A verbal pain-rating scale consists of 4-15 words that are ranked according to expression ofpain (from no pain to excruciating pain). The patient chooses the words that best describe thepain. Verbal scales not only m easure pain intensity but also assess sensory and affective dimensions

of the pain experience. Verbal scales also can b e used to measu re pain description. Th e patientchooses words from a list of words, such as piercing, stabbing, shooting, burning, and throbbing,that best describe the pain experience.7. What is the McGill Pain Questionnaire?The M cGill Pain Questionnaire (MP Q) is a popular, comprehensive questionnaire that includes20 subclasses of descriptors as well as a numerical pain-intensity scale and a derm atomal pain draw-ing. It is a frequently employed clinical tool in the subjective measurement of pain. A short form alsois popular. The M PQ allows for measurement of different aspects of the pain experience and is sen-sitive to treatment effects and the differential diagnosis.8. What tools best evaluate psychopathology in chronic pain patients?There is ongoing debate am ong m ental health professionals about the best ways to measure psy-chopathology in chronic pain p atients. Mo st chronic pain patients do not have a history of premorbidpsychiatric d isturba nce, but sho w reactive em otion al distress in resp onse to their pain. However,when present, major psychopathology is indicative of a poor prognosis for pain therapy. Pain pa-tients frequently endo rse som atic complaints in response to their condition. Thus, caution is neces-sary in interpreting psychological tests in which som atic com plaints are consid ered indicative ofpsychopathology in pain patients.The measures m ost comm only used to evaluate psychopatholog y and emotional distress inchronic pain patients include the Minnesota Multiphasic Personality Inventory (MMPI), theSymptom Checklist 90 (SCL-90-R), the Millon Behavior Health Inventory (MBHI), the IllnessBehavior Questionnaire (IB Q), and the Beck Depression Inventory (BDI).

Assessment Categories and Frequently Used Psychometric MeasuresPSYCHOSOCIAL HISTORYCAGE QuestionnaireComprehensive Pain QuestionnaireMichigan Alcoholism Screening Test (M AST )Self-Administered Alcoholism Screening Test (SAAST)Structured Clinical Interview for DSM-IV SCID)

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T h e Management of Chron ic Pain 39Assessment Categories and Frequently Used Psychometric Measures Cont.)

PAIN INTENSITYNumerical rating scalesPain drawingsVerbal rating scales VRS)Visual analog scales VAS)Beck Depression Inventory BDI)Center for Epidemiologic Studies Depression Scale CES-D)Illness Behavior Questionnaire IBQ)Millon Behavior Health Inventory MBHI)Minnesota Multiphasic Personality Inventory MMPI-2)Symptom Checklist 90-R SCL-90)

Coping Strategies Questionnaire CSQ)Inventory of Negative Thoughts in Response to Pain INTRP)Pain Management Inventory PMI)Pain Self-Efficacy Questionnaire PSEQ)Survey of Pain Attitudes SOPA)Multidimensional Pain Inventory MPI)Oswestry Disability Questionnaire ODQ)Pain Disability Index PDI)Short-Form Health Survey SF-36)Sickness Impact Profile SIP)

MOOD AND PERSONALITY

PAIN BELIEFS AND COPING

FUNCTIONAL CAPACITY

9. How is the MMPI used in assessing chronic pain patients?The MMPI, which consists of 561 true-or-false items, produces distinct profiles of pain patients.Studies have shown that profile patterns allow prediction of return to work and response to surgicaltreatment in males. A revised version, MMPI-2, replicates the profile patterns of the original MMPI.Again, despite this tests popularity in measuring the presence of psychopathology, remember thatprofiles of chronic pain patients can be misinterpreted because these patients frequently endorsephysical symptoms.10. Describe the Beck Depression Inventory.The BDI is a 2l-item, self-report questionnaire that provides a measure of severity of depres-sion. It is commonly used to assess depressive symptomatology in chronic pain patients and deter-mine treatment outcome. It is easy to administer and score.11. What other tools are valuable in assessing depression?Other valuable measures include the Center for Epidemiologic Studies Depression Scale and theHamilton and the Zung Depression Scales. Regardless of the tool used, a shared limitation is thepossible misinterpretation of an elevated score: chronic pain patients frequently report fatigue, sleepdisturbances, and loss of sexual interest, which can be interpreted as signs of clinical depression.12. Describe the SCL-90-R, the MBHI and the IBQ.The SCL-90-R is a 90-item checklist that uses a five-point scale. It offers a global index score aswell as nine subscale scores to provide a general assessment of emotional distress. The SCL-90-R isa relatively brief measure and offers some validity for pain patients the items make sense to them).It is easy to inspect individual items that may pertain specifically to persons with chronic pain. Thedisadvantages of this measure are that all subscales are highly correlated and there are no validityscales to determine the presence of subtle inconsistencies in responses.


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392 T h e M a n a g e m e n t of Chron ic PainThe MBH I conta ins 150 true-or-false items to assess mood and personality, and offers 20subscales that measure styles relating to pro viders, psychosocial stressors, and response to il l-ness. T he advantage of the MB H l is that the scales are not subject to misinterpretat ion du e tophysical sym ptom s. Unlike the other measures, the MB HI em phasizes medical rather than emo-tional concerns.The IBQ determines emotionality and illness behavior in chronic pain patients. It contains 62true-or-false items and com prises seven subscales measuring sym ptom c omp laints and abnormal ill-ness behavior. Patients who are not known to have organic pathology that would account for theirpain tend to produce higher IB Q scores. The IBQ also is correlated with anxiety measures.

13. How are pain related beliefs measured?A persons beliefs about pain are important in predicting the outcome of treatment. Negativethoughts about an ongoing pain problem may contribute to increased pain and emotional distress,decreased functioning, and greater reliance on m edication. C ertain chronic pain patients are prone tomaladaptive beliefs abo ut their condition that may no t be com patible with its physical nature (e.g.,This pain will make m e lose my mind. Soon I will becom e an invalid.). The tests mo st frequentlyused to measure maladaptive beliefs include the Coping Strategies Questionnaire, the PainManagem ent Inventory, the Pain Self-Efficacy Q uestionnaire, the Survey of Pain Attitudes, and theInventory of Negative Thoughts in Response t o Pain.14. What are the best ways to measure functional capacity?The assessm ent of funct ion al capacity and interference w ith activity is important s ince third-party payers frequently jud ge treatment ou tcome as successful on the basis of improved function andreturn to work. Reliable instrum ents for measuring function include the Sickness Imp act Profile, theShort-Form Health Survey, the M ultidimensional P ain Inventory, the Pain D isability Index, and theOswestry Disability Questionnaire.Other functional measures, which are not as popular, include The Chronic Illness ProblemInventory, The W addell Disability Instrument, and The F unctional R ating Scale. Automated devicessuch as the portable up-time calculator and the pedometer are useful ways to obtain accurate measuresof activity. These devices shou ld be used in conjunction w ith self-monitoring assessment techniques.15. List the options for treating chronic pain.Hot and cold packs PsychotherapyMassage therapy AcupuncturePhysical therapy Medication

Didactic instruction Nerve block therapyRelaxation training Implan table devicesHypnosis Surgical treatmentsBiofeedback16. What is an interdisciplinary pain treatment program?Chro nic pain involves a comp lex interaction of physiological and psychosocial factors, and suc-cessful intervention requires the coordinated effort of a treatment team with expertise in a variety oftherapeutic disciplines. Although some pain centers offer a unimodal treatment approach, most pro-grams blend medical, psychological, vocational, and educational techniques. The interdisciplinarycore staff typically includes on e or m ore physicians, a clinical psychologist, and a physical therapist.Other health p rofessionals who m ay play im portant roles include clinical nurse specialists, occupa-tional therapists, vocational rehabilitation counselors, and acupuncturists.17. How are outpatient pain programs typically structured?Multidisciplinary pain programs administered on an outpatient basis often are highly structured,time limited, and organized along a specific treatment schedule. The patient is expected to attend clinicsessions and to participate actively in all aspects of the program . These expectations must be made clear.


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T h e M a n a g e m e n t of Chronic Pain 393To this end, patients frequently sign a treatment contract that spells out the general program require-ments as well as individual treatment goals. In addition to helping patients understand exactly what isexpected of them, such a contract provides a mechanism for identifying those patients who, prior totreatment, lack motivation or may have difficulty conform ing to the structure of the program. Patientsare asked to keep a daily w ritten record of their pain intensity, med ication use, and activity levels.18. What are the desired outcomesof interdisciplinary treatment?The therapeu tic aims of interdisciplinary interventions for chronic noncancer pain include de-creased pain intensity, increased physical activity, decreased reliance on pain medication, a return towork, improved psychosocial functioning, and reduced use of healthcare services.19. List the main objectivesof cognitivehehavioral therapy for chronic pain patients.Help patients view their problem as manageable, instead of overwhelming. Patients who areprone to catastrophize benefit from examining the way they view their situation. What could beperceived as a ho peless condition can be reframed as a difficult yet m anageable condition overwhich they can exercise so me control.Help convince patients that the treatment is relevant to their problem and that they need to b eactively involved in their treatment and rehab ilitation.Teach patients to monitor maladaptive thoughts an d substitute positive thoughts. P ersons withchronic pain are plagued, either consciously o r unconsciously, by negative thoughts related to theircondition. These negative thoughts perpetuate pain behaviors and feelings of hopelessness. Adaptivemanagem ent techniques for chronic pain are an imp ortant compon ent of cognitive restructuring.20. What is the role of group therapy for pain patients?Pain patients frequently show signs of emotional distress, with evidence of depression, anxiety,and imtability. Group therapy with a cognitivehehavioral orientation is designed to help patients gaincontrol of the em otional reactions associated with chronic pain. Specific problem-solving strategiescan be offered, including: identifying maladaptive and negative though ts, disrupting irrational thinking,constructing and repeating positive self-statemen ts, learning distraction techniques, working to preventfuture catastrophizing, and examining ways to increase social support. In addition, group therapypresents an opportunity to discuss any concerns or problems that patients may h ave in com mon.21. How important is family involvement in therapy?Chronic pain significantly impacts all members of a family. Family members need to be edu-cated about the goals of therapy and should have an opportunity to share their worries and concerns.Moreover, active involvement of family members helps ensure the patients long-term success.Therefore, both patients and members of their families should be invited to attend family therapysessions. Besides enhanced communication, important outcomes of these sessions are that familymemb ers learn how to help the patient achieve and m aintain goals, and they come to understand thatthey are not alone in their dealings with the person in pain.22. What are the benefitsof relaxation training for chronic pain patients?Chron ic pain patients tend to experience substantial residual muscle tension as a function o f thebracing, posturing, and emotional arousal often associated with pain. Such responses, maintainedover a long period, can exacerbate pain in injured areas of the body and increase muscular discom-fort. For example, patients with low back pain or limb injuries com monly experience neck stiffnessand tension-type headaches. R elaxation training can lead to pain reduction by relaxing tense m usclegroups, reducing anxiety, distracting the patient from the pain, and enhancing self-efficacy. In addi-tion, this training can increase the patients sense of control over physiological responses.In a pain m anagement pro gram, patients are taught and encou raged to practice a variety of re-laxation strategies, including diaphragmatic breathing, progressive muscle relaxation, autogenic re-laxation, guided imagery, and cue-controlled relaxation. Hypnosis and biofeedback training also arecommonly employed.


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94 The M a n a g e m e n t of Chron ic Pain23. Which variables predict a low probabilityof return to work?Th e most relevant predictor of return to work is the duration of unem ployment. After 6 monthsof unemployment due to chronic pain, the probability of return of work is 50 ; the likelihood de-creases to 10 after 1 year. Other factors negatively impacting the likelihood of return to wo rk in-clude limited formal education, limited transferable skills, poor perceived social support, ongoinglitigation, a p oor relationship with the employer, and jo b dissatisfaction.24. How can vocational rehabilitation help chronic pain patients?The goal of vocational rehabilitation is to return a patient with chronic pain to work. After anextended period out of work, patients becom e both physically and psychologically deconditioned tothe demands and stresses of the workplace. A vocational rehabilitation counselor helps the patientdevelop a plan that incorporates long-range employment goals and short-term objectives based onmedical, psychological, social, and vocational information. These counselors are specialists in theassessment of ap titudes and intere sts, transf erable skills, phy sical capacity, modifications in theworkplace, skills training, and jo b readiness.25. What is the role of activity and exercise for persons with chronic pain?Most patients lose physical stamina and flexibility because of reluctance to exercise and a per-ceived need to protect themselves from additional physical injury. Some patients have been medicallyadvised to restrict activity when pain increases. Patients with chr on ic pain need to know that exer-cise is important. Getting back to usual activities as soon as possible after an injury helps to preventdisability. Some stretching, cardiovascular activity, and weight training should be considered.26. Under what circumstances should opioid therapy be prescribed?The use of opioid analgesics for chron ic noncancer pain is controversial, du e to concerns aboutefficacy, adverse effects, tolerance, and addiction. Opioid therapy is contraindicated by a history ofsubstance abuse, a major psy chiatric diagnosis, the seeking of drug s fro m multiple physicians, un -controlled dose escalation, and/or evidence of lack of com pliance. Patients with significant adversereactions to low-dose opioid therapy als o are poo r candidates. T he decision to use opioid therapyoften rests on clinical judgment and treatment orientation.27. What are the roles of invasive procedures and implantable devices in pain management?There are m any types of invasive interventions f or pain. They range from trigger point injectionsto spinal cord stimulation and d eep brain surgery. Patients are attracted to any treatment that is de-signed to decrease their pain. However, careful assessment and evaluation of the patients prior to theprocedures, including a thorough psycho logical evaluation, helps to identify those patients who arepoor candidates and im proves the chances for a positive outcome. Many insurance ca m er s require acomprehensive psychological evaluation prior to approval of an implantable device for pain.28. How can relapse be avoided?Most chronic pain patients need support after completing a pain treatment program, to m aintain thegains they have achieved . Patients should be encouraged to identify and anticipate situations that placethem at risk fo r returning to previous maladaptive behavior patterns. They also should be encouraged torehearse problem -solving techniques and behavioral responses that enable them to avoid a relapse. Thegoals of relapse prevention are to help the patient 1 ) maintain a steady level of activity, emotional sta-bility, and appropriate medication use; (2) anticipate and deal with situations that cause setbacks; and (3)acquire skills that decrease reliance on the healthcare system. Followup has been shown to be vital inhelping to prevent relapse. A specific followup plan should be w ritten out for each patient.29. What criteria are important in the evaluationof a pain treatment program?An impo rtant comp onent of any group-b ased pain program is its ability to measure its owneffectiveness and determ ine which services are most b eneficial in the treatment of chro nic painpatients. A number of recommendations for effective program evaluation have been put forward bythe Com mission on the Accreditation of Rehabilitation Fac


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T h e A s s e s s m e n t and T r ea tmen t of Sexual Dysfunction 395A system should be in place for obtaining followup information from patients on the use ofmedications, use of healthcare services, return to gainful employm ent, functional activities, ability tomanage pain, and subjective pain intensity.Provisions should also be made for periodic contact after discharge.Program evaluation should encom pass goals and objectives that are achievable and end resultsA program evaluation report should include primary objectives, measures, time of measure-that are measurable.ment, source of information, and expectancies as well as outcome.

BIBLIOGRAPHYI Accident Rehabilitation and Compensation Insurance Corporation and the National Health Com mittee: NewZealand Acute Low Back Pain Guide. Wellington, New Z ealand, AAC and N HC, 1997.2. American A cademy of Pain Medicine and American Pain Society Consensus Statement: The use of opioidsfor the treatment of chronic pain. Pain Forum 6:77-79, 1997.3. Cicala RS, Wright H: Outpatient treatment of patients with chronic pain: An analysis of cost savings. Clin J

Pain 5:223-226, 1989.4. Comm ission on the Accreditation of Rehabilitation Facilities: Standards Manual for O rganizations S ervicingPeople w ith Disabilities, Tucson, Arizona, CAR F, 1999.5 Fishbain DA, C utler R, Rosomoff H L, Rosomoff RS: Ch ronic pain-associated depression: Antecedent orconsequence of chronic pain? A review. Clin J Pain 13:116-137, 1997.6. Follick MJ, Ah ern DK, Aberger EW: Behavioral treatment of chronic pain. In Blumenthal JA, McKee DC(eds): Applications in B ehavioral Medicine and Health Psychology: A C linicians Sourc e Book. Sarasota,Florida, Professional Resource Exchange, Inc., 1987, pp 237-270.7. Fordyce WE (ed): Back Pain in the Workplace: Management of Disability in Nonspecific Conditions.Seattle, International Association for the Study of Pain Press, 1995.8. Gatchel RJ, Turk DC (ed s): Psychological Approa ches to Pain Managem ent: A Practitioners Han dboo k.New York, The G uilford Press, 1996.9. Jamison R N Learning to Master Your Chro nic Pain. Sarasota, FL, Professional Resource Press, 1996.10 Jamison RN : M astering Chronic Pain: A Professionals Guide to Behavioral Treatment. Sarasota, FL,

1 I Karoly P, Jensen MP: Multimethod Assessment of Chro nic Pain. New York, Pergamon Press, 198 7.12. Nigl AJ: Biofeedback and Behavioral Strategies n Pain Treatment. New York, Spectrum Publications, Inc., 1984.13. Turk DC , Melzack R (eds): Handbook of Pain Assessment. New York, The Guilford Press, 1992.

Professional Resource Press, 1996.

70. TH E ASSESSM ENT A ND TREATMENTOF SEXUAL DYSFUNCTION

Thomas D tewart, M . D

1. Can sexual dysfunction be a symptom of medical illness?Yes. Sexual dysfun ction is a neglected vital sign in medical history taking. It can be the first pre-senting symptom for cond itions as diverse as diabetes mellitus, temporal lobe epilepsy, multiplesclerosis, and thyroid dysfunction.2. Describe a framework for the clinical evaluation of sexual dysfunction.Masters and Johnsons well-known sexual response cycle provides a paradigm for understand-ing and treating sexual dysfunction:

Appetitive phase involves noticing attractive people and having an intact libido. There are nospecific physiologic responses.Excitement is marked by vascular engorgement and lubrication in wo me n and erection i nmen. These responses, associated with flushed skin, intensify and reach a plateau phase beforeorgasm.

69. the Management of Chronic Pain

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