Evaluating the Effects of Somatization Disorder for Patients With Severe End‐Stage Lower‐Extremity Osteoarthritis

This study examined how somatization disorder relates to physical and psychosocial measures for patients with chronic lower‐extremity osteoarthritis (OA). A cohort of 421 patients with lower‐extremity OA of the hip or knee consented to preoperative evaluations. The Patient Health Questionnaire was administered to identify patients with and without somatization disorder. Analyses were conducted to determine differences between demographic and preoperative physical and psychosocial variables. Patients with somatization disorder scored significantly worse on measures of pain, stiffness, function, perceived disability, and quality of life measures. Somatization disorder can have profound effects on patients' physical and psychosocial measures. Recommended treatment for chronic pain patients often includes using a biopsychosocial approach, which involves treating both the psychological state along with the pain condition.     

Comparing physical and behavior therapy for chronic low back pain on physical abilities,psychological distress,and patients' perceptions

A treatment-outcome study was conducted to study the impact of behavior and physical therapy on components of the chronic low back pain syndrome. Eighteen patients received behavior therapy and 15 patients received physical therapy. All patients had at least a 6-month history of seeking treatment for chronic low back pain. Prior to treatment patients were assessed in four principal areas of functioning: (1) physical abilities; (2) current physical functioning; (3) psychological and psychosocial functioning; and (4) pain intensity and pain perception. Treatments were conducted in a group (five to eight patients) outpatient setting. Both behavior therapy and physical therapy groups met for 10-weekly sessions, each lasting 2 hr. Behavior therapy was designed to address the environmental, social, and emotional components of the low back pain syndrome as well as the depression and decreased activity that result from chronic low back pain. Physical therapy was based upon traditional rehabilitation theory and was designed to improve low back function. Patients were reevaluated at posttreatment, 6 months, and 1 year. The results showed a general improvement for patients in both groups and a few treatment-specific differences in outcome measures.This research was supported by the Veterans Administration Medical Research Program. Portions of this paper were read at the Annual Meeting of the American Pain Society, New York, September 1980.     

Predicting subjective disability in chronic pain patients

Subjective disability is considered as the variable that reflects the impact of chronic pain on a patient's life. This study examines the questions of which syndrome or patient characteristics determine subjective disability and whether there are differences between samples of patients with chronic headaches and low back pain. Direct pain variables and depression, pain coping strategies, and pain-related self-statements (including catastrophizing) are introduced into multivariate regression analyses as potential predictors of disability using a sample of 151 pain patients. Disability is not predicted by pain severity in patients with headaches or back pain. Psychological variables, especially coping strategies, are far more influential. Coping explains more variance in disability in the headache sample than in the chronic law hack pain group, whereas depression is more relevant for the degree of disability in the back pain sample. In this study, we present a critical analysis of possible interpretations of our results. We point to an overlap of concepts underlying some of the variables used: this overlap also considerably invalidates conclusions drawn from a multitude of studies done in this field, including the one presented. We strongly argue for a conceptual clarification, and consequently for the revision of assessment instruments, before further empirical work in this area is done.     

Chronic back pain and rheumatoid arthritis: Predicting pain and disability from cognitive variables

Cognitive-behavioral models of chronic pain emphasize the importance of situation specific as well as more general cognitive variables as mediators of emotional and behavioral reactions to nociceptive sensations and physical impairment. The relationship of situation-specific pain-related self-statements, convictions of personal control, pain severity, and disability levels was assessed in samples of chronic back pain and rheumatoid arthritis patients. Both the more general and the situation-specific sets of cognitive variables were more highly related to pain and disability than disease-related variables. This association was found in the back pain patients who displayed only marginal levels of organic findings as well as the rheumatoid arthritis sample who had a documented basis for their pain. The combination of both situation-specific and general cognitive variables explained between 32 and 60% of the variance in pain and disability, respectively. The addition of disease-related variables improved the predictions only marginally. These results lend support to the importance of cognitive factors in chronic pain syndromes.Support for this research was provided to the first author by DFG (German Research Foundation) Grants Fl 156/1-1 and Fl 156/2-1 and to the second author by NIH Grant RO1 AR NS 38698-01.     

Long-term predictors of outcome in fatigued employees on sick leave: a 4-year follow-up study

BACKGROUND: Persistent fatigue is strongly associated with functional status and can lead to absenteeism and work disability. Despite several prognostic studies on chronic fatigue, little attention has been paid to occupational outcomes. METHOD: A total of 127 fatigued employees on sick leave were followed-up after 4 years to determine long-term predictors of work disability, fatigue caseness and chronic fatigue syndrome (CFS)-like caseness. Measures included fatigue, physical functioning, illness attributions, psychological problems and emotional exhaustion. RESULTS: Thirty-three participants (26%) were receiving work disability benefits at the 4-year follow-up. Older age and lower levels of physical functioning predicted work disability. Weaker psychological attributions and lower levels of physical functioning were predictors of fatigue caseness. CFS-like caseness was predicted by female gender and lower levels of physical functioning. Self-reported physical functioning remained a strong and statistically significant determinant of work disability [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.24-0.87] and CFS-like caseness (OR 0.20, 95% CI 0.09-0.43) after controlling for confounders. CONCLUSIONS: This study suggests that physical functioning plays an important role in the persistence of fatigue complaints and work disability in employees on sick leave. The course of fatigue is a complex process, and exploring temporal relationships between fatigue, functional status and work status in future research could provide valuable information for the improvement of fatigue management.     

Committed Action,Disability and Perceived Health in Individuals with Fibromyalgia

Committed action, one of the components of psychological flexibility, has been shown to be related with measures of pain-relevant function domains in patients with chronic pain. However, the associations between measures of committed action and of physical health and function in individuals with fibromyalgia (FM) have not yet been examined. The aim of the present cross-sectional study was to better understand the role that committed action plays in (1) pain-related disability and (2) mental and physical health in individuals with FM. One hundred twenty-nine adult females with a diagnosis of FM from a rheumatologist were administered measures of committed action, disability, physical health, and mental health. After controlling for age and pain intensity, committed action explained an additional 24% of the variance of pain disability, 39% of the variance of physical health, and 41% of the variance of mental health. This study provides important new information on the associations between a measure of committed action and perceived health and function in a sample of women with FM. The findings are also consistent with the psychological flexibility model for understanding pain and its impact in patients with FM.     

The patient–physician relationship in patients with chronic low back pain as a predictor of outcomes after rehabilitation

For patients with chronic diseases, especially those with chronic low back pain, the patient–physician relationship is significant for treatment adherence. In a sample of N = 688 low back pain patients, we examined the hypothesis that aspects of the patient–physician relationship (e.g. satisfaction with care, trust in the physician, patient participation) have a significant association with outcomes (pain, disability, quality of life, pain-related psychological impairment) after a multimodal treatment program (rehabilitation) after adjusting for a number of sociodemographic, medical, and psychological factors. Results show that the patient–physician relationship is significantly associated with the outcome. In the medium term (6 months after rehabilitation), the effect of the patient–physician relationship is clearer than in the short term (end of rehabilitation). In addition, risk factors for less improvement are female gender, higher age, low income, comorbidity, low treatment motivation, fear avoidance beliefs, and external locus of control. Future studies should examine the causal paths between the relationship variables and the outcome variables.     

Group outpatient physical and behavioral therapy for chronic low back pain

Conducted a treatment-outcome study to investigate the effectiveness of behavioral (BT) or physical therapy (PT) for treating chronic low back pain (CLBP). Thirteen patients received BT; 12 patients received PT. All patients had at least a 6-month history of seeking treatment of CLBP. Prior to treatment patients were assessed in four principal areas of functioning: (1) physical abilities; (2) current physical functioning; (3) psychological and psychosocial functioning; and (4) pain intensity and pain perception. Treatments were conducted in a group (5-8 patients) outpatient setting. Both BT and PT met for 10 weekly 2-hour sessions. BT was designed to address the environmental, social, and emotional influences of the pain experience, depression, and decreased activity from CLBP. PT was based upon traditional rehabilitation theory and was designed to improve low back function. The posttreatment results showed general improvement for patients in both groups, but few treatment-specific differences in outcome measures.     

Radiography for low back pain: a randomised controlled trial and observational study in primary care.

BACKGROUND: Lumbar spine radiography has limited use in diagnosing the cause of acute low back pain. Consensus-based guidelines recommend that lumbar spine x-rays are not used routinely. However there have been no studies of the effect of referral for radiography at first presentation with low back pain in primary care. AIM: To compare short and long-term physical, social, and psychiatric outcomes for patients with low back pain who are referred or not referred for lumbar spine x-ray at first presentation in general practice. DESIGN OF STUDY: A randomised unblinded controlled trial with an observational arm to enable comparisons to be made with patients not recruited to the trial. SETTING: Ninety-four general practices in south London and the South Thames region. METHOD: Patients consulting their general practitioner (GP) with low back pain at first presentation were recruited to a randomised controlled trial (RCT) or to an observational group. Patients in the trial were randomly allocated to immediate referral for x-ray or to no referral. All patients were asked to complete questionnaires initially, and then at six weeks and one year after recruitment. RESULTS: Six hundred and fifty-nine patients were recruited over 26 months: 153 to the randomised trial and 506 to the observational arm. In the RCT referral for x-ray had no effect on physical functioning, pain or disability, but was associated with a small improvement in psychological wellbeing at six weeks and one year. These findings were supported by the observational study in which there were no differences between the groups in physical outcomes after adjusting for length of episode at presentation; however, those referred for x-ray had lower depression scores. CONCLUSIONS: Referral for lumbar spine radiography for first presentation of low back pain in primary care is not associated with improved physical functioning, pain or disability. The possibility of minor psychological improvement should be balanced against the high radiation dose involved.     

Comparison of Efficacy of Neural Therapy and Physical Therapy in Chronic Low Back Pain

The aim of this prospective study was to evaluate the effects of neural therapy, and physical therapy on level of pain, disability, quality of life, and psychological status in patients with chronic low back pain. Patients admitted to the physical therapy and rehabilitation outpatient clinic with the complaint of low back pain of at least 3 months duration. Group 1 (n=27), physical therapy (PT, hotpack, ultrasound, TENS 15 sessions), group 2 (n=33), neural therapy (NT, 1:1 mixture of 20 mg/mL Lidocaine HCl (Jetokain simplex®) and saline for 5 sessions. For pain, Visual Analogue Scale (VAS), for disability Roland Morris Disability Questionnaire (RMDQ), for quality-of-life Nottingham-Health-Profile (NHP), for depression, and anxiety, Hospital Anxiety-Depression Scale (HADS) were used before and after the treatment. Mean age was 47.3±11.32 years, symptom time was 13.78±11.98 months. There were no differences for demographic variables between groups. Significant improvements were detected for VAS, RMDQ, NHP-Pain, NHP-Physical activity, HADS for both of two groups after treatment. In addition to these findings, significant improvements were found for NHP-Energy, NHP-Social isolation in NT group. The differences of pre- and post-treatment values of parameters were evaluated for each group. Although there were no differences for VAS, NHP-sleep, NHP-Emotional reaction, HADS between groups, RMDQ, NHP-Pain, NHP-Physical activity, NHP-Social isolation were higher in NT than PT before treatment, the improvements for these parameters were better in NT than PT. In conclusion both of NT and PT are effective on pain, function, quality of life, anxiety, and depression in patients with chronic low back pain.     

A controlled trial of corticosteroid injections into facet joints for chronic low back pain.

BACKGROUND. Chronic low back pain is a common problem with many treatments, few of which have been rigorously evaluated. This randomized, placebo-controlled trial was designed to evaluate the efficacy of injections of corticosteroid into facet joints to treat chronic low back pain. METHODS. Patients with chronic low back pain who reported immediate relief of their pain after injections of local anesthetic into the facet joints between the fourth and fifth lumbar vertebrae and the fifth lumbar and first sacral vertebrae were randomly assigned to receive under fluoroscopic guidance injections of either methylprednisolone acetate (20 mg; n = 49) or isotonic saline (n = 48) in the same facet joints. Ninety-five patients were followed for six months and their condition assessed with scales of pain severity, back mobility, and limitation of function. RESULTS. After one month, none of the outcome measures evaluating pain, functional status, and back flexion differed clinically or statistically between the two study groups. Forty-two percent of the patients who received methylprednisolone and 33 percent of those who received placebo reported marked or very marked improvement (95 percent confidence interval for the difference, -11 to 28 percentage points; P = 0.53). The results were similar after three months. At the six-month evaluation, the patients treated with methylprednisolone reported more improvement, less pain on the visual-analogue scale, and less physical disability. The differences were reduced, however, when concurrent interventions were taken into account. Moreover, only 11 patients (22 percent) in the methylprednisolone group and 5 (10 percent) in the placebo group had sustained improvement from the first month to the sixth month (95 percent confidence interval for the difference, -2 to 26; P = 0.19). CONCLUSIONS. We conclude that injecting methylprednisolone acetate into the facet joints is of little value in the treatment of patients with chronic low back pain.     

Psychological correlates of pain behavior in patients with chronic low back pain

Pain behaviors that are excessive for the degree of known physical disease are common in patients with chronic low back pain and are frequently assumed to arise from a comorbid depressive illness. Although some studies have confirmed an association between depression and excessive pain behavior, methodologic problems (such as the use of depression ratings that also recorded symptoms attributable to physical disease) make interpretation of this finding difficult. We recruited 54 consecutive patients with chronic (>6 months) low back pain from a hospital clinic. Subjects completed self-rated assessments of anxiety and depression (Hospital Anxiety and Depression Scale) designed to be minimally affected by physical symptoms, along with assessments of disability (ODQ), pain (visual analogue scale), pain behavior (Waddell checklist), and physical impairment. Seventeen subjects (31%) exhibited excessive pain behavior. Overall, they were no more depressed or anxious than the remainder, although men with excessive pain behavior showed a trend toward being more depressed. Patients with excessive pain behavior were more disabled (self-rated and observer-rated), reported greater pain, and were more likely to be female and to have pain of shorter duration. Pain behavior did not correlate with anxiety or depression, but correlated with measures of disability and pain intensity. Factor analysis revealed that physical disability, pain intensity, and pain behavior loaded heavily on the first factor. Anxiety and depression loaded together on a separate factor. We conclude that pain behaviors were not related to anxiety or depression in our group, although gender differences between groups could have contributed to our negative findings. Pain behaviors may influence other physical measures. Further studies are required to investigate the relation between depression and pain behavior while controlling for gender differences.     

Development of a diagnostic checklist for low back pain patients.

The study of psychosomatic disorders implies that environmental variables, as well as attitudes and personality, can influence an individual's physical health. The present study developed a checklist composed of demographic and psychological variables to help to make diagnostic decisions related to chronic low-back pain. The need for the checklist stems from the situation that medical clinical evidence is often inconclusive to identify the etiology of patient complaints of low back pain. Cut-off scores on the checklist were able to discriminate with greater than 80% accuracy patients who received a specific medical diagnosis from patients who received a non-specific medical diagnosis. The findings provide additional support for procedures used to make difficult diagnoses of low back pain.     

The prognostic significance of psychological factors in the management of chronic bronchitis.

Eighty-three chronic obstructive bronchitic patients were psychologically assessed before being randomly allocated to 1 of 3 management regimes. The following measures were taken: psychiatric disturbance, personality, social-desirability response set, vocabulary, expectations about treatment, attitudes and beliefs about bronchitis, effect of patient's bronchitis on the family, work, self, physical exercise, smoking, and general health. Outcome was assessed after one month and again one year later, and the measures included physiological tests of lung functioning, an exercise tolerance test, reported symptoms, time off work, drop-out, and death. Contrary to expectations, it was found that psychological variables had some prognostic significance for outcome assessed by medical measures of illness severity. More important was the finding that, in bronchitics under retiring age, weeks off work during the year of the study could be predicted by psychological variables but not by physiological measures of illness severity.     

Predicting persistent disabling low back pain in general practice: a prospective cohort study

BACKGROUND: Patients may adopt active and/or passive coping strategies in response to pain. However, it is not known whether these strategies may also precede the onset of chronic symptoms and, if so, whether they are independent predictors of prognosis. AIM: To examine, in patients with low back pain in general practice, the prognostic value of active and passive coping styles, in the context of baseline levels of pain, disability and pain duration. DESIGN OF STUDY: Prospective cohort study. SETTING: Nine general practices in north west England. METHOD: Patients consulting their GP with a new episode of low back pain were recruited to the study. Information on coping styles, pain severity, disability, duration, and a brief history of other chronic pain symptoms was recorded using a self-completion postal questionnaire. Participants were then sent a follow-up questionnaire, 3 months after their initial consultation, to assess the occurrence of low back pain. The primary outcome was persistent disabling low back pain, that is, low back pain at 3-month follow-up self-rated as >or=20 mm on a 100 mm visual analogue scale, and >or=5 on the Roland and Morris Disability Questionnaire. RESULTS: A total of 974 patients took part in the baseline survey, of whom 922 (95%) completed a follow-up questionnaire; 363 individuals (39%) reported persistent disabling pain at follow-up. Persons who reported high levels of passive coping experienced a threefold increase in the risk of persistent disabling low back pain (relative risk [RR] = 3.0; 95% confidence interval [CI] = 2.3 to 4.0). In contrast, active coping was associated with neither an increase nor a decrease in the risk of a poor prognosis. After adjusting for baseline pain severity, disability, and other measures of pain and pain history, persons who reported a high passive coping score were still at 50% increased risk of a poor outcome (RR = 1.5; 95% CI = 1.1 to 2.0). CONCLUSION: Patients who report passive coping strategies experience a significant increase in the risk of persistent symptoms. Further, this risk persists after controlling for initial pain severity and disability. The identification of this low back pain subgroup may help target future treatments to those at greatest risk of a poor outcome.     

Group treatment for pain and discomfort

Rheumatic patients very often suffer from chronic pain and impairment and show psychological reactions as a consequence of their physical condition. These reactions may vary from psychophysiological symptoms to anger, anxiety, or depression. We developed a cognitive-behavioral treatment programme in a group setting format with components of relaxation, cognitive restructuring, and the promotion of well-being. Subjects included in the study were given diagnoses of low back pain, tension headache, rheumatoid arthritis, and ankylosing spondylitis. Treatment effects in different diagnostic groups were compared to each other, supporting the assumption that pain reduction is greatest in low back pain and least in ankylosing spondylitis. Subjects with inflammatory rheumatic diseases showed some improvement in self-reported physical complaints and in their feelings of well-being.     

Psychological factors in the long-term prognosis of chronic low back pain patients.

This study appraised the significance of psychological factors in the long-term prognosis of patients with chronic low back pain (LBP). The MMPI ratings of 80 long-term sick-listed LBP patients were set in relation to their disability pension status 6 to 12 years later. The number of elevated scales, in combination with the level of certain scales (HS and HY), proved to be a better predictor than profile patterns, advocated in some studies. Moreover, in a review of prognostic studies, the HS and HY scales appeared most frequently as significant predictors. That result also was confirmed in this study of long-term prediction of overall functional level. The results are discussed in relation to the concepts of pain-fear and sick role.     

The relationship between pain,disability, guilt and acceptance in low back pain: a mediation analysis

Pain-related guilt is a common yet unexplored psychological factor in low back pain (LBP). It has recently been linked to greater depression, anxiety and disability in LBP, hence an understanding of how it can be managed in the presence of pain and disability is necessary. Since acceptance of pain has been shown to be associated with improved outcomes in chronic pain, we examined whether it might also help reduce guilt in people with LBP. To this end, a series of mediation analyses were conducted on data from 287 patients with chronic LBP, in which acceptance of pain was tested as a mediator of the relationship between pain/disability and guilt. Results showed that acceptance of pain reduced the impact of pain/disability on pain-related guilt in all mediation analyses. Pain-related guilt might be a potential target for acceptance based interventions, thus this relationship should be further tested using longitudinal designs.     

Low back pain patients in primary care: Subgroups based on the multidimensional pain inventory

Classification of patients into homogeneous subgroups is an important objective in primary care management of low back pain patients. The purpose of this studyis to (a) identify and describe cluster profiles based on self-reported multidimensional pain inventory Scale (MPI) scores among subacute and chronic nonspecific low back pain patients; (b) describe characteristics of the clusters in relation to disability, life satisfaction, functional self-efficacy, and exercise self-efficacy; and (c) compare grouping by clusters based on self-reported MPI scores with grouping by symptom duration. Eighty-eight individuals participated. These had a median lower back pain duration of 7 months (range 1 to 144 months). Three clusters were identified; these were labeled interpersonally distressed, adaptive copers, and dysfunctional. The clusters differed significantly in disability and functional self-efficacy scores, but not in life satisfaction and exercise self-efficacy scores. The results of this study in a primary care setting are discussed in relation to previous results in pain clinic settings.