Do physical and sexual abuse differentially affect chronic pain states in women?

To evaluate the role of physical and/or sexual abuse on chronic pain symptoms and health care utilization in women, 104 consecutive female patients presenting to a multidisciplinary pain center for management of chronic pain were surveyed. Outcomes included a measure of sexual or physical abuse history (Drossman Sexual-Physical Abuse Survey), and measures of anxiety, health care utilization, substance abuse, and somatic symptoms. Forty-eight percent of the sample reported a history of physical abuse (PA) or sexual abuse (SA). Forty percent of the abused patients reported both PA and SA and the remainder reported SA (37%) or PA (23%) alone. The women who reported abuse had increased pain, physical symptoms, anxiety symptoms, and mental health care utilization compared to nonabused women. The women who reported abuse were also more likely to smoke and abuse street drugs. Women who reported both PA and SA were more likely to report head pain when compared to those who reported only PA or SA. Given the impact of abuse, particularly SA, on the presentation of chronic pain, queries regarding abuse should become a routine component of the patient interview. Abused patients should be referred to mental health care practitioners as a component of successful pain management if unresolved issues persist.     

A community model of group rehabilitation for older patients with chronic heart failure: a pilot study

Purpose. The aim of this study was to develop and evaluate a community-based programme for heart failure patients, with emphasis on exercise and education.

Method. In a before-and-after trial, subjects with heart failure underwent a 12-week group programme comprising of exercise, education and mutual support. Outcome measures included subjects' compliance and views of the programme, knowledge related to disease management, physical parameters (symptoms, exercise tolerance, muscle strength) and psychosocial well-being (using generic and disease-specific tools). A focus group was held and participants' feedback noted.

Results. Overall patient compliance and satisfaction rate was high. Significant changes were observed in knowledge, physical performance and psychosocial parameters. Subjects' feedback following the programme was generally positive.

Conclusions. This pilot study shows that a group programme for heart failure patients is feasible, acceptable and improved physical status and quality of life. It can be a useful model in the management of chronic disease in the community.     

Psychological distress among abused minority women with sexually transmitted diseases

PURPOSE: To describe psychological distress among abused minority women with sexually transmitted diseases (STDs) and to identify needs for psychotherapeutic intervention for reduction in abuse, sexual risk behavior and STD. DATA SOURCES: A controlled randomized trial of the effects of a behavioral intervention on STD recurrence. Eligibility was limited to English speaking Mexican-American and African-American women with a current non-viral STD confirmed by laboratory testing (gonorrhea, chlamydia, syphilis or trichomonas). All eligible women who could be contacted were recruited from public-health clinics in San Antonio. T-tests, Chi square and correlation were used to analyze the data. CONCLUSIONS: Women with STD and a history of abuse reported more symptoms of current psychological distress than nonabused women. This psychological distress was present in all dimensions of the SCL-90-R, including somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism. Increased current psychological distress and correlation was found not only for women with reports of sexual abuse but also forms of physical or psychological abuse. The majority of abuse was reportedly experienced during a relationship with a boyfriend or friend/acquaintance. IMPLICATIONS FOR PRACTICE: Abused women with STD may benefit from the identification and assessment of abuse history and psychological distress so that appropriate psychological treatment can accompany medical treatment. The prevalence of woman abuse within a population of women with STD mandates the inclusion of violence in STD prevention programs.     

Pilot study of a 4-week Pain Coping Strategies (PCS) programme for the chronic pain patient

Purpose. A 4-week Pain Coping Strategies (PCS) programme has been developed for chronic pain patients who may still be undergoing medical interventions but who would benefit from learning pain management skills. The long-term negative behaviours associated with chronic pain may be prevented by introducing pain management strategies at an earlier stage. The PCS programme combines all the fundamental aspects of the traditional Pain Management Programme including exercise, relaxation, pacing, medication review, pain pathways, posture and challenging negative thoughts.

Method. The study compared 31 patients' mood, functional status and physical ability pre and 6 weeks post the programme using the Hospital Anxiety and Depression Scale (HAD), Canadian Occupational Performance Measure (COPM) and a series of physical tests. A paired samples t-test showed a significant improvement in levels of depression and anxiety, functional status and physical ability.

Results. The results reveal that an early intervention programme may be effective for chronic pain patients by promoting self-management and teaching positive coping strategies.

Conclusions. The current study has found promising results for a brief early intervention for chronic pain, regardless of completion of medical interventions.     

Protective and risk behaviors of rural minority adolescent women

Studies of adolescent risk and protective behaviors have focused on identifying modifiable psychosocial variables that predict differential outcomes for subsequent intervention efforts. Research has been scarce in studies of rural minority adolescent women. This study examined the protective and risk behaviors of these women and their relationship to physical or sexual abuse. Rural minority adolescent women endured high levels of psychological distress and many high risk behaviors, yet experienced many protective behaviors. Barriers to health care included access and confidentiality. Physically or sexually abused adolescents endured relatively greater risk and fewer protective behaviors than nonabused adolescents. The prevalence of risk behaviors and abuse among rural minority adolescent women presents a need for development of psychotherapeutic interventions as part of behavioral interventions for risk reduction. These women may benefit from confidential identification and assessment of abuse history and risk and protective behaviors so that appropriate psychological treatment can accompany accessible medical treatment.     

The impact of psychosocial factors on neck pain and disability outcomes among primary care patients: results from the UCLA Neck Pain Study

Purpose. The purpose of this study is to estimate the associations of psychosocial factors with pain and disability outcomes among neck-pain patients enrolled in a randomized clinical trial of chiropractic treatments.

Methods. Neck-pain patients were randomized to one of 8 modes of chiropractic treatment. Health status and psychosocial variables were measured at baseline. Changes in neck pain severity and disability from baseline to 6 months were the primary outcome variables. Multivariable regression models were used to estimate effects of psychosocial variables adjusted for potential confounders.

Results. Of 960 eligible patients, 336 were enrolled and 80% were followed up through 6 months. Coping strategies involving self-assurance resulted in better disability outcomes, whereas getting angry or frustrated resulted in worse pain and disability outcomes. Participants with high levels of social support from individuals were more likely to experience clinically meaningful reductions in pain and disability. No consistent relations of internal health locus of control, and physical and psychological job demands with improvements in pain and disability were detected.

Conclusions. We found some evidence that certain coping strategies and types of social support are associated with pain and disability outcomes in this population of largely subacute and chronic neck-pain patients.     

PROTECTIVE AND RISK BEHAVIORS OF RURAL MINORITY ADOLESCENT WOMEN

Studies of adolescent risk and protective behaviors have focused on identifying modifiable psychosocial variables that predict differential outcomes for subsequent intervention efforts. Research has been scarce in studies of rural minority adolescent women. This study examined the protective and risk behaviors of these women and their relationship to physical or sexual abuse. Rural minority adolescent women endured high levels of psychological distress and many high risk behaviors, yet experienced many protective behaviors. Barriers to health care included access and confidentiality. Physically or sexually abused adolescents endured relatively greater risk and fewer protective behaviors than nonabused adolescents. The prevalence of risk behaviors and abuse among rural minority adolescent women presents a need for development of psychotherapeutic interventions as part of behavioral interventions for risk reduction. These women may benefit from confidential identification and assessment of abuse history and risk and protective behaviors so that appropriate psychological treatment can accompany accessible medical treatment.     

Prior Physical and Sexual Abuse in Women with Chronic Headache: Clinical Correlates

SYNOPSIS
Physical and/or sexual abuse in women with chronic headache has never been addressed. This pilot study addressed differences in women with chronic headache who reported such a history, compared to a control group of women with chronic headache without a traumatic history. Thirty women were divided into two groups, based on self-report of abuse, and all women given an MMPI as part of their assessment. Sixty-six percent of women reported significant traumatic histories, with a mean of 8 years of abuse; headache pain developed after trauma in 100% of these cases. Abused women had shorter chronicity of headache but reported greater psycho-social distress and significantly more headaches. Results lend support to a model of life stress etiologically involved in the development of headache. Variables related to personality prior to headache development may be more important than the chronicity determinant. Assessment and identification of abuse early in the cycle may prevent long-term adjustment problems.     

Factors associated with marital satisfaction and mood among spouses of persons with chronic back pain.

Few studies have examined the impact of chronic pain on the spouse. In this study the impact of pain and disability as rated by both the patient and the spouse on spouse marital satisfaction and affective distress was examined in 110 couples. Zero-order correlations indicated that absolute ratings of perceived disability by the spouse, rather than discrepancies between spouse and patient ratings, were most highly associated with spouse marital dissatisfaction and affective distress. Predictors of spouse marital satisfaction and distress were examined by using simultaneous multiple regression. Spouse ratings of greater physical disability were significantly related to greater spouse affective distress. Spouse ratings of higher psychosocial disability, lower spouse marital satisfaction, and being a patient of male gender were marginally related to higher spouse affective distress. Spouse marital dissatisfaction was significantly associated with patient ratings of greater psychosocial disability and lower pain. Spouse-rated psychosocial disability and affective distress were also marginally related to spouse marital satisfaction. These findings highlight the importance of patient disability, particularly limitations in function as perceived by the spouse, on spouse adjustment. PERSPECTIVE: The impact of chronic pain on the spouse of the person with pain has received little empirical attention. The present study examines the relationship between patient and pain-related factors and psychosocial adjustment in the spouse.     

An integrated physiotherapy/cognitive-behavioural approach to the analysis and treatment of chronic whiplash associated disorders, WAD

Purpose : The aim of this paper was to describe a model for an integrated physiotherapy/cognitive-behavioural approach in the analysis and treatment of chronic WAD patients, as well as to evaluate the effectiveness of this approach in three experimental single case studies.

Method : Three patients with a diagnosis of chronic WAD were included in the study. Psychological and physical functional analyses were used to describe the problem areas and as a basis for the management of WAD. A programme including learning of basic and applied skills, generalization, and maintenance was carried through.

Results and Conclusion : The results showed that functional behavioural analyses can be useful in physiotherapy for structured patient assessment and in planning of treatment. It was also shown that physiotherapy integrated with cognitive behavioural components decreased the patients' pain intensity in problematic daily activities.     

Characteristics of sex offenders who were sexually victimized as children

From a data bank of 479 sex offenders, a comparison was undertaken of those reporting any childhood sexual abuse versus those reporting none. A total of 201 men (42.0%) reported abuse, 261 (54.5%) did not and for 17 (3.5%), information was unavailable. The Abused and Nonabused Groups were compared on demographic information, the MMPI, Clarke Sex History Questionnaire and the Clarke Parent Child Relations Questionnaire. The Abused and Nonabused groups were similar in age, marital status, income, and criminal history, but the Abused Group had significantly less education. The Abused Group showed sexualization of their childhood, not only in the number of contacts with adults but also with age peers and siblings of both sexes. They tended to have wider ranging and more frequent sexual experiences as adults both with men and women. They more often raped. The Abused Group tended to show more emotional instability than the Nonabused Group in more frequent suicidal ideation and suicide attempts, as well as in elevated Mania Scale Scores on the MMPI. The family background of the Abused Group was more disturbed than the Nonabused Group's; especially father-son relations. They reported more alcohol use and abuse in their parents and more parent-child aggression than nonabused offenders did. Although it is unlikely that child sexual abuse causes sexual anomalies, the results of the present study suggest that childhood sexual victimization in the lives of adult sex offenders merits further investigation and has implications for treatment.     

Preliminary evaluation of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain

Purpose. To describe the outcome of a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain.

Methods. Study design: exploratory retrospective cohort study. The study sample consisted of a cohort of 70 children and adolescents (age: 8 - 21 years) with chronic musculoskeletal pain who completed a 3-month inpatient multidisciplinary pain management program. The program consisted of graded physical exercises, graded activities and counseling of the children and their parents. Assessed were motor and social activities, pain intensity, global assessment of physical functioning and psychosocial well-being (by patient and physician), understanding of the pain process and reduction of medical consumption. Assessments were performed at pre-admission, day of admission, day of discharge and at three months after discharge. Data collection took place over a 10-year period.

Results. Compared to admission, at discharge there were significant improvements in motor performances, school attendance, reduction of pain scores, understanding of the chronic pain process and reduction of medical consumption. Results remained stable at follow-up after three months.

Conclusion. The results of this study indicate that a multidisciplinary pain management program for children and adolescents with chronic musculoskeletal pain may be effective.     

Prevalence and correlates of posttraumatic stress disorder and chronic severe pain in psychiatric outpatients

This cross-sectional study reports the prevalence and correlates of posttraumatic stress disorder (PTSD) and chronic severe pain in psychiatric outpatients (n = 295), a sample that has not previously been examined for the co-occurrence of these two disorders. Nearly half the participants (46%) met the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition criteria for PTSD; 40% reported chronic severe pain; and 24% had both disorders. We compared four groups of subjects who had either both disorders, PTSD only, chronic severe pain only, or neither disorder for variables previously found to be associated with both disorders or either disorder alone (e.g., psychiatric distress, substance use, stressful life events, physical/sexual abuse). Multiple pairwise comparisons indicated that persons with both disorders were significantly different from persons with neither disorder for all dependent variables and that they had greater physical and psychosocial stressors. Persons with either PTSD or chronic severe pain alone were more likely to have a chronic medical condition, higher ratings of psychiatric distress, and more stressful life events than persons with neither disorder. Mental health treatment providers should be aware of the potential for the co-occurrence of PTSD and chronic severe pain and of the many related factors in psychiatric outpatients.     

Psychosocial aspects of chronic widespread pain and fibromyalgia

Purpose. To study the impact on health status as measured by SF-36 in groups of subjects having chronic musculoskeletal pain with different degree of generalization: No chronic pain (NCP), chronic regional pain (CRP), chronic widespread pain (CWP), CWP with a stricter 'Manchester' definition (CWP-M), and clinically defined fibromyalgia (FM). The study also examines the association between psychosocial and lifestyle background variables, and these pain-groups.

Method. A cross-sectional study with a postal survey to 3928 subjects, constituting a representative sample of the adult general population, followed by clinical examination in a selected group of subjects with CWP. CWP and FM were diagnosed according to ACR 1990 fibromyalgia criteria. Health status was measured by SF-36 Health Survey.

Results. Patients with CWP, CWP-M, and FM were found to present with more severe impairment of health status than the other two population groups. Several psychosocial factors, such as belonging to a lower socio-economic group, being an immigrant, living in a compromised housing area, having lower educational level, experiencing lower social support and having a family history of chronic pain, were associated with the populations with CWP and FM

Conclusions. The spectrum of impact on health and association to background variables, with respect to a stricter definition of CWP, indicates that these factors are important to attend to in the understanding and management of CWP and FM.     

Self-reported abuse history and pain complaints among young adults.

OBJECTIVE: Considerable evidence suggests that a self-reported history of physical and/or sexual abuse is more frequently reported among chronic pain populations and is associated with poorer adjustment to pain. However, previous research has typically included patients seeking treatment for pain, whereas few population-based studies have explored the association between abuse history and pain. This purpose of this study was to examine the association between self-reported history of sexual or physical abuse and recent pain complaints, health-related variables, and psychological disturbance among a nonclinical sample of young adults. DESIGN: Subjects were 426 (275 female, 151 male) college students who completed a series of questionnaires assessing abuse history, recent pain, health care utilization, perceived health, and psychological variables. RESULTS: Females reported a positive history of abuse (PHA) more frequently than males (43.5% vs. 23.8%), and females reported significantly higher rates for all types of abuse except physical abuse during childhood (p < 0.05). PHA subjects reported experiencing pain in more sites and pain of higher severity over the past month compared to subjects with a negative history of abuse (NHA) (p < 0.05). PHA subjects also reported more health care utilization and greater psychological disturbance, including depression, somatization, negative temperament, and higher levels of catastrophizing (p < 0.05). Interestingly, when somatization and depression scale scores were used as covariates, group differences in pain complaints and health care utilization became nonsignificant (p > 0.10). CONCLUSION: These findings suggest that a self-reported history of physical or sexual abuse is associated with increased pain complaints, health care utilization, and psychological disturbance even among young adults from a nonclinical population. Moreover, the association between abuse and pain complaints appears to be moderated at least in part by the higher levels of somatization and depression observed in the PHA group.     

Early interdisciplinary rehabilitation programme for whiplash associated disorders

Purpose : To assess the clinical outcomes of a multidisciplinary rehabilitation programme for early intervention of chronic whiplash associated disorders (WAD). The primary aim of the programme was to increase levels of activity and independence in patients suffering WAD.

Methods : Ninety subjects with purported chronic symptoms associated with whiplash associated disorder (WAD) were referred to a multi-centre multi-modal 5- and 8-week rehabilitation programme in 1997-1998, during which prospective and retrospective functional and psychological evaluations were conducted, the follow-up was to 6 months.

Results : Subjects indicated they were satisfied with the programme. Retrospective evaluation indicated increased ability to cope with and control pain and, to some extent, psychological aspects. The pain intensity in the neck and upper back were significantly decreased at 6 months follow-up. However, for most of the functional and psychological markers, no significant changes were found.

Conclusions : A multi-modal rehabilitation programme for the chronic suffering attributed to WAD had positive effects according to several aspects of the retrospective evaluations, but according to most of the aspects evaluated prospectively the programme does not appear to have significant benefits.     

Alcohol use self report in chronic back pain--relationships to psychosocial factors, function performance, and medication use

Background Context: Alcohol consumption is a known risk factor for spinal disability, but there is no data on the relationship between reported alcohol consumption and behaviours in persons who are disabled.

Purpose: To determine the interaction between reported alcohol consumption, physical performance, and medication use in this group. To determine psychosocial correlates of reported alcohol consumption in this group.

Methods: A retrospective review 147 men and 136 women with more than 3 months disability who underwent a multidisciplinary physical, functional and psychosocial Spine Team Assessment. Questions about alcohol consumption were related to outcome measures.

Results: None of the women reported more than 5 drinks/week. Ten men reported more than 12 drinks per week. These performed significantly better on the Progressive Isoinertial Lifting Evaluation (PILE) low lift and the Functional Assessment Screening Test (FAST) 5 minute twisting test, and trended towards better performance on all other tests (the PILE high lift, all 4 other FAST components, Sorenson trunk extension test, and bicycle ergometer submaximal stress test). They had less back pain disability (Quebec p = 0.061), but no difference in depression (CESD), pain (visual analog scale) or fear (Tampa). They used fewer Non-steroidal medications, but similar narcotic medications as the others. No significant differences in the SF-36 were noted.

Conclusions: This first assessment of the relationship of alcohol consumption with back pain disability suggests that women with chronic back pain disability seldom report heavy alcohol consumption. Men with back pain disability who consume large amounts of alcohol have less physical disability despite similar pain. Despite potential interactions, heavy drinkers with pain do not use fewer narcotic analgesics than light drinkers.     

Relationship between traumatic events in childhood and chronic pain

Purpose: The purpose was to examine the relationships between traumatic events in childhood, such as sexual and physical abuse, alcoholism, and drug addiction, and three types of chronic pain: facial pain, myofascial pain, and fibromyalgia. A fourth group, a heterogeneous group of other pain, was used as a comparison group. Method: Ninety one patients with chronic pain, age range 20-60, were consecutively recruited from the outpatient clinics of a rehabilitation hospital and a general hospital. Patients were given four measures for completion at evaluation: Childhood History Questionnaire; Childhood Traumatic Events Scale; McGill Melzack Pain Questionnaire; Pain Disability Index. Chi-square was used to test significant differences among four pain groups on sexual, physical, and verbal abuse; alcoholism; drug dependence; medications; major upheaval, childhood illness, death of a family member or friend, and separation or divorce of parents. Logistic regression was used to predict membership in the four pain groups. Results: All pain groups had a history of abuse exceeding 48% : fibromyalgia, 64.7% ; myofascial, 61.9% ; facial, 50% ; other pain, 48.3%. All groups had a history of family alcohol dependence exceeding 38%, and a history of drug dependence ranging from 5.8 to 19.1%. A combined history of pain, child physical abuse, and alcoholism was prevalent in 12.9 to 35.3%. Logistic regression showed patients who were female, with an alcoholic parent, using non-narcotic drugs were more likely to be members of the facial, myofascial, and fibromyalgia groups. Conclusions: Child traumatic events are significantly related to chronic pain. Since the problem of child abuse is broader than physical and sexual abuse, health and rehabilitation agencies must shift from individualized treatment to interdisciplinary treatment of the family and patient.     

Predictors of handicap situations following post-stroke rehabilitation

Purpose : Many stroke survivors have to cope with impairments and disabilities that may result in the occurrence of handicap situations. The purpose of the study was to explore bio-psycho-social predictors of handicap situations six months after discharge from an intensive rehabilitation programme.

Methods : At discharge from a rehabilitation programme, participants were evaluated with instruments measuring motor, sensory, cognitive, perceptual, affective and psychosocial impairments and disabilities that may play a role in the development of handicap. Some other demographic and clinical variables, and those related to rehabilitation, were also collected. Six months later, they were re-assessed in their own environment in order to document their handicap level with the Assessment of Life Habits (LIFE-H).

Results : One hundred and thirty-two stroke patients participated in the discharge evaluation and 102 of them also participated in the handicap measurement. Relationships between handicap level and impairments and disabilities were all statistically significant. Multiple regression analyses indicated that affect, lower extremity co-ordination, length of stay in rehabilitation, balance, age and comorbidity at the end of an intensive rehabilitation programme are the best predictors of handicap situations six months later (adjusted R 2 : 68.1%).

Conclusions : In spite of its exploratory nature, this study revealed that, among a substantial number of personal characteristics, some were more related to a handicap measure and have greater predictive value. Other studies should be carried out to validate these findings and to consider more environmental factors in order to better understand factors related to the development of handicap situations.     

Health related quality of life and related factors in 539 persons with amputation of upper and lower limb

Purpose : Limb amputation is followed by an important rehabilitation process, especially when a prosthesis is involved. The objective of this study is to assess the nature of factors related to health related quality of life (HRQL) of persons with limb amputation.

Method : The Nottingham Health Profile (NHP) treated 1011 subjects with major amputation of one or several limbs. Correlations were sought in multivariate regression model analyses between the six categories of distress explored by the NHP and age, sex, cause and level of amputation and rehabilitation programme.

Results : Response rate was 53.3%. HRQL measured by the NHP was mostly impaired in the categories of physical disability, pain and energy level. Controlling for sex and age, young age at the time of amputation, traumatic origin and upper limb amputation were independently associated with better HRQL.

Conclusion : It is concluded that HRQL is largely related to factors which are inherent to the patient and the amputation.