News Category: Pain

As the medical community tries to find ways to help patients become more independent in managing their health issues, researchers have discover how emotional development as children may affect how one copes with adverse events, like illness, as an adult.

This article reviews research that investigated the relationship between attachment styles and how this may affect how people react to stressors such as illness or pain. Attachment behaviors are developed during infancy, as babies depend on those around them. A child may become very attached or clingy, or distance himself from his caregiver if, for example, his needs aren’t being met when he is hungry or hurt. The attachment behaviors developed during early childhood generally follow through adulthood.

Two negative attachment styles are attachment anxiety and attachment avoidance. Both of these are seen as extremes, with attachment anxiety causing excess worry and dependence on others, and attachment avoidance causing a uneasiness with being close to others or being dependant on others.

Among the several studies done, some researchers found that subjects who fell in the two negative attachment styles were not as effective in dealing with threats (ie. pain) than were those who had more positive attachment styles.

The researchers found that those who fell into the attachment anxiety group had a harder time handling threatening issues and showed poorer coping mechanisms. Those who fell in the attachment avoidance group also didn’t cope well, but by avoiding the situation, minimizing the threat, and not seeking help when it would have been appropriate.

Yet other studies have been done to analyze the relationship between attachment style and chronic pain. Not only did the researchers find that the patients had poor coping skills, but there were also higher levels of depression in both the attachment anxiety and the attachment avoidance groups.

Interestingly, there have been some similar findings among the caregivers of children or spouses who were ill or in pain. The researchers found that caregivers of children who fell into either of the two groups had higher levels of depression as did the children. For spouses, a caregiver who fell into the anxiety group tended to have a lower level of marital quality.

The researchers of this review pointed out that there remains a lot to be studied before being able to draw direct connections between attachment styles and coping with illness or pain. However, the preliminary evidence is convincing enough to warrant further studies that examine direct association between attachment and pain intensity, how this affects health care and its cost, and how this all comes together in treatment for the long-term.

Living with chronic pain can be hard, both physically and emotionally. Taking medications or participating in pain management programs can make life easier, but patients can also help themselves through self-management, or taking control of their own pain management.

Not everyone who has chronic pain is ready for self-management, so doctors are studying how to predict who would benefit most from this approach. Patients who are ready for self-management are more successful in completing programs and are able to cope with their chronic pain better than those who are not ready. In this study, researchers wanted to learn what might help them identify into which group patients may fall.

Researchers examined questionnaires, called the Pain Stages of Change Questionnaire, that had been filled out by patients with chronic pain. They answered a subgroup of questions, Precontemplation and Action, that were designed to divide them up into groups according to how ready they may be to self-manage their pain.

After looking at the results, the researchers found that patients in the precontemplation group reported a higher level of pain and were anxious or depressed. They felt as if they had no control over their situation and they depended on their doctors to tell them what to do. The patients in this group didn’t believe that they had any power in changing things and that they didn’t know enough about the injury that caused the pain. Patients in the second group, the action group, however, felt more confident about managing their pain, they understood the causes and what they could do to help live with the pain as comfortably as possible. The patients in this group were considered to be more likely to be able to self-manage their pain.

The authors of the study concluded that using a questionnaire designed to assess a patient’s readiness for self-management could help improve care. By knowing how ready their patients are in terms of managing their pain, doctors can choose the appropriate care for each patient.

Most people don’t suffer pain in silence. Pain behaviors are usually easy to spot. Besides the obvious moaning and groaning along with verbal complaints, there are nonverbal pain behaviors. For example, making faces, grimacing, rubbing the painful area, and guarding are common pain behaviors.

Guarding is defined as any behavior that prevents or reduces pain. Guarding behavior may include stiffness, limping, bracing a body part, and flinching. In this study, researchers found that guarding behavior may be a key component in pain assessment.

The data used came from the study of 148 workers with back pain. All workers had a recent back injury and were on workers compensation. Most of the men were construction workers. The women came from jobs in the health-care setting.

Each patient was given at least five different tests. The tests measured a wide range of items. Mental and physical health, fitness, disability, pain, and quality of life were just a few of the variables tested.

The results suggest that patients with guarding behavior are less likely to return to work after an episode of back pain. Guarding may be a sign that acute pain will become chronic pain. This is called a predictive factor. Higher levels of guarding behaviors were linked with more days missed at work.

Steroid injections are a good treatment choice for some patients with knee osteoarthritis or shoulder rotator cuff problems. There are different formulations of steroids available for such use.

In this study, researchers compare the results from two kinds of steroids: methylprednisolone and betamethasone. Patients with knee or shoulder pain were included. The study used a double-blind method. This means neither the surgeon nor the patients knew which type of steroid was used.

Pain was the main result measured. They looked at pain levels immediately after injection and again three days later. A final measure was taken three weeks after the injection.

The results showed all patients had immediate pain relief with the injection. There was an increase in pain several days later. This increase didn’t last. At the end of three weeks, everyone in both groups reported improved pain levels.

The authors say these findings support their own experience giving steroid injections for joint pain. They suggest that patients should be told what to expect including the short-term ups and downs in pain control.

Patients with high levels of pain to begin with seemed to have the best results. All patients had significant pain relief between three days and three weeks after the first injection.

Back pain can be difficult and complex to treat. Sometimes treatments are used before there’s any real evidence that they work. The use of opioids may fall into this category. Opioids are painkillers that act like morphine in the body.

The use of opioids started to rise in the last 20 years thanks to advice from pain specialists. Drug companies added to the problem. They launched ad campaigns that helped support the belief that these drugs were the answer to chronic pain.

But the evidence to support routine or long-term use of opioids (more than four months) just isn’t there. They may be effective for short-term control of back pain but the evidence is shaky. In addition, studies show major problems from opioid use.

Addiction is more common than previously thought by pain specialists. And more than half the patients don’t really get the pain relief they need. Quality of life isn’t better and may decline with ongoing pain and addiction. According to a large study in Denmark, opioid use is linked with higher levels of unemployment, less physical activity and fun, and poorer overall health.

If the goal of opioids is to get pain relief, increase function, and improve quality of life, then they are not doing what they are supposed to do. Until there is better evidence to support their use, researchers suggest caution when using long-term opioids for the treatment of chronic pain.

Researchers in England are testing the validity and reliability of a test for mental defeat. Mental defeat is defined as thoughts that cause a patient to see pain as an enemy. For a person with mental defeat, the effects of pain assault the person’s life and sense of identity.

This study reports on the use of the Pain Self Perception Scale (PSPS) to measure mental defeat in five groups of people. The groups included 1) chronic pain patients, 2) patients with acute pain, 3) pain-free controls, 4) volunteers with chronic pain who weren’t getting any treatment, and 5) patients with anxiety disorders.

The PSPS was adapted from two other studies in order to use it with chronic pain patients. It was tested on healthy volunteers and a group of chronic pain patients first. Changes were made in the wording of some questions. Then the test was given to these five groups. Pain and mood were also measured using two other tools.

Results showed that the PSPS is a reliable scale to measure mental defeat. Chronic pain patients seeking treatment had the highest scores compared to all the others. They showed higher levels of mental defeat even compared to chronic pain patients who were not seeking care.

The authors conclude it may be possible to find a link between chronic pain, depression, and posttraumatic stress disorder. Using the PSPS to identify patients with mental defeat may help them find more effective treatment. A shorter version of the survey is being developed.

In this study, researchers report how experts diagnose myofascial trigger point (MTrP) pain syndrome. Trigger points are hyperirritable spots within a tight band of muscle or in the fascia over the muscle.

Many people suffer from this painful muscle condition. Accurate diagnosis helps guide treatment. To find out what criteria experts use in the diagnosis, the authors reviewed 93 studies on the subject.

They found 19 different ways health care providers assess and diagnose MTrPs. Four factors were used most often:

It is well-known that sleep is important to our health and daily function. Poor sleep patterns are linked with depression and pain-related disability. But what about the quality of sleep? Does it matter how well you sleep or how rested you feel when you wake up?

Chronic pain patients participated in this study to try and answer these questions. Each one filled out the Pittsburgh Sleep Questionnaire Index (PSQI). This survey evaluates how well patients sleep over a one-month period of time.

A second survey was used to measure disability. Disability for this study referred to difficulty with activities of daily living such as walking or dressing caused by pain. Depression was also measured.

The authors found that sleep quality didn’t predict pain-related disability. Depression and pain severity were the most important predictors of disability. Depression was a stronger factor in disability than even pain severity.

It’s possible that improving sleep quality could reduce depression and pain severity. To find out, the next step is to improve sleep quality and remeasure depression and disability.

Cognitive-behavioral therapy (CBT), a form of counseling, works well for some chronic pain problems. In this study, researchers explore ways to improve this treatment method. They also try to find factors that might predict who would benefit from CBT.

Patients in the study were adults from a university dental school facial pain clinic. Everyone had face and/or jaw pain for at least three months. The patients were divided into two groups.

The CBT group received four sessions of therapy every other week over a period of eight weeks. The second (control) group received education. Everyone still had their usual treatment in the pain clinic. Relaxation techniques were also taught to each patient.

Results were analyzed for anyone who completed at least three of the four scheduled sessions. CBT worked better and faster at both the six month and the 12-month check up. Relaxation methods used to cope with pain did not seem to effect CBT outcomes.

Factors that improved CBT results included increased sense of control over pain, decreased belief that pain was disabling, and improved ability to use self-efficacy to manage pain. Self-efficacy is the confidence a patient has that he or she can decrease their own pain.

The authors suggest these findings support the need to improve multidisciplinary programs. CBT can be more effective and efficient when patients are taught how to stop worrying about their pain. The patient’s sense of control over pain levels decreases disability. Changing patient beliefs about pain may be the best way to help chronic pain patients cope.

Collecting data and analyzing it over time is called epidemiologic research. Epidemiologic studies give us the big picture. In health care, the resuls help direct patient education, prevention, and treatment for many conditions and illnesses.

In this study, findings from the last 20 years are reported on chronic pain. Here’s what we know so far:

About 10 years ago, the Tampa Scale for Kinesiophobia (TSK) was developed and validated. It is a scale used to measure fear of movement or reinjury in chronic pain patients. Since that time, the scale was translated into Dutch. Most of the research has been done using the Dutch version.

In this study, researchers from Canada used the English version of the TSK with a group of 200 chronic back pain patients. Everyone in the study had back pain from a work-related or motor-vehicle accident. The 17-item TSK survey was filled out by each person.

The patients retook the survey after a nine-week program of supervised exercise and a five-week counseling program. Analysis of the data told the researchers:

This is the first study to report the results of using ultrasound (US) to guide needle injection of the piriformis muscle (PM). The PM is located deep in the buttock and can cause painful buttock or hip symptoms along with sciatica.

Sciatica refers to irritation of the sciatic nerve from any cause. In the case of piriformis syndrome, it’s likely the PM is compressing or contracting around the sciatic nerve. A steroid injection into the PM can help ease the symptoms and restore pain free hip and leg motion.

In the past, physicians have used electromyography, CT, MRI, and fluoroscopy to guide the needle injection. Fluoroscopy is a special X-ray technique that gives the doctor a real-time image of the body part in question. Researchers at the Mayo Clinic in Rochester, Minnesota studied steroid injection of the piriformis using ultrasound imaging instead.

US has several advantages over other imaging methods. It does not expose the patient to any X-rays. US gives a clear image of each layer of soft tissue. The physician is able to advance the needle right to the sheath or lining of the piriformis. The steroid drug can be injected into the sheath or directly into the muscle.

Today’s US machines are compact making this an easy-to-apply diagnostic test and treatment. Physicians already trained in US techniques can learn how to perform this treatment technique in one day.

The authors of this article provide detailed step-by-step instructions with ultrasound photos to help the reader in this process.

The Minnesota Multiphasic Personality Inventory (MMPI) is a personality inventory often used by psychologists. Scores on the test help predict which patients might improve with treatment. Surgeons started using this test some years ago to select patients who were good candidates for surgery.

Researchers from the Department of Psychology at the University of Texas (Arlington) have further classified chronic back pain patients. Using the MMPI in a large group of patients with chronic occupational spinal disorders (COSD), a new disability profile (DP) was discovered.

More than half of the COSD group could be classified as DP based on MMPI results. What makes the DP group different from other patients? The study showed they were 14 times more likely to be depressed or anxious. They were also five times more likely to have a separate diagnosable personality disorder. And the DP group was less likely to go back to work after treatment.

The authors suggest patients with COSD must be evaluated and treated for clinical depression when present. Without this important step, recovery or even improvement for patients with chronic pain disorders cannot progress. With the right treatment, a better response to surgical or nonoperative care may be the outcome. This conclusion applies to COSD patients who fall into the DP group when tested with the MMPI.

The use of opioid medicine to control chronic, severe pain is on the rise. But according to a large study from the National Institute of Public Health in Denmark, there’s no evidence to support its use.

Opioids are pain relievers such as morphine, codeine, and oxycodone. In recent years, there has been an increased use of opioids in the management of non-cancer chronic pain. This trend is still highly debated due to issues of tolerance and dependence.

Tolerance refers to the patient getting used to the drug and needing higher doses for the same pain relief. Dependence means the person starts to experience symptoms of withdrawal if the drug isn’t taken regularly.

Most patients using opioids are seeking pain relief, improved function, and a better quality of life. Are these goals met with long-term use of these drugs? A general health survey of over 10,000 adults was conducted. People were divided into two groups based on their response to the question, “Do you have chronic or long-lasting pain lasting six months or more?”

The groups included a pain group (PG) and a control group (CG). The pain group was further divided into opioid users and non-opioid users. Results of the survey showed that just as many people with chronic pain were coping without opioids.

Opioid users did not have less pain, greater function, or better quality of life when compared with non-opioid users in the pain group. Opioid users were less active and less likely to be employed. They were more likely to be on disability and to use the health care system. There did not seem to be any benefit of opioid use for the users over the nonusers.

Denmark has the highest rate of opioid usage in the world. There has been a trend toward increasing use for chronic, non-cancer pain over the last few years. The authors of this study suggest caution in the long-term use of opioids until further studies can prove their value.

Nonsteroidal antiinflammatory drugs (NSAIDs) still remain one of the most commonly used drugs for joint pain from osteoarthritis (OA). Changes have come about over the years to improve these drugs. Reducing side effects such as stomach bleeds and kidney problems has brought a whole new generation of NSAIDs to the market.

In this article, doctors from NYU Hospital for Joint Diseases in New York review current trends with NSAID use. Choosing the right NSAID for each patient is the first step. Acetaminophen (Tylenol®) is still the first choice for mild OA. Tylenol is a pain reliever but not an NSAID.

When Tylenol® is not effective, an NSAID may be needed to control pain and inflammation. Aspirin used to be the most popular NSAID. But aspirin use in some people can result in ulcers, GI bleeding, and kidney failure.

Scientists discovered that certain enzymes called cyclooxygenase (COX) were part of the problem. A new group of NSAIDs was developed to inhibit or stop one specific enzyme (COX-2). These drugs were called COX-2 inhibitors.

Over time it became apparent that some patients taking COX-2 inhibitors had higher rates of heart attack. Two of these drugs were removed from the market (Vioxx and Bextra). Celebrex is still available but no longer advertised.

The authors say that until a better product is developed, doctors should still use these drugs for patients with OA. All drugs come with some side effects. The goal is to benefit from the drug with minimal effects. Acetaminophen should be used first, then the lowest dose COX-2 inhibitor for as short a time as possible.

Patients with known GI problems who still need an NSAID can also take proton pump inhibitors (PPIs). Prilosec, Nexium, and Prevacid are examples of PPIs commonly used. These drugs help reduce acid in the stomach but must be used with caution as well. PPIs can also mask symptoms of serious GI disorders such as cancer. Patients should remain under a doctor’s care when taking any of these drugs to manage side effects appropriately.

In this study, psychiatrists at the David Geffen School of Medicine in Los Angeles test a tool for measuring self-efficacy in children who have chronic pain. Self-efficacy is a person’s belief about his or her ability to do something.

A person with a strong sense of self-efficacy feels certain he or she can master a task or activity. People who doubt themselves have low self-efficacy. They give up easily and often when faced with new or tasks viewed as difficult or challenging.

The subject of this test was children functioning normally when in pain. Children ages eight to 18 were included. Each one had some type of chronic pain such as headaches, stomachaches, or chest or back pain. Each child and one of the parents filled out the same form answering the same questions. The questions were about the child’s ability to function while in pain. They were not allowed to see each other’s answers.

The questions measured the physical and psychosocial well-being of each child. Body pain, self-esteem, and mental health were tested. Self-efficacy for normal function when in pain was the main focus.

The parents and children rated the child’s self-efficacy about the same. This is what the researchers expected would happen. Children with high self-efficacy had fewer physical complaints and higher self-esteem. Children’s ability to function was not based on pain levels as much as on their level of self-efficacy.

The authors suggest that improving self-efficacy may be a better way to help children cope with chronic pain. For example improving a child’s sense of confidence may work better than other methods such as relaxation training.

This study continues the work already done investigating the use of botulinum type A toxin (Botox A) for relief of muscle pain. A specific Botox agent called Dysport® was used in patients with upper back pain. Dysport® has a much higher biologically active dosage compared to Botox®.

All patients had been diagnosed with a condition called myofascial pain syndrome (MPS). MPS is described as chronic muscle pain from shortened or contracted muscles. Trigger points (TrPs) are often part of the clinical picture. TrPs are areas of hyperirritable spots. When pressed or stimulated, TrPs cause a predictable pain pattern.

Patients included were men and women between the ages of 18 and 70 years. All had MPS with at least 10 TrPs present in the neck or upper back. Symptoms had been reported for at least six months.

Each patient was given a single injection of Dysport® into the 10 most painful TrPs. Pain level after five weeks was the main result measured. Change in pain intensity and number of pain-free days each week were also recorded. Results were compared to a placebo (control) group who had saline injections without the Botox.

The researchers report patients in the Dysport® group had greater pain relief at week five compared to patients in the placebo group. Pain intensity was less in the Dyport® group. The benefits of the injection lasted at least 12 weeks.

Patients receiving the Botox treatment had better pain relief throughout the course of the study. They said they would recommend this treatment to other patients with MPS.

In this study researchers from Belgium and the Netherlands designed and tested a questionnaire used to assess patient attitudes to solving the problem of pain. The survey was called the Pain Solutions Questionnaire or PaSol.

The final survey ended up with 14 questions divided into four sections. The sections included: 1) Solving Pain, 2) Meaningfulness of Life Despite Pain, 3) Acceptance of Pain (that won’t go away), and 4) Belief in a Solution.

Each section was able to measure some aspect of pain. For example, beliefs and values such as coping with pain or attempting to cure or control pain were measured. Efforts at changing the problem or situation were also measured.

The results of such a survey will help professionals guide patients in matching a coping strategy with a realistic view of the problem. For example, if the patient continues to try and find a cure for pain that is incurable, then other solutions can be introduced.

Patients who believe that life has meaning even with pain tend to pay less attention to their pain. They have less disability and more function. Patients who keep looking for ways to solve the pain do so at the expense of pursuing other more functional goals. The result is they focus on their pain in a hypervigilant way.

The authors suggest several areas for future studies. For example, are styles of coping linked with disability caused by pain? How can we help patients who focus on their pain and who keep trying to solve the problem when it’s incurable? Can chronic pain patients become more flexible in finding other solutions (besides cure) to the problem of pain?

The authors’ final comment is that it remains to be seen whether patients who express an interest in problem solving actually make any attempts to do so.

This is the first study to look at how patients who catastrophize pain see or perceive pain in others. Pain catastrophizing is a term used to describe a particular response to pain. The person thinks about the pain often. This is referred to as rumination. The experience is magnified until the patient feels helpless because of the pain. Their perception of pain is greater than someone who does not catastrophize.

In this study 60 college students watched videos of 11 subjects as the subjects’ arms were put in cold water for one minute. The film clips showed the subject’s entire body and response to the cold. The subjects rated and reported their own pain every 20 seconds during the one minute the arm was in the water. Observers also rated the subjects’ pain without knowing what the actual (self-reported) ratings were.

The authors say there was a general trend to underestimate pain by the observers. The observers relied on facial cues more than body movement to rate the subjects’ pain. Facial pain scores were actually poor indicators of the self-reported pain given by the subjects. The observers who catastrophized were more accurate compared to others who underestimated pain.

The results of this study show that people who score high on tests of pain catastrophizing have more intense pain themselves. They see other people as having greater pain too. Scientists may be able to use this information for future studies related to caregiving. Pain perception may have an impact on caregiving behavior.

Social scientists help us understand the theories behind pain and disability. For patients with chronic pain, pain intensity and disability are linked with anxiety, self-efficacy, and attachment styles. Self-efficacy refers to people’s beliefs about their ability to do something.

For example, someone in pain with a strong sense of pain self-efficacy feels able to appproach the difficult task of overcoming pain. This person sees pain as a challenge not a threat. Someone with low pain self-efficacy is more threatened than challenged by the pain experience.

Attachment styles refers to how each person relates to others. Four types of attachment styles include secure, anxious, fearful (anxious and avoids others), or dismissive (avoids others).

In this study 152 patients entering a chronic pain rehab center took several surveys. Each survey was a tool to measure levels of pain self-efficacy, attachment style, and pain intensity. The relationship of anxiety and closeness as it is linked with pain was examined. Differences in style and self-efficacy were compared between men and women.

The authors found that people with secure attachment to others have a shorter duration of pain. Women were more comfortable with closeness and better able to ask for help. Self-efficacy was higher for people with secure relationship styles. Patients with secure attachments had lower levels of anxiety.

Patients with lower levels of anxiety had lower levels of pain. People with higher levels of pain self-efficacy had less disability. Attachment style didn’t seem to be directly linked with disability or pain intensity.

Overall there was proof that pain self-efficacy is linked with anxiety, adult attachment style, and perceptions of pain and disability. Insecure, anxious patients are more likely to have chronic pain. People who are more comfortable with closeness, who have high levels of pain self-efficacy, and low levels of anxiety are less likely to become disabled.

The authors suggest treatment of chronic pain patients must focus on attachment styles. Strategies for patients in pain should include secure relationship-based or emotion-focused psychotherapy. Treatment can be individual based on what each patient psycho-social profile may be.