Psychopathology amongst acute and chronic patients with occupationally related upper limb pain versus accident injuries of the upper limbs

Problems of Drop-out in the Self-help Treatment of Chronic, Occupational Pain of the Upper Limbs

The present study evaluated the effectiveness of a self-help, cognitive-behavioural programme in the rehabilitation of a sample of chronic pain patients. The results demonstrated significant benefits for subjects who completed the self-help treatment on measures of depression, anxiety, coping strategies, impact on daily living, pain beliefs and self-monitored pain. These benefits were generally maintained at 6 month follow-up and no differences were found in outcome between subjects who completed the self-programme compared to those who completed the same treatment in a traditional clinic-based format. Unfortunately, a very high drop-out rate was found for the self-help condition, indicating the approach to be unsuitable for many clients. Attempts to identify the characteristics of subjects who completed the self-help programme versus those who dropped-out revealed only one predictor, namely pretreatment ratings of the credibility of the programme.

Pain, Functional Disability, and Psychologic Status in Tennis Elbow

OBJECTIVES

First to compare pain and functional disability in tennis elbow (TE) patients with healthy controls. Second, to evaluate the relationship between the 2 major psychologic factors (anxiety and depression) and TE.

METHODS

Sixteen TE patients were recruited from 46 consecutive attendees at an upper limb clinic: inclusion criteria were lateral epicondyle tenderness, pain with resisted wrist and middle finger extension and at least 3 months localized lateral elbow pain. Sixteen healthy controls with no upper limb problem were recruited from students and staff. Participants were given 4 questionnaires, together with instructions for completion: Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, Patient-Rated Wrist Evaluation Questionnaire, and Hospital Anxiety and Depression Scale. The independent t test was used to compare the total and subscale scores between the groups.

RESULTS

Significantly higher scores were found in TE for pain and function subscales and also total score for Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, and Patient-Rated Wrist Evaluation Questionnaire. For Hospital Anxiety and Depression Scale, both anxiety and depression subscales (P<0.001) and the total score (P<0.01) were significantly higher in TE. According to the anxiety and depression subscales, 55% and 36% of patients, respectively, were classified as probable cases (score >11).

DISCUSSION

TE patients showed markedly increased pain and functional disability. Significantly elevated levels of depression and anxiety pointed out the importance of psychologic assessment in TE patients. In the development of supportive and treatment strategies, we suggest the combination of "upper limb" and "psychologic" assessment tools.

Effect of EMG biofeedback compared to applied relaxation training with chronic, upper extremity cumulative trauma disorders

This study examined the relative effectiveness of EMG biofeedback, applied relaxation training and a combined procedure in the management of chronic, upper extremity cumulative trauma disorder. Forty-eight patients with a history of about 5-6 years of upper extremity pain were randomly assigned to 1 of 4 treatment conditions, namely applied relaxation training, EMG biofeedback, a combined approach or a wait-list control. Treatments were conducted on an individual basis, twice per week for 4 weeks. Patients in all 3 treatment conditions showed significant short-term reductions in pain and psychopathology in comparison to the wait-list group who showed minimal change. Six-month follow-up data were obtained for patients in the treatment conditions, but not the wait-list group. There was some evidence of relapse on measures of depression, anxiety and pain beliefs for treated patients during the 6-month follow-up period, although measures remained significantly below pre-treatment levels for most outcome indices. Self-monitored pain continued to decrease for the treatment groups through follow-up. Contrary to predictions, however, the strongest short-term treatment benefits were shown by patients receiving applied relaxation training on measures of pain, distress, interference in daily living, depression and anxiety. By 6-month follow-up, differences between treatment groups were no longer evident.

Prevalence of psychopathology in carpal tunnel syndrome patients

This study assessed the prevalence rates of psychopathology in acute carpal tunnel syndrome (CTS) and acute low back pain (LBP) patients. Psychopathology was assessed with the Structured Clinical Interview for the DSM-III-R (SCID). The results showed that the CTS patients had significantly higher rates of anxiety disorders, both current and lifetime, than the LBP patients. However, LBP patients had significantly higher rates of lifetime substance abuse than the CTS patients. In regard to other types of psychopathology, such as depression, current substance abuse, and somatoform pain disorders, CTS patients had similar rates as the LBP patients. It was concluded that anxiety disorders may be a concomitant of carpal tunnel syndrome, and that treating psychological problems along with physical aspects of the syndrome may increase the patient's chance of a successful therapeutic outcome.

Site-specific muscle hyper-reactivity in musicians with occupational upper limb pain

Fourteen musicians who reported a history of pain in the upper limb associated with the playing of their instruments were compared with a sample of pain-free musicians, matched for age, sex and musical instrument. Four tasks were presented in random order and included neutral, general stressor, personal stressor and pain stressor tasks. Ratings of stressfulness and recordings of skin conductance level confirmed the effectiveness of the experimental manipulations for both subject groups. No differences were found between groups or tasks for frontalis surface electromyograph (EMG) activity. Evidence was found, however, of EMG elevation in flexor and trapezius muscles on the pain side for the pain subjects, in response to the task involving recall of a pain experience. This elevation was not found for the pain-free controls or for other stressor tasks, although some elevation in response to the pain stressor task was found for pain subjects in the trapezius muscles of the non-pain side. The duration of return to baseline of EMG following the pain stressor task was found to be extended in pain subjects for the trapezius, but not for the flexor muscles of the pain side. The findings suggest that site-specific muscle hyper-reactivity may play a role in the development and maintenance of occupational upper limb pain in musicians.

RSI revisited: evidence for psychological and physiological differences from an age, sex and occupation matched control group

The present study sought to examine psychological characteristics and function of primary afferent nociceptive mechanisms, as indexed by capsaicin-induced flare responses, in subjects suffering from RSI (n = 72) and in pain free control volunteers (n = 69). After completing a battery of psychological tests including the McGill Pain Questionnaire, Visual Analogue Scale and Word Descriptor Scale for pain, the Profile of Mood States, Illness Behaviour Questionnaire and Multidimensional Health Locus of Control, the neurogenic flare response was assessed on the right and left forearms and across the trapezius at the shoulder. When compared to controls RSI subjects displayed higher levels of mood disturbance and some abnormal patterns of illness behaviour. A reduction in flare size was observed in the pain affected limb of RSI subjects, but an increased response occurred in sites reported as unaffected by clinical pain. Multiple regression analysis revealed that the severity of clinical pain was strongly associated with the magnitude of reduction in flare size. Collectively, these findings provide objective evidence of altered nociceptor mechanisms in RSI subjects, and are consistent with the view that this chronic pain syndrome involves somatic pathophysiology. However, a strong conviction regarding the somatic basis of their symptoms, and a denial of psychological factors may have contributed to the more severe affective disturbance and greater subjective emphasis on the presence of pain.