The effects of long-term intraspinal infusion therapy with noncancer pain patients: evaluation of patient, significant-other, and clinic staff appraisals

Objective. This study examines, in a retrospective fashion, the effects of intraspinal infusion therapy, primarily using opioids, in the treatment of recalcitrant noncancer pain in a sample of 29 consecutive patients. Patients were, on average, 58 years of age having had one surgery, with a pain duration of 221 months. Mean follow-up duration was 31 months. Telephone interviews by a disinterested party were used to obtain follow-up data from patients and their significant others. In addition, clinic staff rated patient improvement. Results. The patients reported an average of 63.4% improvement in pain; 45.5% improvement in activity level; and a 53.8% improvement in "ease" of performing activities. Average pain level on a numerical rating scale decreased from 8.91/10 to 5.03/10. The number of patients reporting a pain level of 5/10 or less increased from 1/29 to 15/29. Patients generally reported long-term benefit to be equal to or greater than that realized during the intrathecal trial. Approximately 86% of patients reported a "good" or "excellent" outcome. Significant-other ratings of improvement correlated more highly with clinic staff than with patients. No statistically significant differences were observed when worker's compensation (WC) patients were compared with nonworker's compensation (NWC) patients. Nearly 50% of the patients reported some type of transient or persistent side effect, mostly related to the infused substance. No mechanical failure of the DAS system was observed. Conclusion. These results in part replicate those from previous studies examining the long-term effects of infusion therapy. Side effects remain fairly common and require continued attention. Their presence, however, did not appear to deter from the patient's overall sense of satisfaction. Acquiring information from significant others and clinic staff may be a useful adjunct in interpreting the overall outcome.

Perineuromal stimulation in the treatment of occipital neuralgia: a case study

This case study is presented to exemplify the application of a perineuromal approach in the treatment of recalcitrant occipital neuralgia. The patient was a 49-year-old female with severe and disabling occipital neuralgia. The pain persisted despite several surgical procedures, injections in the affected area, and medications. Threading the electrode into the cervical epidural space and attempts at peripheral stimulation using the Weiner and Reed approach were unsuccessful. Immediate benefit was derived when the electrode was advanced subcutaneously and positioned underneath the neuroma apparently created by a C2 nerve transection. A Medtronic Octad (model #3898) was utilized. The patient was contacted at seven and nine months post implantation. She reported 90% improvement in her pain. The improvements were also noted in numerical pain ratings, Beck Depression Inventory, and Oswestry Disability Scale. These improvements were corroborated by her husband. The Minnesota Multiphasic Personality Inventory (MMPI) remained relatively unchanged. This case illustrates the possible utilization of perineuromal stimulation in the treatment of occipital neuralgia. The specific mechanism of action remains unclear. Replication and controlled studies are required to determine the general applicability of this approach.

Transforaminal ventral epidural adhesiolysis

Epidural fibrosis with chronic low back pain, nonresponsive to traditional measures of treatment including surgery, is a common entity in modern medicine. Traditionally, epidural steroid injections have been employed to treat chronic low back pain and radiculopathy associated with failed back surgery. Due to the poor effectiveness of epidural steroid injections in post lumbar laminectomy syndrome, epidural adhesiolysis was introduced in the early 1980s. Caudal epidural adhesiolysis with hypertonic saline neurolysis has been described extensively in the literature and has been proven to be relatively successful and safe. To improve the results and reach the target area with steroid, transforaminal ventral epidural adhesiolysis has been utilized. This retrospective case analysis included 14 patients. Transforaminal ventral epidural adhesiolysis was performed on an outpatient basis in all patients. The results showed 93% improvement initially, which decreased to 71% at 1 month, 57% at 3 months, 43% at 6 months and 21% at 1 year. The results of this case study show that ventral epidural lysis of adhesions with hypertonic saline neurolysis is safe and effective in managing chronic low back and lower extremity pain in patients who failed to respond to other conservative modalities of treatments, including fluoroscopically directed transforaminal epidural steroid injections.

Ethnic differences in pain tolerance: clinical implications in a chronic pain population

OBJECTIVE

Although numerous studies have independently examined ethnic differences in clinical and experimental pain, few have investigated differences in both sensitivity to controlled noxious stimuli and clinical pain reports in the same sample. The present experiment examined the effects of ethnicity (African American vs. white) on experimental pain tolerance and adjustment to chronic pain.

METHODS

Three hundred thirty-seven (68 African American and 269 white) patients with chronic pain referred to a multidisciplinary treatment center participated in the study. In addition to completing a number of standardized questionnaires assessing adjustment to chronic pain, participants underwent a submaximal effort tourniquet procedure. This experimental pain procedure yields a measure of tolerance for a controlled noxious stimulus (ie, arm ischemia).

RESULTS

African American subjects reported higher levels of clinical pain as well as greater pain-related disability than white participants. In addition, substantial group differences were observed for ischemic pain tolerance, with African Americans demonstrating less tolerance than whites. Correlational analyses revealed a small but significant inverse relationship between ischemic pain tolerance and the reported severity of chronic pain.

CONCLUSIONS

Collectively these findings support previous research revealing ethnic differences in responses to both clinical and experimental pain. Moreover, the present results suggest that enhanced sensitivity to noxious stimuli on the part of African Americans may be associated with ethnic differences in reported clinical pain, although the magnitude of ethnic differences was much greater for ischemic pain tolerance than for clinical pain measures.

Pain management programs in hand therapy: a literature review and appraisal

This article analyzes literature on pain management programs in hand therapy. Philosophical and practical issues that may influence the approach to pain are reviewed. Possible explanations for the relative lack of interdisciplinary/comprehensive approaches to pain are put forth. Conditions under which more comprehensive treatment should be considered are discussed.

Intrathecal infusion systems for treatment of chronic low back and leg pain of noncancer origin

In this study, 26 patients (average age, 44.3 years) with chronic noncancer pain averaging 115 months' duration had implantation of an infusion pump with intrathecal catheter placement. In general, preservative-free morphine sulfate was used. Average follow-up was 23 months. Measurements of pain reduction, activity improvement, oral medication use, and overall satisfaction by patient, spouse, and clinic staff were obtained. Of the 26 patients, 20 noted a good or excellent outcome. Average daily dosage of intrathecal morphine increased over time by approximately sevenfold. Subjective pain levels decreased an average of 59%, and daily functioning increased 50%. No postoperative complications were noted, but 11 patients required additional surgery (9 for catheter complications). These data support chronic spinal opiate therapy as an option for safe and long-term management of noncancer pain.

Assessment of aerobic power in chronic pain patients before and after a multi-disciplinary treatment program

Physical exercise is widely used in the treatment of chronic pain patients, and direct measurement of physical capabilities is needed to objectively document change. In this study, 46 residential chronic pain patients undergoing treatment at a multidisciplinary rehabilitation center were administered a cycle ergometer graded exercise test, using a Medical Graphics CAD/NET exercise system, to measure aerobic fitness and other physiological parameters before and after the four-week treatment program. Patients evinced highly statistically significant changes in all major indices of cardiopulmonary functioning, including MAXVO2 and METS, and a measure of lower body power (WATTS). Possible mechanisms underlying such dramatic changes in this short time period include improved physical fitness, learning or desensitization to symptoms associated with exertion, and improved effort. Documenting treatment-related changes is important, and metabolic exercise testing provides an objective method for assessing changes in functional capacities. Such changes may have important practical implications for these individuals. The importance of assessing and improving aerobic fitness in chronic pain populations is discussed.

Smoking and narcotics use among chronic pain patients

Among 137 noncancer patients having pain for more than 6 mo. and being within 30 to 69 yr. of age, narcotics users were evenly distributed but tobacco smokers were significantly more likely than nonsmokers to use narcotics.

Evaluation, narcotics and behavioral treatment influences on pain ratings in chronic pain patients

Changes in self-reported pain ratings were assessed in 95 chronic pain patients from data collected at three times: pretreatment evaluation, initial days of treatment and final days of treatment. These data were collected separately for regular, sporadic and nonusers of narcotic medication. Each patient completed a four-week interdisciplinary behaviorally based noninvasive treatment program. There was an average decrease of 7% in self-reported pain ratings between evaluation and the onset of treatment for the three groups. An additional decrease of 21%, 16% and 10% for the sporadic, nonusers and regular users of narcotics respectively was noted during treatment. Statistical analysis revealed a significant decrease in pain ratings across assessment phases but not between groups. Sporadic users of narcotics showed a pattern more similar to nonusers than to the regular users.

Transcutaneous electrical nerve stimulation in urinary retention

A 53-year-old woman with chronic back pain manifesting urinary frequency and incomplete voiding, presumably due to epidural scarring, was treated with standard TENS. Magnitude of residual urine and urinary frequency were decreased to acceptable limits and maintained in the absence of TENS treatment, allowing discontinuance of daily catheterization.

Narcotic utilization for back pain patients housed in private and semi-private rooms

Hospital records from 40 back pain patients in private rooms and 40 back pain patients in semi-private rooms were reviewed to determine: (a) if patients in private rooms used more narcotics than patients in semi-private rooms; and (b) whether room type was a predictive variable for narcotic utilization. Patients in private rooms were found to be more likely to use intramuscular request-contingent narcotics than similar patients in semi-private rooms. No differences in the amount of narcotics were observed for other categories of narcotic analgesics. Room type, relevant medical, and demographic variables failed to account for this difference in medication utilization, suggesting that other factors such as medical staff and patient personality variables may be playing an important role in contributing to the use of narcotic analgesics by back-pain patients.

Response of patients with chronic pain to exercise quotas

The effects of setting exercise quotas were examined using 26 subjects with chronic pain. The subjects were participants in a residential treatment program. Each subject was assigned a group of exercises to perform twice daily. A single subject multiple baseline design across responses was used to evaluate treatment effects. The data analysis revealed that the subjects responded to quotas by showing steady and gradual increases in exercise activity. These effects, however, occurred only when quotas were set and were not generalized from "quota" to "nonquota" exercises. These data were discussed in terms of the usefulness of exercise quotas, the applicability of multiple baseline designs, and the need for more research in the area of generalization.

Dietary management of obesity: evaluation of the time-energy displacement diet in terms of its efficacy and nutritional adequacy for long-term weight control

1. An unsupplemented 4200 kJ (1000 kcal) diet emphasizing large quantities of relatively unrefined complex carbohydrates was evaluated among sixty obese adults for its effectiveness and nutritional adequacy in a long-term weight-control programme. Patients were followed individually as outpatients by a physician and dietician-an average of thirteen visits over 26 weeks. Assessment of health indices included anthropometric measurements, blood pressure, lipid levels and assays for seven vitamins, beta-carotene and iron. 2. Weight loss averaged 8.2 kg or 24% of excess weight during the 6 months of active treatment. Over an average of 17 months of post-treatment follow-up, 44% of patients continued to lose weight and 92% remained below pretreatment levels. 3. Average skinfold thickness fell 7 mm (P less than 0.001) whereas muscle mass was maintained (arm muscle circumference + 10 mm, not significant; creatinine-height index + 3% of standard (Bistrian et al. 1975; not significant). Systolic and diastolic blood pressure fell 7 and 5 mmHg respectively (P less than 0.01). Total serum cholesterol and triglycerides fell 200 and 660 mg/1 respectively (P less than 0.01), while high-density-lipoprotein-cholesterol remained statistically unchanged. Mean serum levels of retinol, beta-carotene, folate, vitamin B12, ascorbic acid, Fe and transferrin saturation, and activity coefficients for thiamin, riboflavin and pyridoxine were within normal limits after periods of treatment ranging from 5 to 84 weeks. 4. An earlier age of onset of obesity tended to be associated with greater weight loss during treatment and lesser weight rebound during follow-up. 5. The results indicate that the experimental diet, without supplementation, was nutritionally adequate as well as effective for long-term weight control.

Toilet training and enuresis

Toilet training is often taken for granted because it appears to occur so readily in such a large majority of children. It would be easy to hypothesize some internal mechanism which, if triggered at the right point in time, results in the initiation of a preprogrammed process that terminates with the child being trained. Variations across cultures regarding the age at which children are trained, the multitude of training procedures used by parents, and the variety of problems encountered during toilet training suggest that such is not the case. Toilet training has not been the focus of extensive systematic research as incontinence appears to impose no immediate or uncompromising physical threat to the child. Our apparent insensitivity to the emotional and psychological discomfort is perhaps highlighted by our rather cavalier attitude regarding the necessity of treating the younger (6 to 10 year old) child. Enuresis takes on added significance to the extent that it seems to be the symptom of some underlying neurologic or urologic abnormality. Once the enuresis is determined to be functional in nature, we are often satisfied with allowing the child and family to deal with the matter on their own and to return if the problem persists into adolescence. If treatment is begun at an early age, it seems to have a greater chance of success with fewer complications. It need not be particularly time-consuming once an adequate assessment has been carried out. Nurses, paraprofessionals, mental health technicians, and so forth, can be trained and utilized effectively in following the process of the parent and child. A compassionate, understanding, and systematic approach encourages compliance and patients on the part of the child and parents.

Social skills training with mildly retarded young adults

Described a social skills assessment and training model for use with mildly retarded young adults (N = 20). The assessment procedure examined social behavior in three types of social situations (e.g., conversational situation, cooperative task and assertive situation) with both male and female respondents. Group behavioral social skills training was compared with a no treatment control condition using various dependent measures collected in the in-vivo social situations. Group behavioral social skills training was more effective than the control condition in increasing positive social behavior, attention to the transaction, and degree of empathy. It was also more effective than a control condition in decreasing negative social skill behavior. A situation effect also was observed, which suggests a need for more focus on particular social skills and a need to address issues of generalization. A comprehensive social skills assessment and training model is discussed.

Effects of social-skills training in a community-based program

The effects of social-skills training upon the behavior of 8 previously institutionalized mentally retarded adults, residing in community group homes were evaluated. In comparison to a control group, the subjects who received training showed substantial changes in the desirable direction for each behavior. Generalization to unfamiliar situations was also noted. The problems in placing retarded clients in the community without social-skills training and the potential disadvantages of inadequate training were discussed.

Situation generality of overcorrective functional movement training

A multiple baseline design across situations was employed to assess (a) the effects of an overcorrective functional movement training procedure on stereotypic head-turning and (b) the generality of behavioral change to two non-treatment situations. Results indicated that the overcorrection procedure was immediately effective in reducing head-turning in the treatment situation. Head-turning initially increased in the two non-treatment situations and then gradually declined.

Preliminary examination of assessment of assertive behavior in retarded persons

Informants' rating, self-report questionnaires and observers' ratings were compared in the assessment of assertive skills of five mildly retarded young adults. Of the three standard assertion scales administered, only the Wolpe-Lazarus correlated positively with behavioral ratings obtained from role-playing. Scores on the Wolpe-Lazarus scale, however, were negatively correlated with those obtained on the Rathus and Adult Self-expression scales. Neither the informants' ratings nor self-reports correlated with behavioral ratings. These data suggest a multi-modal assessment of assertive behavior is needed. The implications for treatment and further research are considered.

The effects of social punishment on noncompliance: a comparison with timeout and positive practice

The effects of social punishment, positive practice, and timeout on the noncompliant behavior of four mentally retarded children were assessed in a multitreatment withdrawal design. When programmed, the experimental procedure occurred contigent on non-compliance to experimenter-issued commands. Commands were given at 55-sec intervals throughout each experimental session. The results showed (1) lower levels of noncompliance with social punishment than with the positive-practice or timeout conditions, and (2) that relatively few applications of social punishment were required to obtain this effect. The advantages of social punishment over other punishment procedures, considerations to be made before using it, and the various aspects of the procedure that contribute to its effectiveness were discussed.

A behavioral treatment program for the Gilles de la Tourette syndrome

The reinforcement of incompatible behavior in both structured and natural environments was examined as a treatment paradigm for multiple tics displayed by an adolescent boy. The procedure was shown to be effective in reducing the frequency of the behavioral tics and in increasing the rate of more appropriate behaviors. The treatment program concentrated on procedures which maximized the transfer of changes occurring in the clinic to more natural environments and the utilization of nonpsychologists and behavioral change agents.