[Rehabilitation for Pain Relief: Preface and Comments]

Chronic intractable pain is difficult to manage as the mechanisms of chronic pain are complicated. Recently rehabilitation is used in patients with chronic pain not responding to NSAIDs, non-opioids, anti-depressants and so on. Rehabilitation includes acute, recovery and maintained modes of rehabilitation. This review is focused on the concept of rehabilitation, rehabilitation therapy, rehabilitation during recovery period, nerve rehabilitation, music-trampoline therapy and so on.

[Fibromyalgia syndrome. General principles and coordination of clinical care and patient education]

BACKGROUND

The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011.

MATERIALS AND METHODS

The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies.

RESULTS AND CONCLUSION

A diagnosis of FMS should be explicitly communicated with the afflicted individual. A step-wise treatment, depending on the severity of FMS and the responses to therapeutic measures, is recommended. Therapy should only be continued if the positive effects outweigh the side effects. The English full-text version of this article is available at SpringerLink (under "Supplemental").

Predicting work status following interdisciplinary treatment for chronic pain

The effectiveness of interdisciplinary treatments for chronic pain is well established. In general, these treatments decrease psychosocial distress and increase physical abilities. Further, return to work rates following interdisciplinary treatment tend to be quite high. Previous studies have highlighted a number of factors that individually influence return to work rates; however, there is a need for more comprehensive and unified models that allow an evaluation of the inter-relations among these factors. The present investigation examined how demographic and treatment outcome variables interacted to influence post-treatment return to work rates in a sample of individuals with chronic pain following interdisciplinary treatment. Results indicated that patient age, lifting ability, pain duration, depression level, and reported disability were individually related to return to work; however, when these variables were evaluated relative to one another, level of depression and patient age had the best ability to predict post-treatment work status. These results add to the literature by specifically highlighting post-treatment factors that best discriminate patients who had returned to work from those that had not. Furthermore, they provide evidence that general emotional distress is perhaps the most important predictor of work status following treatment.

Exposure and acceptance in the rehabilitation of adolescents with idiopathic chronic pain - A pilot study

For chronic pain of unclear origin (idiopathic), pharmacological therapy is often insufficient. Psychological treatment strategies have been developed and evaluated for adults with chronic pain. However, few such studies are seen with youths, and to date there is limited empirical evidence regarding the effectiveness of psychological treatment for generalized musculoskeletal pain syndromes in adolescents. Acceptance and commitment therapy (ACT) is a development of cognitive behaviour therapy emphasizing exposure and acceptance. In this pilot study, 14 adolescents referred to the pain treatment service due to chronic debilitating pain were treated using an ACT-based approach. It was hypothesized that avoidance of pain and related stimuli was central to the disability seen among these patients, and that exposure and acceptance strategies could increase functioning and decrease pain. In contrast to emphasizing reductions in pain and distress, the treatment objective was to improve functioning by increasing the patient's ability to act in line with personal values in the presence of negative thoughts, emotions or bodily sensations. Following treatment, and retained at 3- and 6-month follow-up, improvements in functional ability, school attendance, catastrophizing and pain (i.e., intensity and interference) were seen. The outcome of this pilot study indicates that exposure and acceptance can been useful in the rehabilitation of adolescents with chronic debilitating pain. Randomized controlled studies are needed to empirically evaluate the effectiveness of this approach.

[Cervical spine and pain]

Chronic pain originating from the cervical spine, that may have diverse etiological factors, is a common condition in the clinical practice. Having distinct properties in the spine, cervical column has a wide range of motion and is commonly subject to traumatic injury. In this review, after the anatomical properties that has clinical significance and the evaluation of a patient with cervical pain are explained, the common cervical spinal pain conditions are discussed by emphasizing the therapeutic approaches in each condition.

Patient Evaluation and General Treatment Planning

Treating pain patients is difficult. The usual problems encountered in providing coherent and effective treatment for any chronic medical illness are compounded in painful conditions by time, society's choices, and the cultural role of the patient. Effective treatment of these patients depends on the persistence of the clinician. We must persist in requiring a complete history to understand the patient and his or her problem. We must persist in performing a thorough physical examination to uncover sufficient under-standing of the patient's physiology. We must persist in developing a comprehensive treatment plan to cover all of the intervening concerns. We must persist in following the patient in the clinic to make sure that the plan is completed and that complications that arise are dealt with efficiently. This can lead to considerable satisfaction and frustration. There remain many unanswered questions in the evaluation of pain patients and of pain itself. How accurate is physical examination in providing information about a given patient that is relevant to treating pain? Can physical examination reliably elicit a nociceptive focus for a specific individual's chronic pain experience? Is all long-term pain a smorgasbord of nociceptive, central sensitization, and neuromodulatory mechanisms? Can acute pain be more consistently aborted to minimize the development of chronic pain? Over the next few years, as our expanding knowledge of neuropharmacology, neurophysiology, and pain modulation in the CNS combines with better understanding of pain psychology and sociology, we clinicians will expect to have happier and more productive patients.

Pain in Patient Groups Frequently Treated by Physiatrists

This article highlights the significant prevalence and impact of pain in persons who have disabilities and points to the need for additional research in this area. Theory-driven research examining biopsychosocial models of and treatments for chronic pain are the important next steps in this area. The extensive literature on persons in whom pain is the primary disability provides a useful basis for such research. Pain may be one of several problems facing rehabilitation professionals in their care of persons with disabilities. Nonetheless, given the suffering associated with it, pain warrants careful assessment and, as indicated, intervention.

Self-Efficacy for Managing Pain Is Associated With Disability, Depression, and Pain Coping Among Retirement Community Residents With Chronic Pain

Little is known about cognitive and behavioral factors that influence older adults' adjustment to chronic pain. The objective of this study was to investigate the relationship of self-efficacy for managing pain to reports of pain intensity, pain-related disability, depressive symptoms, and pain coping strategy use among 140 retirement community residents (88% female; age mean = 81.7, range 66-99 years) with chronic pain. The 8-item Arthritis Self-Efficacy Scale, modified to specify pain rather than arthritis, demonstrated good psychometric characteristics (Cronbach alpha = .89, minimal floor and ceiling effects, and validity) in this sample. Controlling for age, gender, and pain intensity, self-efficacy was associated significantly and negatively with pain-related disability and depressive symptoms (P values < .001), and positively with use of pain coping strategies previously found to be associated with better outcomes (task persistence, exercise/stretch, coping self-statements, activity pacing; P values < .05). Self-efficacy for managing pain appears to be important in the adjustment of older adults with pain. Research is needed to determine whether interventions designed to increase self-efficacy improve quality of life and prevent functional declines in this population.

PERSPECTIVE

Among retirement community residents (mean age of 82 years) with chronic pain, higher self-efficacy for managing pain is associated with less disability and depression and with the use of pain coping strategies related to better adjustment. This suggests the potential value of interventions to increase self-efficacy in this population.

Electrical spinal cord stimulation in the long-term treatment of chronic painful diabetic neuropathy

AIMS

Electrical spinal cord stimulation (ESCS) is a technique for the management of chronic painful diabetic neuropathy (CPDN) affecting the lower limbs. We assessed the efficacy and complication rate of ESCS implanted at least 7 years previously in eight patients.

METHODS

After a trial period of percutaneous stimulation, eight male patients had been implanted with a permanent system. Mean age at implantation was 53.5 years and all patients were insulin treated with stage 3 severe disabling CPDN of at least 1 year's duration. The ESCS was removed from one patient at 4 months because of system failure and one patient died 2 months after implantation from a myocardial infarction.

RESULTS

Six patients were reviewed a mean of 3.3 years post-implantation. With the stimulator off, McGill pain questionnaire (MPQ) scores (a measure of the quality and severity of pain) were similar to MPQ scores prior to ESCS insertion. Pain scores (visual analogue scale) were measured with the stimulator off and on, respectively: background pain [74.5 (63-79) mm vs. 25 (17-33) mm, median (interquartile range), P = 0.03), peak pain (85 (80-92) mm vs. 19 (11-47) mm, P = 0.03]. There were two further cardiovascular deaths (these patients had continued pain relief) and the four surviving patients were reassessed at 7.5 (range 7-8.5) years: background pain [73 (65-77) mm vs. 33 (28-36) mm, median (interquartile range)], peak pain [86 (81-94) mm vs. 42 (31-53) mm]. Late complications (> 6 months post-insertion) occurred in two patients; electrode damage secondary to trauma requiring replacement (n = 1), and skin peeling under the transmitter site (n = 1). One patient had a second electrode implanted in the cervical region which relieved typical neuropathic hand pains.

CONCLUSIONS

ESCS can continue to provide significant pain relief over a prolonged period of time with little associated morbidity.

[Chronic pain and rehabilitation]

The perception and interpretation of pain is the end point of an interaction of cognitive, cultural, and environmental factors and this complex interaction effects the pain response and quality of life of each person which shows that pain perception and the verbal and behavioral response shows variations and is specific for each patient. Chronic pain can be due to Fibromyalgia Syndrome (FMS) and Neuropathic Pain (NP) where the underlying pathophysiologic mechanisms are being revealed or it can be chronic low back pain (CLBP) where pain persists in spite of healing of tissue and no underlying pathologic mechanism can be defected. Central sensitization, inhibition of descending pain inhibitory systems, functional changes in autonomic nervous system amd neurotransmitter as well as changes in stress response system are factors contributing to the initiation and maintenance of pain and cognitive, behavioral factors are also important contributors in chronic pain. Biopsychosocial and biomedical mechanisms should be assessed in the rehabilitation interventions. The aims of rehabilitation in chronic pain are to increase activity tolerance, functional capacity and to decrease socio-economic loads. The targets of activity should be physical, functional and social. Psychologic based programs as cognitive-behavioral techniques and operant conditioning are also valid procedures in rehabilitation of chronic pain patients. Rehabilitation should be multidisciplinary and of long-term targeted to valid out-come for success.

Effectiveness and cost-effectiveness of comprehensive rehabilitation programs

Comprehensive rehabilitation involving multidisciplinary involvement of healthcare professionals is available to patients with rheumatic diseases. Studies were reviewed on the effectiveness of such programs for patients with chronic low back pain, widespread pain, and rheumatoid arthritis. When effects on the various outcome measures are demonstrated, improvements can only with difficulty be attributed to a specific component of a comprehensive program. Economic analyses for the effectiveness of comprehensive programs are scarce, but are needed by policy makers to allow optimal allocation of resources. Preferably the overall performance of comprehensive rehabilitation programs, not the individual components, should be evaluated.

Auriculotherapy stimulation for neuro-rehabilitation

The capability of reflex points on the external ear to alter neuromuscular and neuropathic disorders has been attributed to the descending pain inhibitory pathways of the central nervous system. The inverted fetus perspective of the somatotopic arrangement of auricular acupuncture points was first described in the 1950's by Dr. Paul Nogier of France, and has received scientific support from double blind studies examining auricular diagnosis of musculoskeletal and of coronary disorders. Acupuncture points on the ear and on the body have lower levels of electrical skin resistance than surrounding tissue. These electrodermal differences are apparently related to autonomic control of blood vessels rather than increased sweat gland activity. The heightened tenderness of reactive acupuncture points may be explained by the accumulation of noxious, subdermal substances. Electrical stimulation of specific points on the external ear leads to site specific neural responses in different regions of the brain. Behavioral analgesia produced by auricular acupuncture can be blocked by the opiate antagonist naloxone, indicating the role of endorphinergic systems in understanding the underlying mechanisms of auriculotherapy. The anatomical structures and electrical application of the auricle are described as they relate to the localization of master points, musculoskeletal points, internal organ points, and neuroendocrine points.

Physical disability and the experience of chronic pain

OBJECTIVES

To obtain an insider's view about disability-related pain to help rehabilitation clinicians understand the experience and to show how people with disability manage daily living and encounters with other people.

DESIGN

Qualitative methods by using open-ended interviews and thematic analysis.

SETTING

Rehabilitation research program.

PARTICIPANTS

Nine adults with chronic physical disability and pain were recruited from study groups. The 9 included people with spinal cord injury, acquired amputation, or cerebral palsy.

INTERVENTION

Interview protocol.

MAIN OUTCOME MEASURE

Phenomenologic analysis of interviews based on codewords derived from interview topics and themes.

RESULTS

Study participants described pain as a part of daily living that influenced many lifestyle decisions. They characterized pain as plural, meaning that it has multiple locations, distinctive descriptions, and different implications. They also were concerned about pain being a mystery, having unclear causes and consequences. Typically they described pain as a personal venture, with little or dissatisfying communication about pain with family, friends, or health care providers.

CONCLUSIONS

Understanding pain associated with physical disability can help guide rehabilitation practitioners in their pain assessments, interventions, and related research. Our findings suggest that some people with disability-related pain may benefit from reassurance and specific planning for expected and unexpected pain episodes.

Analysis of pain behavior profiles and functional disability in outpatient physical therapy clinics

STUDY DESIGN

Descriptive, ex post facto.

OBJECTIVES

To determine the proportion of physical therapy outpatients with pain who exhibit various pain behavior profiles, and to determine whether there are differences in functional disability across the profiles.

BACKGROUND

Physical therapists treat many patients who have chronic pain. Research suggests that early identification and multidisciplinary treatment are effective and economical for these patients. The Multidimensional Pain Inventory (MPI) and the Pain Disability Index (PDI) are potential screening tools that could be used in physical therapy clinics to determine which patients should be referred for multidisciplinary treatment.

METHODS AND MEASURES

MPI and PDI data were gathered on 57 physical therapy outpatients (mean age 44.3 +/- 14.5 years, 22 men and 35 women) with pain of 3 or more months duration. ANOVA was used to analyze differences in mean PDI scores across the MPI profiles.

RESULTS

Of all patients, 42.1% fit the Adaptive Coper profile, 29.8% fit the Interpersonally Distressed profile, and 28.1% fit the Dysfunctional profile. There were significant differences in PDI scores among profile groups. Post hoc analysis showed that the PDI scores of the Adaptive Coper and Interpersonally Distressed groups were different from the Dysfunctional group, but that there was no difference between the Adaptive Coper and Interpersonally Distressed groups.

CONCLUSIONS

Many patients in outpatient physical therapy settings exhibit behavioral, affective, and cognitive characteristics associated with chronic pain. Thirty-three patients (57.9%) had MPI profiles (interpersonally distressed and dysfunctional) that suggest they might benefit from multidisciplinary treatment.

Outcomes of pain center treatment in Washington State workers' compensation

BACKGROUND

Injured workers with chronic pain who have failed conventional therapies often receive treatment at pain centers. This study evaluated the effect of pain center treatment on time loss status of Washington State injured workers. The primary hypothesis was that treatment at a pain center would lead to a reduction in the probability of a worker's receiving time loss benefits at a 2-year follow-up.

METHODS

A population-based retrospective cohort study was performed on 2,032 Washington State workers' compensation patients who underwent pain center evaluations. Subjects who received pain center treatment were compared to those who were evaluated but not treated with respect to time loss status at 2-year follow-up.

RESULTS

Univariate analysis revealed that at 2-year follow-up, 35% of treated subjects were receiving time loss payments vs. 40% of evaluated only subjects (P < 0.05). Subjects who were younger, female, and less chronic were more likely to undergo pain center treatment and were less likely to be on time loss at 2-year follow-up. In multivariate analyses, which statistically controlled baseline differences between the two groups, there was no difference between treated subjects and evaluated only subjects.

CONCLUSIONS

There was no evidence that pain center treatment alters 2-year time loss status of already disabled workers.

Management of chronic pain and control of long-term disability

Chronic pain has become a major public health problem. Often, the availability of entitlement programs as well as psychosocial, occupational, and other nonmedical factors-rather than objective pathophysiology-are major contributors to disability. In this chapter, the authors discuss the relationship between impairment and disability and detail factors likely to predict or contribute to adverse clinical outcome and disability. Guidelines for disability prevention also are examined.

Injury threshold: whiplash-associated disorders

OBJECTIVES

To review current knowledge and recent concepts of the causes of injuries after minor impact automobile collisions and to acquaint those who treat these types of injuries with possible injury thresholds and mechanisms that may contribute to symptoms.

DATA SOURCES

A review of literature involving mechanisms of injury, tissue tensile threshold, and neurologic considerations was undertaken. A hand-search of relevant engineering, medical/chiropractic, and computer Index Medicus sources in disciplines that cover the variety of symptoms was gathered.

RESULTS

Soft-tissue injuries are difficult to diagnose or quantify. There is not one specific injury mechanism or threshold of injury. With physical variations of tissue tensile strength, anatomic differences, and neurophysiologic considerations, such threshold designation is not possible.

CONCLUSIONS

To make a competent assessment of injury, it is important to evaluate each patient individually. The same collision may cause injury to some individuals and leave others unaffected. With the variability of human postures, tensile strength of the ligaments between individuals, body positions in the vehicle, collagen fibers in the same specimen segment, the amount of muscle activation and inhibition of muscles, the size of the spinal canals, and the excitability of the nervous system, one specific threshold is not possible. How individuals react to a stimulus varies widely, and it is evident peripheral stimulation has effects on the central nervous system. It is also clear that the somatosensory system of the neck, in addition to signaling nociception, may influence the control of neck, eyes, limbs, respiratory muscles, and some preganglionic sympathetic nerves.

Analgesics. Opioids, adjuvants, and others

The purpose of this article is to summarize the main categories of pain-relieving medications. The authors review a number of analgesic preparations and treatments, with special emphasis on advantages, precautions, limitations, and various routes of administration.

Antidepressants in rehabilitation

Antidepressant medications have a variety of uses in addition to the treatment of depression. This article focuses on the two most widely used categories of antidepressants, tricyclic antidepressants (TCAs) and the newer selective serotonin reuptake inhibitors (SSRIs), and highlights their use in post-stroke depression and chronic pain.

A survey of pain during rehabilitation after acute spinal cord injury

There has been little research on pain in the acute phase of spinal cord injury (SCI) rehabilitation. This study surveyed the pain experience and management strategies in such patients. The subjects consisted of inpatients who were undergoing rehabilitation following their acute injury, and were assessed regarding the presence and type of any pain upon admission to the rehabilitation ward, and reviewed weekly during their stay. They were reassessed on reporting any new pain. Pain intensity was recorded on a Visual Analogue Scale. The maximum intensity of pain during admission was compared to that at discharge. All interventions directed at pain management were documented. Patients were reviewed one year after discharge regarding current pain experience. Almost all of the patients (n = 23; 96%) experienced pain at some stage during their inpatient rehabilitation. Overall pain intensity for those patients with pain during inpatient admission decreased by the time of discharge. At the one year review however, pain intensity tended towards that seen on admission. The reasons for pain tending to increase after discharge were not apparent. Neuropathic and Myofascial Pain Syndrome (MPS) were the most common types of pain experienced. A combination of pharmacological, interventional, physical and psychological approaches were used in pain management. At one year review, neuropathic pain remained common while MPS and orthopaedic pain had decreased. Pain is a common and significant problem for many SCI patients and is a challenge for the treating team to manage.

Management of pain in brachial plexus lesions

Pain in avulsion lesions of the brachial plexus represents the most significant impediment to rehabilitation. The mechanism by which pain is felt is not widely understood. This paper demonstrates, how, with careful management, use of TENS can play a vital role in relief of pain and ultimate rehabilitation.

Pain profile of patients with low back pain referred to physical therapy

Detailed pain descriptions for patients with low back pain referred to physical therapy have not been adequately summarized in the literature. The purpose of this study was to present a detailed pain characteristic profile for patients who were referred to physical therapy for treatment of low back pain. One hundred patients (52 males and 48 females) completed portions of the McGill Pain Questionnaire and were interviewed to obtain additional descriptions of pain using a comprehensive pain questionnaire developed for this study. The scores on the McGill Pain Questionnaire demonstrated variability from those previously reported in other populations of patients with low back pain. The comprehensive pain questionnaire revealed that the most intense pain was distributed across the waking hours. Seventy-seven of the 98 subjects (79%) noted that lifting and forward flexed postures increased the pain intensity. In contrast, only 27 of 98 subjects (28%) reported an increase in symptoms with backward bending. Seventy-four of the 98 subjects reported that sitting made their pain worse, and 17 of 84 subjects (20%) reported that sitting resulted in their worst pain. Fifty-nine of 84 subjects stated a recumbent position was the most effective means of relieving the pain. Fifty-two subjects (53%) reported that they experienced pain severe enough to wake them from sleep (night pain). Only three of these patients (6%) stated they were unable to fall back asleep once they were awakened. It was concluded that the detailed pain profile was consistent with symptoms associated with activity-related spinal disorders.

Pain in arthritis and musculoskeletal disorders: the role of coping skills training and exercise interventions

There is growing recognition of the limitations of conventional, biomedical approaches to the management of pain in individuals having arthritis and musculoskeletal disorders. This article provides an overview of newly developed biopsychosocial approaches to the management of pain in this population. The presentation is divided into three sections. In the first section, a biopsychosocial model of pain is presented. This model highlights the role that biological factors (eg., disease severity, comorbid conditions), cognitive-behavioral factors (eg., thoughts, emotions, and behaviors), and environmental factors (eg., spouse or family responses to pain behavior) can play in influencing the pain experience. In the second section, we provide an overview of two newly developed treatment protocols based on the biopsychosocial model of pain: a pain coping skills training protocol and an exercise training protocol. Practical aspects of implementing these protocols are illustrated by highlighting how they are applied in the management of patients having persistent osteoarthritic pain. In the final section of the article, we pinpoint several important future directions for research in this area. Future studies need to explore the utility of combining pain coping skills and exercise training protocols. In addition, there is a need to identify variables that predict patients' response to biopsychosocial treatments.

Physical limitations are not required for chronic pain rehabilitation success

A high performance, active duty fitness requirement group rehabilitated equally to a low performance needs civilian group, both suffering from disabling chronic pain. The purpose of this prospective study was to determine whether higher physical performance requirements adversely affected outcome in a chronic pain rehabilitation program. Twenty-three active duty, chronic pain patients were treated along with 22 civilian chronic pain sufferers in a behavior modification, including positive, verbal reinforcement for performance, stress management and family counseling, physical reconditioning, including stretching, strengthening and aerobic conditioning in a slowly progressive fashion to required needs, and narcotic and muscle relaxant detoxification program at a major military medical center. Eighteen patients in each group, representing, respectively, 78 and 82% of the military and civilian participants, successfully completed the inpatient program. Success was defined by (1) elimination of all narcotics and minor tranquilizers, (2) elimination of all physical restrictions that precluded any desired work or play, which required much higher levels for the active duty patients that included: (3) elimination of all physical profile restrictions and (4) objectively passing annual aerobics field test requirements before the program's end. Review of military disability separation records, averaging 24 mo posttreatment, showed that no formerly successful active duty patients had later been discharged because of physical impairments. Of individuals responding to mail questionnaires at an average of 19 mo postprogram, 12 of 14 (86%) initially successful military patients reported continued unrestricted maintenance of physical abilities, whereas 10 of 14 (71%) of the initially successful civilians reported no restrictions in desired activities.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of a chemically dependent patient with a thalamic pain syndrome treated with amitriptyline

A fifty year old white male with a right sided thalamic pain syndrome became alcohol and benzodiazepine dependent in an attempt to alleviate the pain. He entered an inpatient alcohol and drug treatment facility where, in an attempt to treat this pain, he was placed on low dose amitriptyline. Comparison of results on a symptoms checklist (SCL-90-R) completed at amitriptyline dosages of 30 mg. and 50 mg. showed a statistically significant difference in the somatization scale (p = .029). The low dose of amitriptyline used, its low blood level, and the early onset of effect make it unlikely that its antidepressant action was a significant factor in this patient's pain relief. This is, perhaps, the first described case where low dose amitriptyline has been shown to relieve the thalamic pain syndrome in a chemically dependent person.

Chronic pain. Sizing up the team approach

Chronic pan management is still an evolving field, one with high fees and debatable results. It's open to a variety of practitioners, but pain specialists concerned about accountability, reimbursement, and their own survival are developing needed standards for treatment and outcome measurement.

Pain clinics: reassessment of objectives and outcomes

A review of published reports on pain clinic programs was done in order to demonstrate the limitations of treatment goals which do not encompass the biologic, psychologic, and social aspects of pain rehabilitation. The reason for these limitations can be attributed to several factors, an important one being the lack of attention given to the patient's social situation. Since chronic pain is truly a biopsychosocial syndrome, it is recommended that treatment objectives include restoration of social functioning of the patient as much as pain relief or control of pain behavior.

Principles of rehabilitation medicine as applied to lesions of the peripheral nerves

The increase in the knowledge of pain mechanisms has contributed to a wide variety of modalities available to treat this sensory disability. More recent experience has shown that an intensive multidisciplinary approach gives better success rates. Further involvement of physicians, surgeons and basic scientists in the study of pain can only lead to mutual benefit.

An instrument to measure nurses' knowledge of behavioral methods with chronic pain patients

A 32-item multiple-choice questionnaire is described to assess nurses' knowledge of behavioral methods with chronic pain patients. The instrument was designed to assess knowledge across four areas: (a) behavioral principles, terms, and facts about pain patients, (b) application of behavioral methods to decrease negative pain behavior, (c) application of behavioral methods to increase positive well behavior, and (d) when, and with which pain patients to apply behavioral methods. Factor analyses identified two basic factors measured by the instrument. These included general knowledge of behavioral methods with chronic pain patients and the ability to differentially apply these methods in various medical circumstances. Further analysis revealed that the instrument contained adequate internal consistency, reliability and validity.

The effects of detoxification, relaxation, and brief supportive therapy on chronic pain

Seven chronic pain patients (six with abdominal pain and one with headache pain) were detoxified from analgesic medications, taught relaxation techniques, and given an average of 3 supportive therapy sessions. The effects of these procedures at posttreatment and at 6 months follow-up were analyzed by means of self-report diaries of pain, mood, activity and medication usage. There was a significant reduction in pain from posthospital in 5 of 7 patients and a significant reduction in pain at 6-month follow-up for all patients. There was a significant reduction in medication use for all subjects. Mood ratings tended to improve when pain was reduced, and some patients reported increased activity levels. Detoxification combined with relaxation and supportive therapy appears to produce significant relief from pain for these 7 patients.

Treatment of chronic pain in the general psychiatric hospital

Patients with chronic pain present many diagnostic and therapeutic challenges to primary physicians and psychiatric consultants. The authors present a series of twelve patients with chronic pain who were hospitalized on the psychiatric ward of a general hospital. Ten of the twelve patients presented decreased their medication use and were markedly improved at the end of their brief stay. Treatment goals, attitudes and interventions are discussed.