The role of pain behaviors in the modulation of marital conflict in chronic pain couples.

Sixty-one married male chronic benign back patients and their spouses were recruited in order to examine the relationship between marital conflict/stress and patient pain behaviors. The results suggest that marital conflict in pain couples is associated with increases in subsequent display of pain behaviors which, in turn, are associated with greater negative affective responses and more punitive behaviors by the spouse. A positive association was found between punitive spouse behaviors and patient physical and psychosocial impairment. The findings are discussed in terms of their clinical implications and the need for further experimental study of these relationships.

The clinical significance of behavioral treatment for chronic low back pain: an evaluation of effectiveness.

The clinical effectiveness of behavioral treatment for chronic low back pain (CLBP) was evaluated using an empirical strategy to quantify individual patient change. Patients with CLBP (n = 17) presenting to an outpatient pain clinic were evaluated at baseline and six months posttreatment on variables of pain, disability and distress. Similar patients receiving usual medical care (n = 17) were evaluated on the same outcome measures and time line for purposes of descriptive comparison. Validated and widely-used measures of pain (McGill Pain Questionnaire), disability (Sickness Impact Profile), and depression (Beck Depression Inventory) served as outcome measures. Forty-seven percent of patients receiving behavioral treatment evidenced clinically significant improvement in at least one of the dimensions of pain, disability and depression associated with CLBP. However, clinically significant improvement across all three measures was rare. These findings are discussed in terms of the viability of behavioral treatment for CLBP, the need to enhance the degree of clinically significant outcome associated with behavioral treatments, and the value of empirical evaluation of clinically significant improvement following treatment interventions.

Effects of noradrenergic and serotonergic antidepressants on chronic low back pain intensity.

To understand the relative efficacy of noradrenergic and serotonergic antidepressants as analgesics in chronic back pain without depression, we conducted a randomized, double-blind, placebo-control head-to-head comparison of maprotiline (a norepinephrine reuptake blocker) and paroxetine (a serotonin reuptake blocker) in 103 patients with chronic low back pain. Of these 74 completed the trial; of the 29 who did not complete, 19 were withdrawn because of adverse effects. The intervention consisted of an 8-week course of maprotiline (up to 150 mg daily) or paroxetine (up to 30 mg daily) or an active placebo, diphenhydramine hydrochloride (up to 37.5 mg daily). Patients were excluded for current major depression. Reduction in pain intensity (Descriptor Differential Scale scores) was significantly greater for study completers randomized to maprotiline compared to placebo (P=0.023), and to paroxetine (P=0.013), with a reduction of pain by 45% compared to 27% on placebo and 26% on paroxetine. These results suggest that at standard dosages noradrenergic agents may provide more effective analgesia in back pain than do selective serotonergic reuptake inhibitors.

Negative and positive cognition in depressed and nondepressed chronic-pain patients.

Several studies have suggested that depressed pain patients evidence more cognitive distortion than nondepressed pain patients and healthy controls. Although these studies have generally supported notions relating cognitive distortion to depressive functioning, other aspects of dysfunctional cognition have not been assessed in the chronic-pain population. The present study examined negative and positive automatic thoughts and attributional style in depressed pain patients, nondepressed pain patients, and healthy controls. Depressed chronic-pain patients were found to exhibit significantly more negative automatic thoughts than nondepressed pain patients and healthy controls. Conversely, nondepressed chronic-pain patients reported significantly more positive automatic thoughts than did depressed patients and healthy controls. No significant differences were found for attributional style. These results suggest that different cognitive-behavioral interventions might be considered for depressed compared to nondepressed chronic-pain patients.

Transition to chronic pain in men with low back pain: predictive relationships among pain intensity, disability, and depressive symptoms.

Pain intensity, disability, and depressive symptoms are hallmarks of chronic pain conditions, but little is known about the relationships among these symptoms in the transition from acute to chronic pain. In this study, an inception cohort of men with low back pain (N = 78) was assessed at 2, 6, and 12 months after pain onset. At 6 months, pain intensity, disability, and depressive symptoms were predicted only by their respective levels at 2 months after pain onset. At 12 months, pain intensity and depressive symptoms were predicted by heightened disability at 6 months after pain onset; 12-month depressive symptoms also were predicted by 2-month disability. Pain intensity was not predictive of changes in disability or depressive symptoms. These findings suggest that functional disability plays a more prominent role than pain intensity in the transition from acute to chronic pain. A "failure to adapt" conceptual model is presented to account for these results.

Interpersonal stress and pain behaviors in patients with chronic pain.

This study was designed to empirically evaluate the role of interpersonal stress in eliciting pain behavior. Thirty-four married male patients with chronic back pain (CBP) and their wives participated in a randomized between-groups study examining the effects of 2 interactional conditions (i.e., maritally focused stress interview and neutral talking control task) on subsequent persistence in a physically demanding task and with self-reports of pain. Results indicated that a significantly greater proportion of patients in the stress interview group terminated the physical activity task prematurely, compared with controls. The findings provide some of the first experimental support for the notion that uncomfortable interpersonal interactions may increase the likelihood of subsequent pain behavior in patients with CBP. Clinical implications and directions for future research are addressed.

Neurodevelopment of monitored versus nonmonitored very low birth weight infants: the importance of family influences.

Very low birth weight (VLBW) infants are at increased risk for neurodevelopmental delays. Follow-up programs have been instituted as one form of secondary prevention, to identify delays early and refer affected children to intervention. To examine the relationship between follow-up care and later development, 82 neonates who weighed 1500 g or less at birth were followed to 36 months of age. Effectiveness of care was assessed by neurodevelopmental status of 45 patients who participated and 37 patients who failed to participate in annual post-neonatal intensive care unit (NICU) monitoring service. At the outset, the groups had similar medical and socioeconomic status characteristics. However, by the third year of life, the monitored patients had a 14-point General Cognitive Index (GCI) advantage over the nonmonitored group. Examination of family process variables, family organization styles, and mother-child behaviors revealed significant differences between the groups, and suggested that monitored patients were raised in more normal, supportive home environments. Correlation and stepwise regression analyses indicated that mother-child behaviors and quality of the home environment were most predictive of 3-year intellectual development, with neonatal and biological measures adding to the predictive classification of neurosensory delays. It is suggested that an infant's medical record, mother-child behaviors, and overall quality of home environment be measured prior to hospital discharge, followed by home-based intervention where indicated.

Modification of mother-child interaction processes in families with children at-risk for mental retardation.

An intervention study designed to investigate the effects of maternal behavior on children's cognitive and language functioning was conducted with 40 disadvantaged preschool children at risk for mental retardation and 20 control children. Intervention was based in part upon Sigel's distancing theory, with 20 mothers encouraged to increase inductive, responsive, and complex behavior and the other 20, only inductive and responsive behavior. Results indicated that both procedures were effective in increasing targeted maternal and child behavior; control measures remained stable over sessions. Posttest results suggested that training procedures significantly increased treated children's cognitive skills compared to the control children; the treated children who were encouraged to increase the complexity of behavior outperformed the others. Training generalized to the home environment. Implications of the results for early intervention were discussed.

Survey: statewide family support programs.

Results of a survey of 23 state conducted family support programs are presented. Sixteen programs are legislatively mandated and the majority have a similar purpose: reduction of out-of-home placements. However, great variability exists on eligibility criteria, methods of program administration, amount of support, and types of services provided. Program evaluation data are reviewed indicating that cost-benefits, decreased rates of out-of-home placement, and effects on family enhancement are primary concerns of these programs. Implications for future program development based upon normalization philosophy and stress/coping theories are presented.

Established cell lines from different groups of vertebrates undergo metabolic cooperation with one another.

The prelabeled-donor technique was used to study metabolic cooperation in the established cell lines, RTG-2, FHM, and IgH-2, which are respectively from rainbow trout, fathead minnow, and green iguana. The donors were grown with [3H]hypoxanthine for 3 h after which the radioactive medium was removed and the recipients, marked by the presence of latex beads, were added. Cells from each of these lines were capable of cooperating with themselves and with one another because after 5.5 h the recipients in contact with donors were more significantly labeled than those that were not in contact. Cells FHM and IgH-2 were grown with HGPRT-Chinese hamster fibroblasts, CHW-1102, in the presence of [3H]hypoxanthine. In all cases the CHW-1102 cells that were in contact with the nonmammalian cells were more heavily labeled than those that were not in contact. Thus cells from a fish and a reptile undergo metabolic cooperation with cells from a mammal.

The clinician rating of adult communication (CRAC): a clinician's guide to the assessment of interpersonal communication skill.

This paper reports the results of an initial investigation of the psychometric properties of a new clinical marital communication assessment instrument, the Clinician Rating of Adult Communication (CRAC). The sample consisted of 36 marital communication samples from both maritally satisfied and distressed couples. Reliability results indicated that the CRAC demonstrated high levels of internal consistency, test-retest reliability, and interrater agreement. Support for the validity of the CRAC was found in its correspondence with a marital interaction coding system, its relationship to ratings of marital satisfaction, and its concordance with couples' perceptions of their conflict management behavior. Overall, these findings support the conclusion that the CRAC may provide a useful addition to the measurement armamentarium of the marital clinician and researcher.

Somatization symptoms in chronic low back pain patients.

Chronic low back pain (CLBP) patients often are described as "somatizers", who report multiple somatic complaints beyond back pain itself, but the nature and clinical significance of this observation is poorly understood. To clarify the characteristics, correlates and severity of somatization in CLBP, we rigorously assessed somatization symptoms in a sample of patients not selected for psychiatric or pain clinic referral. Male CLBP patients (N = 97), attending a primary care orthopaedic clinic, and matched healthy controls (N = 49), were assessed using the Diagnostic Interview Schedule III-A (DIS), Beck Depression Inventory (BDI), Hamilton Rating Scale for Depression (HRSD), McGill Pain Questionnaire (MPQ), Sickness Impact Profile (SIP), and the Pain and Impairment Relationship Scale (PAIRS). Although none of the subjects met strict DSM-III criteria for a lifetime diagnosis of Somatization Disorder, 25.8% of CLBP patients reported a lifetime history of 12 or more somatic symptoms, as compared to only 4.1% of controls. In the less symptomatic ranges, patients still generally reported more symptoms than controls, with 51.5% of patients vs. 8.2% of controls reporting 7-11 symptoms, and 22.7% vs. 87.8% of controls reporting 0-6 symptoms (p < .001). Major depression and alcohol dependence were significantly associated with increased severity of somatization (p < .05). Lower mood and increased impairment, but not pain intensity, were related to greater number of somatic complaints. Symptoms of somatization are prevalent, but not universal, in CLBP and the pattern of these symptoms is reminiscent of the "spectrum of severity" reported in other medical populations. Recognizing this spectrum of somatization may lead to better patient-treatment matching and improved clinical outcomes.

The contribution of job satisfaction to the transition from acute to chronic low back pain.

OBJECTIVE: To determine the extent to which job satisfaction predicts pain, psychological distress, and disability 6 months after an initial episode of low back pain (LBP). DESIGN: A longitudinal design was used to follow an inception cohort experiencing first-episode low back pain with assessment at 2 and 6 months after pain onset. SETTING: Urban medical center outpatient orthopedic clinic. PATIENTS: The consecutive sample was comprised of 82 men with initial-onset acute LBP (T6 or below, daily pain for 6 to 10 weeks). INTERVENTION: Usual orthopedic care. MAIN OUTCOME MEASURES: The primary study outcomes were pain (Descriptor Differential Scale, Visual Analog Scales); disability (Sickness Impact Profile, Quality of Well-Being); and psychological distress (Beck Depression Inventory, Hamilton Rating Scale for Depression, Automatic Thoughts Questionnaire); predictor variables were orthopedic impairment (Waddell Physical Impairment Index) and job satisfaction (Job Descriptive Index, Work APGAR). RESULTS: Measures of job satisfaction, pain, disability, and psychological distress at baseline and 6 months after pain onset were separately reduced into factors using principle components factor analysis. In hierarchical multiple regression analyses, baseline job satisfaction significantly predicted variance in outcome scores at 6 months after pain onset, beyond the variance explained by control factors (demographics; baseline pain, mood, and disability; orthopedic impairment). Zero-order correlations between job satisfaction and orthopedic impairment were small and nonsignificant, suggesting that these two variables act independently in predicting outcome. Although type of work performed (desk work or work requiring light, moderate, or heavy lifting) and social position were correlated with job satisfaction at baseline, neither contributed to the prediction of outcome at 6 months. CONCLUSIONS: Satisfaction with one's job may protect against development of chronic pain and disability after acute onset back pain and, alternatively, dissatisfaction may heighten risk of chronicity. Vocational factors should be considered in the rehabilitation of acute back injury.