Refractory Chronic Pain and Obesity: Promising Implications for Multidisciplinary Pain Rehabilitation.

OBJECTIVE: Individuals with obesity frequently contend with chronic pain, but few studies address the clinical impact of coordinated pain services on this population. The current study addresses this topic by comparing the effectiveness of a comprehensive pain rehabilitation program for patients with and without obesity. METHODS: A retrospective analysis of registry data was conducted. Obesity was considered as one of three weight groups, based on the following body mass index cutoffs: normal weight (18.5 to < 25 kg/m2), overweight (25 to < 30 kg/m2), and obese (> 30 kg/m2). These groups were compared on the Pain Severity Ratings (PSR) Scale, the Pain Disability Index (PDI), and the Depression, Anxiety, Stress Scales-Short Form (DASS-SF). RESULTS: Groups differed on baseline pain disability and depression. Patients with obesity had higher scores on both the PDI (P = .028) and the DASS-SF depression subscale (P = .006). Contrary to the hypothesis, after controlling for baseline score and sex there were no significant differences between weight groups with regards to PSR, PDI, or any DASS-SF subscale at discharge. At 1-year follow-up, individuals who were overweight and obese had significantly more anxiety compared to individuals whose weight was in the normal range. CONCLUSIONS: Multidisciplinary pain rehabilitation programs appear to be an effective treatment intervention for patients who have concomitant chronic pain and obesity, to a degree comparable to patients who have chronic pain but do not contend with obesity. Implications for program development, clinical interventions, and future research are discussed.

A Prospective Cohort Study of Outpatient Interdisciplinary Rehabilitation of Chronic Headache Patients.

OBJECTIVE: To evaluate the efficacy of an intensive outpatient program designed to improve functioning and reduce psychological impairment in chronic headache patients. BACKGROUND: Chronic headaches, occurring 15 or more days per month, for three or more months, may arise from multiple International Classification of Headache Disorders diagnoses: Chronic Migraine, Chronic Tension Type Headache, New Daily Persistent Headache, Chronic Post Traumatic Headaches, and Medication Overuse Headache. Several interdisciplinary programs that treat patients with chronic headaches have reported decreases in headache frequency. This study sought to evaluate the effect of a 3 week interdisciplinary treatment program for patients with chronic headache disorders on headache severity, functional status, and psychological impairment. METHODS: Subjects were 379 patients admitted to an outpatient chronic headache treatment program. Assessments of headache severity, psychological status, and functional impairment were completed by 371 (97.8%) of these at the time of admission. At discharge, 340 subjects (89.7%) provided assessment data, and 152 (40.1%) provided data at 1-year follow-up. RESULTS: Subjects' mean ratings on a 0-10 scale for their headache pain in the prior week declined, and these improvements were maintained at follow-up. (Estimated marginal means on a 0-10 scale for Average pain: admission 6.1, discharge 3.5, follow-up 3.3; for Least pain: admission 3.2; discharge 1.5; follow-up 1.3; for Worst pain: admission 8.2; discharge 6.4; follow-up 5.7), and similar results were found for current pain (admission 4.7; discharge 2.8; follow-up 2.4): Measures of functional impairment also improved following treatment, and these gains were maintained at 12 month follow up (Estimated marginal mean Headache Impact Test-6 score: admission 66.1, discharge 55.4, follow-up 51.9; Estimated marginal mean Pain Disability Index score: admission 36.2, discharge 14.1, follow-up 11.6). As measured by the Depression, Anxiety and Stress Scale, anxiety and reactivity to stress decreased following treatment, and remained improved at follow-up (Estimated marginal mean score for Anxiety: admission 8.7, discharge 5.2, follow-up 4.4; Estimated marginal mean score for stress: admission 14.9, discharge 7.2, follow-up 7.6). Depression decreased with treatment, but while 1-year follow-up depression scores remained significantly lower than at admission, they were also significantly higher than at discharge (Estimated marginal means: admission 13.3, discharge 4.1, follow-up 6.6). CONCLUSIONS: The study supports the efficacy of the treatment model. Limitations of the study and suggestions for future research are also discussed.

Spiritual Struggle Among Patients Seeking Treatment for Chronic Headaches: Anger and Protest Behaviors Toward God.

This study examined anger and protest behaviors toward God among 80 US adults seeking treatment for chronic headaches (66 women, 14 men; 71 completed treatment). Measures were administered before and after an intensive 3-week outpatient treatment program. At both times, anger and protest toward God correlated with lower pain acceptance, more emotional distress, and greater perceived disability. However, when considered simultaneously, anger predicted sustained distress, whereas protest behaviors (e.g., complaining, questioning, arguing) predicted both reduced distress and an increased sense of meaning. These findings suggest the utility of distinguishing between anger toward God and behaviors suggesting assertiveness toward God.

Adherence to acute migraine medication: what does it mean, why does it matter?

Proper use of medications is an important part of successfully managing migraine headache, yet migraineurs frequently switch, discontinue, or delay taking effective prescription therapies such as triptans. Medication persistence in the treatment of chronic-episodic disorders such as migraine is not well understood. In this article we review this topic, by critically reviewing studies conducted using pharmacy claims, clinical records, survey, and patient-reported data to explore acute medication use for migraine headache. While efficacy, cost, drug tolerability, and side effects impact whether a patient takes migraine medication, low perceived disease importance and factors related to the patient's internal decision-making process play a strong role in the sustained use of acute medication for migraine attack. We propose a model that combines the patient's perceived severity of migraine, their beliefs regarding the safety of acute medications, and factors related to the physician-patient relationship to identify migraineurs at high risk for medication adherence problems.

A rating system for use with patient pain drawings.

Patients entering treatment for chronic benign pain often are asked to complete drawings indicating the intensity and location of their pain as part of the diagnostic process. While inferences have been made from pain drawings about the relative contributions of physiological and psychological factors to the patient's experience of pain, previous research has provided only equivocal support for this practice. A reliable method for assessing pain drawings is needed both for clinical use and to assess the validity of such interpretations. While a number of systems for using such drawings have been proposed, it is not always clear exactly what aspect of the drawing is being quantified. In this study, 101 patients who presented with chronic pain were asked to complete pain drawings which were than scored for the presence or absence of pain in each of 45 body areas. Scorers achieved a high rate of inter-rater agreement with relatively little training. The body surface scores obtained were shown to correlate highly with the penalty point system developed by Ransford et al., suggesting that extent of pain may account for much of the variance in this system. The results are discussed in relation to the clinical and experimental uses for such a system.

Lateralization of chronic pain.

A number of recent articles have discussed the issue of laterality of chronic pain with inconclusive results. While some authors have found evidence for a preponderance of left-sided pain, others have failed to find such evidence. Unfortunately, none of the studies have clearly explained the rules used for deciding laterality. Consequently, considerable differences exist in the frequency of lateralized versus unlateralized patients in these studies, raising the question of whether variance in results reflects actual differences or different methodologies. In the current study, 101 chronic pain patients were asked to complete a drawing indicating the location and extent of their pain. These drawings were scored for the presence and absence of pain in each of 45 body areas, using a highly reliable rating system. The results suggest that laterality may be normally distributed. The findings are discussed in light of previous research, and suggestions are made for possible uses of the rating system.

Development of a neuropathic pain questionnaire.

Ongoing efforts to develop mechanisms-based assessment and treatment of chronic pain have been hindered by the lack of assessment tools differentially sensitive to various phenomena underlying different mechanisms of pain. This study describes the development of an assessment instrument intended to measure neuropathic pain based on qualities of pain as they are inferred from pain descriptors. Subjects were 528 chronic pain patients from several clinics. Of these, 149 had strictly neuropathic pain, while 233 had non-neuropathic pain. Subjects completed a 32 item preliminary questionnaire, which asked them to rate their usual pain on multiple descriptors, as well as the degree to which their pain differed in response to various internal and external factors. This preliminary questionnaire was submitted to factor analysis, and this yielded 6 factors. Representatives of each of these factors were combined with additional items that demonstrated significant differences between neuropathic and non-neuropathic pain groups, to yield a 12 item Neuropathic Pain Questionnaire (NPQ). These items were able to differentiate neuropathic pain patients from non-neuropathic pain patients in a holdout sample with 66.6% sensitivity and 74.4% specificity. The newly developed instrument, NPQ, may be used for the initial screening of neuropathic pain patients. It also has the ability to provide a quantitative measure for the descriptors important in the diagnosis and assessment of neuropathic pain. Consequently, it can be used for monitoring of neuropathic pain treatments and as an outcome measure.