Effects of instructions on physical capacities outcome in a workers' compensation setting.

UNLABELLED: Physical Capacity Evaluations (PCE) are often used in Pain Management Programs (PMP) to help determine patients' return-to-work status, continued rehabilitation and compensation. STUDY DESIGN: Groups of patients participating in a 4-week PMP were given the PCE upon entry to the program and again near discharge. Change in performance between the first and second testing was examined. OBJECTIVES: The study was designed to examine the effects of instructions on patients' performance on the PCE. SUMMARY OF BACKGROUND DATA: An extensive literature suggests that, although commonly used, the PCE is of questionable validity in measuring actual physical capacity. METHODS: Patients were assigned to one of 2 physical therapists and given a PCE (in this setting, a dynamic vs static strength test) on admission and near the time of discharge. The assessment by the 2 therapists differed in the instructions they gave their patients for the PCE. Both therapists told their groups, "Do the best you can," but only one therapist added, "This test will be used to determine your job classification." In the second half of the study both therapists gave identical instructions, "Do the best you can," and did not add the explanation. RESULTS: Patients who were informed that the test would be used to determine their job classifications performed considerably worse than those not so informed. When both therapists gave the same instructions, groups performed comparably, suggesting that therapist variables did not explain the differences between the groups. CONCLUSIONS: Instructions on the PCE have an effect on performance.

Anticonvulsants for neuropathic pain and detoxification.

It is now well demonstrated that several anticonvulsants have a role in the treatment of neuropathic pain and also in withdrawal from benzodiazepines, sedatives, and perhaps alcohol. Valproic acid, carbamazepine, gabapentin, clonazepam, and lamotrigine are appropriate treatments for neuropathic pain, effective to a degree dependent on the underlying pathophysiology. While less effective than newer agents, there are situations in which phenytoin remains useful. Currently, a limited understanding of both the processes responsible for pain and the specific effects of each agent prevents prediction of individual response to these drugs, often necessitating trials of several drugs before the best one is found. It is interesting that the anticonvulsant drugs most useful for neuropathic pain are the same ones effective in sedative withdrawal, bipolar disorder, and several anxiety disorders. Issues of neural hypersensitivity and kindling, therefore, may prove to be unifying concepts for these conditions.

Long-term results of peripheral nerve stimulation for reflex sympathetic dystrophy.

This prospective, consecutive series describes peripheral nerve stimulation (PNS) for treatment of severe reflex sympathetic dystrophy (RSD) or complex regional pain syndrome, in patients with symptoms entirely or mainly in the distribution of one major peripheral nerve. Plate-type electrodes were placed surgically on affected nerves and tested for 2 to 4 days. Programmable generators were implanted if 50% or more pain reduction and objective improvement in physical changes were achieved. Patients were followed for 2 to 4 years and a disinterested third-party interviewer performed final patient evaluations. Of 32 patients tested, 30 (94%) underwent permanent PNS placement. Long-term good or fair relief was experienced in 19 (63%) of 30 patients. In successfully treated patients, allodynic and spontaneous pain was reduced on a scale of 10 from 8.3 +/- 0.3 preimplantation to 3.5 +/- 0.4 (mean +/- standard error of the mean) at latest follow up (p<0.001). Changes in vasomotor tone and patient activity levels were markedly improved but motor weakness and trophic changes showed less improvement. Six (20%) of the 30 patients undergoing PNS placement returned to part-time or full-time work after being unemployed prestimulator implantation. Initial involvement of more than one major peripheral nerve correlated with a poor or no relief rating (p<0.01). Operative modifications that minimize technical complications are described. This study indicates that PNS can provide good relief for RSD that is limited to the distribution of one major nerve.

Long-term intraspinal infusions of opioids in the treatment of neuropathic pain.

Long-term intraspinal infusions of opioid drugs are being increasingly utilized in patients with noncancer pain. Despite this, there is a lack of long-term information, including success and failure rates for pain relief and technical problems. During a 5-year period, 18 noncancer patients underwent implantation of programmable infusion pumps for long-term intrathecal opioid infusion. Patients had (a) neuropathic pain, (b) had failed or been ineligible for noninvasive treatments, and (c) obtained greater than 50% pain relief with intrathecal trial infusions of morphine sulfate or sufentanil citrate. A disinterested third-party reviewer evaluated patients at the most recent follow-up. Sixty-one percent (11/18) of patients had good or fair pain relief with mean follow-up 2.4 +/- 0.3 years (0.8-4.7 years). Average numeric pain scores decreased by 39% +/- 4.3%. Five of the 11 responders required lower opioid doses (12-24 mg/day morphine) and the remaining six patients required higher opioid doses (> 34 mg/day morphine). Failure of long-term pain relief occurred in 39% (7/18) despite good pain relief in trial infusions and the use of both morphine and sufentanil. Technical problems developed in 6/18 patients but appeared to be preventable with further experience. Long-term intrathecal opioid infusions can be effective in treatment of neuropathic pain but might require higher infusion doses.

Spinal cord stimulation versus spinal infusion for low back and leg pain.

The relative roles of spinal cord stimulation and the spinal infusion of opioids in the treatment of chronic, non-cancer lower body pain remains unclear. This report contains a retrospective analysis of patients with chronic lower body, neuropathic pain and treated over a 5 year period. Unilateral leg and/or buttock pain was treated initially with spinal stimulation and bilateral leg or mainly low back pain was treated initially with spinal infusions. 26 patients received spinal stimulation. Pain relief was > or = 50% in 16 (62%) with increased activity levels. Stimulator coverage was most difficult or failed in patients with buttock pain. 16 patients received long-term spinal infusions. Pain relief was > or = 50% in 2 (13%) but 25-49% in another 8 (50%) with stable infusion doses and was best in patients requiring low-dose (< 1 mg/h morphine intrathecal) infusions in the trial period. The review indicates that spinal infusions may be best for bilateral or axial pain that has not responded to spinal stimulation. Clonidine appears to be an alternative in high-dose morphine patients. New diamond-shaped electrode and dual quadripolar arrays appear to be very helpful for back, buttock, and/or bilateral leg pain patterns.

The effects of multidisciplinary pain management treatment on locus of control and pain beliefs in chronic non-terminal pain.

OBJECTIVE: To determine whether chronic pain patients' beliefs and attributions about pain control are amenable to change in a short-term inpatient multidisciplinary pain management program. DESIGN: Non-randomized consecutive sample with prospective, before-after treatment. SETTING: Pain-management, tertiary care center in a major U.S. city. PATIENTS: All adult patients (n = 50) who were treated in an inpatient multidisciplinary pain management center were contrasted with those of a control group of 46 adult patients who were treated in an outpatient pain center. OUTCOME MEASURES: Pain Locus of Control Scale, the Pain Beliefs and Perceptions Inventory, subjective pain intensity, and medication usage were measured before and after treatment. RESULTS: Statistically significant posttreatment changes were found for the treatment group, but not the control group. Patients who completed the inpatient pain management program reported significant decreases in subjective pain intensity despite discontinuation of narcotic analgesics. Patients in the treatment group showed an increased sense of personal control over their pain and substantial decreases in attributions of pain control to powerful others and chance. Patients in the treatment group also showed a significant reduction in their endorsement of the belief that their pain was a mysterious phenomenon. CONCLUSIONS: Chronic non-terminal pain patients' beliefs about pain and attributions of pain control are amenable to change in a short-term inpatient multidisciplinary pain management program. These results suggest that an intensive multidisciplinary program involving psychotherapy might be more effective in treating chronic pain patients similar to those in this study than outpatient treatment without psychotherapy.

Trigeminal cisternal injection of glycerol for treatment of chronic intractable cluster headaches.

Medical treatment of chronic cluster headaches (cluster headaches that occur frequently without remission) can be very difficult. In many patients, the pain remains severe despite all medication trials. For these patients, previous reports recommend radiofrequency trigeminal rhizotomy, which risks corneal anesthesia and subsequent corneal decompensation. As a safer, yet effective, treatment, retro-Gasserian injections of glycerol were given to eight patients having intractable chronic cluster headaches. Needle penetration into the trigeminal cistern, glycerol amount (0.55 ml), and length of patient elevation after the procedure (80-90 degrees upright for 10 h) were modified for maximal exposure of the V1 division. Three patients required one additional injection, and one patient required two additional injections. Verbal pain scales (means +/- 1 standard error of the mean) were: 9.1 +/- 0.30 (preoperative), 2.6 +/- 1.10 (1 mo postoperative), and 2.1 +/- 0.64 (1 yr postoperative). Daily headache frequency decreased from 6.0 +/- 2.0 (preoperative) to 0.2 +/- 0.09 (i.e., one headache every 5 days) (1 yr postoperative). Three of the eight patients had no headaches after 1 year. There were no instances of corneal or facial anesthesia. One year postoperatively, five patients required no medication, and three remained on low doses of medication for headache treatment. In contrast to previous limited reports of glycerol injections for cluster headaches, results with these patients having chronic cluster headaches support the use of glycerol injections as a viable treatment alternative, with significant pain relief and corneal safety.

Sufentanil citrate and morphine/bupivacaine as alternative agents in chronic epidural infusions for intractable non-cancer pain.

Intraspinal narcotic (usually intrathecal morphine) infusions with implanted pumps are increasingly used in patients with intractable chronic pain not caused by cancer. In some patients, pain control is difficult with infusions of morphine. Seven patients with diagnoses of arachnoiditis, epidural scarring, and/or vertebral body compression fracture were treated with alternative solutions in an epidural route. For maximal flexibility, Medtronic implanted programmable infusion pumps with catheters to T6-T10 were used, and pain was monitored by verbal pain scales. In three patients, epidural infusions of morphine in 0.5% bupivacaine (MS-MARC) resulted in little or no pain relief without significant side effects (e.g., headache, nausea, or vomiting). In these same patients, epidural infusions of sufentanil citrate resulted in pain scale reductions of 92%, 82%, and 40%, respectively, with no side effects. Four other patients found more effective pain relief when switched from initial sufentanil citrate infusions to MS-MARC. Pain scale reductions (with no side effects) were 92%, 76%, 59%, and 47% in these patients. Pain relief and minimal side effects with sufentanil citrate is theorized to result from its higher lipophilicity promoting local transdural diffusion to spinal cord and limiting upward diffusion to the brain stem. Sufentanil citrate is also advantageous for programmable pumps because it is 100 times more potent than morphine and therefore allows longer pump refill times and higher infusion doses. Although this study was done on a limited number of patients, sufentanil citrate and MS-MARC in epidural infusions using programmable infusion pumps for non-cancer patients provide significant alternative drug combinations and routes.

Depression and chronic fatigue in the patient with chronic pain.

Chronic benign pain is commonly associated with chronic fatigue and depression. Depression and chronic fatigue syndrome are also associated with each other and often include pain. Psychologic factors are prominent in these conditions, and they may share neurobiologic factors as well. Management requires separately addressing each component of patients' distress and usually includes physical rehabilitation, education, administration of nonhabituating medications and often counseling. Depression may be a favorable prognostic sign, as it suggests a treatable condition and provides incentive for recovery.

Constant infusion of morphine for intractable cancer pain using an implanted pump.

In the past, pain control for chronic pain syndromes using narcotic infusion has been carried out primarily via the intrathecal (subarachnoid) route. This report presents one of the first large series of terminally ill cancer patients with intractable pain treated with continuous epidural morphine infusions by means of implanted pumps and epidural spinal catheters. The purpose of the study was to demonstrate that the epidural route is effective with minimal complications, and that screening with temporary epidural catheter infusions results in a high rate of subsequent pain relief. A multidisciplinary team (neurosurgeon, anesthesiologists, psychiatrists, oncologists, and nurse clinicians) evaluated and treated all of the patients studied. Percutaneous placement of temporary epidural catheters for a trial assessment was performed by the anesthesiologists. Pain evaluations were conducted independently by psychiatrists using both verbal and visual analog scales. From 1982 to 1988, 41 (59.4%) of 69 patients evaluated for eligibility experienced good pain control during trial assessment and were subsequently implanted with Infusaid infusion pumps. Preinfusion pain analog values were 8.6 +/- 0.3 and postimplantation values at 1 month were 3.8 +/- 0.4 (p less than 0.001). Over this same 1-month period. requirements of systemic morphine equivalents decreased by 79.3% with epidural infusions as compared to preinfusion requirements (p less than 0.001). There were no instances of epidural scarring, respiratory depression, epidural infections, meningitis, or catheter blockage. One patient developed apparent drug tolerance and three patients required further catheter manipulations. This series strongly suggests that significant reductions in cancer pain can be obtained with few complications and a low morphine tolerance rate using chronic epidural morphine infusion. Anesthesiology and psychiatry input, along with temporary catheter infusion screening and quantitative pain evaluations using analog scales, are essential.

Patient-controlled analgesia for postcholecystectomy pain: a pilot study.

Patient-controlled analgesia (PCA) is designed to avoid both excessive and inadequate analgesia in postoperative pain by allowing the patient self-administration of intravenous narcotics within a range of parameters established by the physician. Of 24 patients undergoing elective cholecystectomy referred to our study over a 12-month period, 11 were assigned to PCA and eight successfully completed the study. Most of them had good analgesia, were satisfied with PCA, and had no evidence of confusion, psychic distress, or visual-motor impairment. Serum morphine concentrations of 10-30 ng/mL were sufficient to obtain good analgesia in six of eight patients. Complications included severe respiratory depression and abdominal cramps.

Motor phenomena in benzodiazepine withdrawal.

Chronic use of benzodiazepines, the most widely prescribed of all psychotropic medicines, may lead to severe symptoms of withdrawal when the drugs are discontinued. The authors describe two cases of benzodiazepine withdrawal accompanied by unusual muscle activity. The neurologic mechanism for the motor abnormalities appears to be marked disinhibition of subcortical motor areas normally inhibited by gamma-aminobutyric acid. The motor phenomena may persist long after the more common signs of withdrawal have resolved and, if unrecognized, can lead to such misdiagnoses as drug seeking, conversion, hysteria, or malingering.

Psychiatric training for primary care residents: proposed standards.

Most of the nation's psychiatric care is provided by primary care physicians, and this trend is expected to continue. Primary care physicians see themselves as poorly trained in psychiatry, and evidence supports a high incidence of missed diagnosis and inadequate or inappropriate treatment. In addition, poor training may underlie the indifference to psychiatric problems often demonstrated by primary physicians. The Ohio Psychiatric Association Foundation has designated an annual award to be given to the primary care program which provides the best psychiatric training in the state, and the psychiatric training directors met to develop criteria for selecting the recipients. The resulting standards emphasize the importance of training which is relevant to a medical care setting, provided by psychiatrists, and supportive of the integration of psychiatric methods into medical care.