Significant differences of brain blood flow in patients with chronic low back pain and acute low back pain detected by brain SPECT.

BACKGROUND: The aim of this study was to examine and compare the areas of brain blood flow in patients with chronic low back pain (CLBP) without structural abnormality and acute low back pain (ALBP) with lumber disc herniation (LDH). Functional neuroimaging studies provide evidence of abnormalities in the regional cerebral blood flow during low back pain. Recent studies have shown that CLBP is associated with plastic, pathophysiological changes in the brain. However, there has been no report yet statistically or by neuro-images on the compared brain single photon-emission computed tomography (SPECT) findings between CLBP and ALBP patients. METHODS: The subjects comprised 14 patients, 7 CLBP and 7 ALBP patients. The CLBP group included the patients who had no or minor structural abnormality in the lumbar spine on magnetic resonance imaging (MRI) and met the criteria for a classification of "pain disorder" (chronic) according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. The ALBP group included the patients who had symptoms within 3 months of onset and LDH revealed by MRI. All patients were assessed using brain SPECT. We then performed a two-tailed view analysis using the easy Z score imaging system, determined the mean Z scores, and performed vBSEE software (Fujifilm RI Pharma, Tokyo, Japan) for both CLBP and ALBP patients. RESULTS: The CLBP group showed significantly reduced blood flow in the bilateral prefrontal cortex of the frontal lobe and increased blood flow in the bilateral posterior lobe of the cerebellum. CONCLUSIONS: SPECT images and statistical analyses revealed the brain blood flow alterations in the patients with ALBP and CLBP. These results may suggest that the dysfunction of the prefrontal cortex could lead to the appearance of unconscious pain behavior controlled by the cerebellum in the patients with CLBP.

Brain perfusion abnormality in patients with chronic pain.

We performed single photon emission computed tomography (SPECT) of the brain in 15 patients with chronic pain (males, 7; females, 8; average age 49.1 +/- 17.9 years) and identified the locus of cerebral blood flow reduction by a new analytical method (easy Z-score Imaging System: eZIS) to clarify the functional neuroanatomical basis of chronic pain. Of the 15 patients, 6 had backache, 2 neck pain, 2 gonalgia, and 5 pain at other sites, with an average Visual analog scale of pain (VAS) value of 6.1 +/- 1.9. In comparison with a information on a data base on physically unimpaired persons, the dorsolateral prefrontal area (both sides, right dominant), medial prefrontal area (both sides), dorsal aspect of the anterior cingulate gyrus nociceptive cortex (both sides) and the lateral part of the orbitofrontal cortex (right side) were found to have blood flow reduction in the group of patients with chronic pain. As for chronic pain and its correlation with clinical features such as a depressive state, anticipation anxiety, PTSD, and conversion hysteria, the mechanism in the brain that was suggested by this study should be followed-up by functional neuroimaging studies.

The family's viewpoint of chronic pain.

An indentical questionnaire are administered separately to 100 chronic pain patients and a close family member of each. The majority of patients and relatives agreed on the answers to these questions about the pain problem. Highest congruency between patient and relative was associated with cases in which there were management problems and an ultimately poor treatment result. Rather than reflecting excellent communication between patient and relative, this appears to indicate an undesirable mutuality. Patient answers indicate to us as examiners that their pain is greater than they have revealed to relatives, yet the relatives say the patient is showing more than he realizes.

Chronic pain: which patients may a pain-management program help?

To ascertain whether chronic-pain patients who are likely to benefit from a pain-management program can be identified before treatment, we studied for differences discernible at the beginning of treatment a group who succeeded and did well at 1-year follow-up (n = 34) and a group who failed (n = 35). The two groups differed significantly (P less than 0.01) in regard to duration of pain, work time lost, number of operations, subjective pain level, and drug dependency. Deviations on the MMPI were greater in failures than in successes; but the differences were not statistically significant. A 7-item rating scale based on these data differentiated a favorable group (including 71% of the successes) from an unfavorable group (including 86% of the failures). This scale should be helpful in selection of candidates for a pain-management program, even though it needs further validation.

Ancient pain.

In a group of about 1000 patients with chronic pain, approximately 4% had pain of very prolonged duration--25 years or longer. These subjects were similar in general to other chronic pain patients but they did differ significantly in the following: a higher incidence of face and head pain, greater dependency on analgesics and sedatives, more frequent diagnoses of depression, and a greater elevation of nearly all clinical MMPI scales.

Three year follow-up of patients with chronic pain who were treated in a multidisciplinary pain management center.

Between September 1979 and October 1982, 408 patients with chronic benign pain were evaluated for admission to a pain management program. Of the 408 patients, 249 completed the program; the success rate at the time of dismissal was 70% among these 249 patients. Of the 239 patients who entered the follow-up study, 87% responded to either a mailed questionnaire or a follow-up telephone call by an independent reviewer at the time of 3 year follow-up; the improvement had been maintained by 46.6% of the successfully treated patients (or a third of the original participants). The present finding is strikingly similar to that in a previous study from this institution - an indication of the long-term efficacy of the multidisciplinary pain management program. Further search for modifications for the existing program is indicated to accommodate the needs of patients who fail initially or cannot maintain the improvement.

Pain management as an antidepressant: long-term resolution of pain-associated depression.

Of 100 consecutive patients admitted to a pain management program for patients without malignant disease who had chronic pain, 54 were definitely or probably depressed and 46 were not depressed by Research Diagnostic Criteria. As a result of 98% improvement of depression and low frequency (2%) of new development of depression, 98 of the original 100 patients were not depressed at the time of dismissal. This progress was maintained at long-term follow-up (average, 11.6 months): 89 of 100 patients remained non-depressed.

Substance dependence and chronic pain: experience with treatment and follow-up results.

Fifty patients with chronic pain and substance dependence were admitted to the hospital for treatment of substance dependence. Sixteen patients left treatment prematurely and were noted to have been less flexible in seeking treatment options for relief of pain. Most patients experienced an improved sense of well-being with abstinence, but this was not reflected in pain rating scales. At 1 and 3-4 years follow-up, the group that completed treatment was more outstanding in its commitment to a course of abstinence from drugs and alcohol than the group that had not completed treatment and seemed to experience a greater improvement in overall functioning.

Failure of a predictive scale in identifying patients who may benefit from a pain management program: follow-up data.

A 7-item scale to identify patients who may benefit from a pain management program was prospectively studied. The patient group consisted of 217 patients. The duration of follow-up was 2-3 years. Although an item-by-item analysis revealed some differences between successes, partial successes, and failures, the overlap was such that the total score was not predictive of outcome. Although this finding precludes clinical use of the 7-item scale in its present form, future modifications are suggested that may improve its predictive ability.

The dissatisfied patient with chronic pain.

Patients with chronic pain may become dissatisfied because of their lack of improvement. Thirteen such patients, encountered in a pain-management program, registered formal complaints of their dissatisfaction. From their histories they were found to be the most chronic and treatment-refractory patients encountered, with problems of medication dependency, accident proneness, and dissatisfaction with previous treatment efforts. During hospitalization they opposed psychologic approaches, further manifested their dependency on medication, and some of them had circumscribed delusions. The pain-management program was difficult to apply to these patients; and further, they resisted other recommendations for treatment and even resisted discharge in in some instances. Further psychiatric screening is necessary to avoid the complications presented by this type of patient.

Substance dependence and chronic pain: profile of 50 patients treated in an alcohol and drug dependence unit.

Fifty adult patients with chronic pain and substance dependence were admitted to an inpatient unit for treatment of addiction without primary emphasis on treatment of pain. As a group they had received considerable medical attention for their pain, but relatively little for their addictions. When compared with a group of general medical patients, the study population showed MMPI evidence of considerably more psychopathologic characteristics. MMPI data and family histories of substance dependence did not differentiate the study group from a comparable group in a Pain Management Center.

Prescription medication dependence and neuropsychologic function.

The abuse of prescription drugs is an insidious complication among patients with chronic pain. This study examines cognitive intellectual functions in patients with chronic pain who are using prescribed analgesics, sedatives and hypnotics. A comprehensive battery of psychologic tests measuring intelligence, learning, memory, sensory-perceptual integrity, motor skills and general adaptive abilities was administered to 47 subjects. The subjects were patients admitted to a chronic pain management program, and they were divided into drug-dependent, drug-abusing and non-drug-abusing groups according to strictly defined criteria. Findings indicated that the prescribed use of these medications for pain over a prolonged time is detrimental to the cognitive function of such patients and complicates their clinical management.

Optimism-pessimism assessed in the 1960s and self-reported health status 30 years later.

OBJECTIVE: To study the association between explanatory style, using scores from the Optimism-Pessimism (PSM) scale of the Minnesota Multiphasic Personality Inventory (MMPI), and self-reported health status, using scores from the 36-Item Short-Form Health Survey (SF-36). PATIENTS AND METHODS: A total of 447 patients who completed the MMPI between 1962 and 1965 as self-referred general medical outpatients and also completed the SF-36 thirty years later compose the current study sample. The associations between the scores on the SF-36 and the MMPI PSM scale were evaluated by analysis of variance and linear regression analysis. RESULTS: Of 447 patients, 101 were classified as optimistic, 272 as mixed, and 74 as pessimistic. Scores on all 8 health concept domains from the SF-36 were significantly poorer in the pessimistic group than in both the optimistic and the mixed group. CONCLUSION: A pessimistic explanatory style, reflected by higher PSM scale scores, was significantly associated with a self-report of poorer physical and mental functioning on the SF-36 30 years later.