Are chronic low back pain patients who smoke at greater risk for suicide ideation?

OBJECTIVES: There is significant psychiatric literature indicating that smoking is associated with all forms of suicidality, including suicide ideation. The goal of this study was to determine if smoking is associated with suicide ideation in chronic low back pain (CLBP) patients. DESIGN: CLBP patients identified themselves as either current smokers (N = 81) or nonsmokers (N = 140) and completed a number of evaluation instruments, which included the Beck Depression Inventory (BDI) and the Coping Strategies Questionnaire (CSQ). BDI question number 9 was utilized to define CLBP with suicide ideation and subsequently, in addition, items number 3 and number 6 from the CSQ were added to the BDI item number 9 in order to fully capture CLBP with suicide ideation. Utilizing this expanded definition of suicide ideation (BDI plus CSQ), CLBP smokers were compared with CLBP nonsmokers for the frequency of suicide ideation. Regression analysis was utilized to investigate the CLBP smoking suicide ideation group. Finally, we investigated whether heavy use of alcohol and coffee impacted on CLBP heavy smokers in terms of increasing suicide ideation risk. SETTING: CLBP patients were recruited from a pain facility. RESULTS: CLBP smokers were more likely to complain of suicide ideation, and this relationship correlated with the number of cigarettes smoked per day. Seventy-eight percent of the CLBP smokers were classified correctly in terms of the presence of suicide ideation by three variables: diagnosis of major depression, Function Assessment Questionnaire total score, and BDI total score. The relative risk of suicide ideation was increased by combining heavy smoking (greater than one pack per day) with heavy alcohol use. CONCLUSIONS: CLBP smokers appear to be at greater risk for suicide ideation than nonsmoking CLBP patients. The risk of suicide ideation is even greater if the CLBP patient is a heavy smoker and has problems with alcohol.

Is chronic pain associated with somatization/hypochondriasis? An evidence-based structured review.

STUDY DESIGN: This is an evidence-based structured review. OBJECTIVES: The objectives of this review were to answer the following questions: (1) Are somatization/hypochondriasis associated with chronic pain? (2) Is the degree of somatization/hypochondriasis related to pain levels? (3) Does pain treatment improve somatization/hypochondriasis? (4) Are some pain diagnoses differentially associated with somatization/hypochondriasis? METHODS: Fifty-seven studies which fulfilled inclusion criteria and had high quality scores were sorted by the above-mentioned objectives. Agency for health care policy and research guidelines were utilized to type and characterize the strength/consistency of the study evidence within each objective. RESULTS: Somatization and hypochondriasis were both consistently associated with chronic pain (consistency ratings B and A, respectively). Study evidence indicated a correlation between pain intensity and presence of somatization and hypochondriasis (consistency rating A and B, respectively). Pain treatment improved somatization and hypochondriasis (consistency rating B and A, respectively). Some chronic pain diagnostic groups somatized more (consistency rating B). CONCLUSIONS: Somatization is commonly associated with chronic pain and may relate to pain levels.

Does smoking status affect multidisciplinary pain facility treatment outcome?

OBJECTIVES: Smoking may be a major problem in chronic low back pain (LBP) patients. The goal of this study was to determine whether smoking status affected multidisciplinary pain facility treatment outcome. DESIGN: As part of a grant study, chronic LBP patients identified themselves as either current smokers (N = 81) or current nonsmokers (N = 140), and were compared by chi-square for employment status at 1, 6, 12, and 24 months after multidisciplinary pain facility treatment. Smokers who were unemployed at each time interval were then compared with employed smokers for a large number of assessment scales and clinical variables of interest by chi-square or Student's t-test. The significant independent variables from these analyses were then utilized in a logistic regression to determine predictors for smoker nonemployment. SETTING: Pain facility. RESULTS: Current smokers were less likely to be employed at each follow-up time point. Pain levels over the previous 24 hours predicted employment status for current smokers at 1-, 12-, and 24-month follow-up, while worker compensation status predicted employment status at 6 months. CONCLUSIONS: Current smoking status appears to be associated with poorer treatment outcome after multidisciplinary pain facility treatment. Return to work within smokers is predicted by pain and worker compensation status. Pain facilities should target current smokers with significant perceived pain for close treatment monitoring in an attempt to improve treatment outcome.

Impact of chronic pain patients' job perception variables on actual return to work.

OBJECTIVE: To examine the impact of preinjury job perceptions on chronic pain patients (CPPs) return to work after pain facility treatment. DESIGN: A total of 128 CPPs completed a series of rating scales and yes/no questions relating to their preinjury job perceptions and a question relating to "intent" to return to the same type of preinjury job following pain facility treatment. These CPPs were part of a grant study for prediction of return to work, and therefore their work status was determined at 1, 3, 6, 12, 18, 24, and 30 months after treatment. The preinjury job perceptions and other demographic variables were used to predict return to work. Stepwise discriminant analysis was used to predict return to work at the 1-month and final time points utilizing the above variables. Stepwise regression analysis was used to predict mean employment status (at all time points) also using the above variables. SETTING: Multidisciplinary Pain Center. PATIENTS: Consecutive CPPs. RESULTS: For the 1-month time point, employment status was predicted by "intent," educational status, work dangerous perception complaint, job stress, job physical demands, job liking, and job role conflicts. Here, 79.49% of the CPPs were correctly classified. For the final time point, employment status was predicted by the first three predictors for the 1-month time point (in the same order) and age, job stress, and gender. Here, 74.58% of the CPPs were correctly classified. Mean employment status was predicted by "intent" and educational status. CONCLUSIONS: There is a relationship between preinjury job perceptions and actual return to work after pain facility treatment. Voiced "intent" not to return to the preinjury type of job is highly predictive of not returning to work after pain facility treatment.

Validity of the dictionary of occupational titles residual functional capacity battery.

BACKGROUND DATA: The Dictionary of Occupational Titles (DOT) is a U.S. government publication that defines each job in the United States according to 20 job factors. Fishbain et al. (Spine 1994;19:872-80) developed a DOT residual functional capacity (RFC) battery whose predictive validity for employment/unemployment had not been tested previously. OBJECTIVES: The purposes of this study were as follows: (a) to determine whether results of a DOT-RFC battery performed at completion of pain facility treatment predicted employment status at 30 months' follow-up and (b) to determine whether the DOT-RFC battery predicted employment capacity as determined by the DOT employment levels of the chronic pain patients' (CPPs) jobs. STUDY DESIGN: This is a prospective low back pain CPP pain facility treatment study using employment status and the DOT occupational levels as outcome measures. METHODS: One hundred eighty-five consecutive CPPs who fitted the selection criteria completed a DOT-RFC battery at the completion of pain facility treatment and were contacted at 1, 3, 6, 12, 18, 24, and 30 months for determination of their employment status and DOT employment level. Eight DOT job factors plus pain and worker compensation status were found to be significantly different between employed and unemployed CPPs and between those employed in different DOT employment levels. For the 10 variables, stepwise discriminant analysis was used to select final predictor variables. Sensitivity and specificity were calculated along with pain level cutpoints that separated the groups. RESULTS: The eight DOT job factors found to be statistically significant between groups were the following: stooping, climbing, balancing, crouching, feeling shapes, handling left and right, lifting, carrying, and pain and worker compensation status. In the discriminant analysis, these variables could discriminate between the employed and unemployed categories, with a sensitivity and specificity of approximately 75%. The pain level cutpoint between employed and unemployed was 5.4 on a 10-point scale. CONCLUSIONS: We cannot as yet predict DOT-RFC employment levels. However, if a CPP can pass the above eight DOT job factors and has a pain level less than the 5.4 cutpoint, that CPP will have a 75% chance of being employed at 30 months after treatment at the pain facility. Therefore, some DOT-RFC battery job factors demonstrate a predictive validity in the "real work world."

Prediction of "intent", "discrepancy with intent", and "discrepancy with nonintent" for the patient with chronic pain to return to work after treatment at a pain facility.

OBJECTIVE: We previously determined that "intent" to return to work post pain facility treatment is the strongest predictor for actual return to work. The purposes of the present study were the following: to identify variables predicting "intent"; to predict membership in the "discrepant with intent" group [those chronic pain patients (CPPs) who do intend to return to work but do not]; and to predict membership in the "discrepant with nonintent" group (those CPPs who do not intend to return to work but do). DESIGN: A total of 128 CPPs completed a series of rating scales and yes/no questions relating to their preinjury job perceptions and a question relating to "intent" to return to the same type of preinjury job post-pain facility treatment. These CPPs were part of a grant study for prediction of return to work, and therefore their work status was determined at 1, 3, 6, 12, 18, 24, and 30 months posttreatment. Preinjury job perceptions and other demographic variables were utilized using stepwise discriminant analysis to identify variables predicting "intent" and predicting membership in the "discrepant with intent" and "discrepant with nonintent" groups. SETTING: Pain facility (multidisciplinary pain center). PATIENTS: Consecutive low back pain CPPs, mean age 41.66+/-9.54 years, with the most frequent highest educational status being high school completion (54.7%) and 60.2% being worker compensation CPPs. RESULTS: "Intent" was predicted by (in decreasing order of probability) postinjury job availability variables, job characteristic variables, and a litigation variable. "Discrepant with intent" was predicted by (in decreasing order of probability) for the 1-month follow-up time point, postinjury job availability variables, pain variables, a litigation variable, and a function perception variable, and for the final follow-up time point, pain variables only. "Discrepant with nonintent" was predicted by (in order of decreasing probability) for the 1-month follow-up time point, a job availability variable, a demographic variable, and a functional perception variable, and for the final follow-up time point a pain variable and a job availability variable. The percentage of CPPs correctly classified by each of these analyses was as follows: "intent" 81.25%, "discrepant with intent" 87.01% (at 1-month follow-up) and 74.03% (final follow-up), "discrepant with nonintent" 92.16% (at 1-month follow-up) and 75.00% (final follow-up). CONCLUSIONS: CPPs intentions of returning to their preinjury jobs are mainly determined by job availability and job characteristic variables but surprisingly not by pain variables. However, the results with "discrepant with intent" and "discrepant with nonintent" groups indicate that actual return to work is determined by an interaction between job availability variables and pain variables with pain variables predominating for long-term outcome.

I. Do chronic pain patients' perceptions about their preinjury jobs determine their intent to return to the same type of job post-pain facility treatment?

OBJECTIVE: To demonstrate that chronic pain patients' (CPPs') perceptions about their preinjury jobs determine their intent to return to the same type of job post pain facility treatment. DESIGN: A total of 225 CPPs completed a series of rating scales and yes/no questions relating to their preinjury job perceptions and a question relating to intent to return to the same type of preinjury job post-pain facility treatment. The CPPs were broken down into subgroups (males, females, college males, noncollege males, college females, noncollege females), and within each subgroup those not intending to return to the same type of pre-injury job were compared to those intending to return on the preinjury job perception questions. In addition for the whole group, stepwise discriminant analysis was used to predict who planned to return to the preinjury job utilizing the job perceptions questions. SETTING: Multidisciplinary Pain Center. PATIENTS: Consecutive chronic pain patients. RESULTS: For the whole group, CPPs not intending to return were more likely to complain of job excessive physical demands, job satisfaction, and job dislike. Job perception complaints that were significantly different between the intending and not intending to return groups differed between the subgroups. For example, noncollege males not intending to return were more likely to complain of excessive physical demands only versus satisfaction and liking as significant items for college males who did not intend to return. Within the discriminant analysis, the combination of job satisfaction, excessive physical demands, employee conflicts, job liking, job dangerousness, supervisory conflicts, job stress, and age classified 73.46% of the CPPs correctly as to intent to return to the same type of preinjury job. CONCLUSIONS: There appears to be a relationship between preinjury job perceptions and intent to return to the same type of job post pain treatment. However, subgroups of CPPs will differ by which job perceptions are important towards making that decision.

II. Do chronic pain patients' perceptions about their preinjury jobs differ as a function of worker compensation and non-worker compensation status?

OBJECTIVES: (1) To demonstrate a relationship between intent to return to preinjury job and preinjury job perceptions about that job; and (2) to demonstrate that worker compensation chronic pain patients (WC CPPs) would be more likely than non-worker compensation chronic pain patients (NWC CPPs) not to intend to return to a preinjury type of job because of preinjury job perceptions. STUDY DESIGN: The relationship between preinjury job perceptions and intent to return to the preinjury job was investigated and compared between worker compensation (WC) and nonworker compensation (NWC) chronic pain patients (CPPs). Within the WC and NWC groups CPPs not intending to return to their preinjury type of work were compared to those CPPs intending to return on preinjury job perception. BACKGROUND DATA: Compensation status, being a WC CPPs or being a non-WC CPPs, has been claimed to be predictive or not predictive of return to work post pain treatment. These studies have, however, ignored the preinjury job stress perception variable as an area of research. METHODS: WC CPPs were age- and sex-matched to NWC CPPs and statistically compared on their responses to rating scale and yes/no questionnaires for intent to return to work and perceived preinjury job stress. In a second analysis, both the WC and NWC groups were divided according to their intent to return to work and statistically compared on their responses to these questionnaires. RESULTS: Both male and female WC CPPs were less likely than their counterparts to intend to return to their preinjury job. Both WC and NWC were found to complain of preinjury job complaints, and these complaints were found to differ between WC and NWC CPPs. An association between intent not to return to work and the perceptions of preinjury job dissatisfaction and job dislike was found for male and female WC CPPs and for male and female NWC CPPs. CONCLUSIONS: There may be a relationship between some preinjury job perceptions and intent to return to the preinjury type of work in some groups of CPPs. However, a specific relationship between WC status, intent not to return to the preinjury type of work, and preinjury job perceptions in comparison to NWC CPPs could not be demonstrated.

"Movement" in work status after pain facility treatment.

STUDY DESIGN: This was a randomized prospective follow-up study of pain facility treatment of chronic pain patients with low back pain, with return to work and work capacity as the outcome measures. OBJECTIVES: To determine if after pain facility treatment chronic pain patients "move" in and out of work and in their work capacity; to determine the patterns of "movement;" and to determine the post-pain facility treatment follow-up sampling time points that would maximize the number of chronic pain patients correctly classified according to their final work and work capacity status. SUMMARY OF BACKGROUND DATA: Past research and empiric observation have indicated that chronic pain patients may "move" after pain facility treatment in and out of work and in their job work capacity. Such "movement" can affect the results of outcome studies. METHODS: Two hundred thirty-six consecutive chronic pain patients who fit study selection criteria were followed up at 1, 3, 6, 12, 18, 24, and 30 months after pain facility treatment for determination of work and work capacity status and separated according to the pattern of movement. Stepwise discriminant analysis was used to answer the study objectives. "Movement" in and out of work for these chronic pain patients also was compared with the US general population. RESULTS: Chronic pain patients demonstrated eight work and four work capacity movement patterns. The 24- and 1-month time points predicted final work status correctly for 97.0% and 77.0% of the chronic pain patients, respectively, whereas the most significant predictor for correct work capacity status was the 24-month point. The annual percentage change in employment status for these chronic pain patients was more than in the US general population. CONCLUSIONS: Because chronic pain patients "move" in and out of employment and for work capacity status after pain facility treatment, future outcome studies using these measures will have to consider carefully the impact of "movement" on their results.

Modafinil for the treatment of pain-associated fatigue: review and case report.

Fatigue is a symptom that is frequently found in chronic pain patients with low back pain and/or neck pain. At the present time, no specific psychopharmacological treatment for this problem has been identified. Modafinil is a wakefulness-promoting agent that the FDA has approved for the treatment of excessive daytime sleepiness associated with narcolepsy. There have been reports on the use of modafinil for the treatment of fatigue in various neurological syndromes. This literature is reviewed. As such, modafinil treatment was initiated for a patient with severe fatigue associated with chronic low back pain and neck pain. There was dramatic improvement in fatigue and associated function. This case is described. It is the first such case report in the literature. The significance of this finding to the treatment of pain-associated fatigue is discussed.

Process analysis of functional capacity assessment.

Researchers and practitioners, as well as vendors, have placed much emphasis on what constitutes a functional capacity testing battery. Statistical, procedural, behavioral, technological, as well as legal issues surrounding this type of human performance evaluation are also continuously being addressed in the literature. In addition, several methods, batteries, equipment, and protocols have been developed for the purpose of evaluating what an injured person can or cannot do. It is a fact that 'testing' of individuals is but one component of an intricate process consisting of: identification of an evaluee, researching a market, referring the evaluee to a facility, evaluating a set of abilities, making inference about the evaluee's performance, reporting the findings, following up on the case, and possibly a legal involvement due to litigation. These components comprise the process of functional capacity testing. The purpose of this paper is to describe and analyze the various components of the process of quantitative testing of functional capacity. It is believed that each component of the FCA process is as important as the actual testing.

Risk for violent behavior in patients with chronic pain: evaluation and management in the pain facility setting.

OBJECTIVE: Recent evidence indicates that physicians are at high risk for patient-perpetrated violence. The objectives of this article, in association with case reports of patients with chronic pain (PWCP), are the following: to review the literature and determine if pain physicians could be at risk for PWCP-perpetrated violence; to review the current evaluation and management procedures for potentially violent patients; and to identify some situations specific to PWCPs that can heighten the risk of PWCP-perpetrated violence. DESIGN: Previous literature on patient-perpetrated violence against physicians was reviewed. In addition, literature on the evaluation for risk of violent behavior and management of violent behavior was also reviewed. Seven potentially violent PWCPs are described, including some who had threatened pain physicians and institutions. PWCP-specific situations thought to be instrumental in increasing the risk of PWCP-associated violence were identified. SETTING: Pain facility (multidisciplinary center). RESULTS OF REVIEW AND ANALYSIS OF CASE REPORTS: The literature on patient-perpetrated violence against physicians indicates that, statistically, pain physicians could be at risk for this type of violence. Seven PWCP cases of threatened or potentially violent behavior are described. These case report data indicate that PWCPs with the potential for violence against physicians or institutions do present for treatment at pain facilities. All seven PWCPs were in a number of situations specific to chronic pain that increased the possibility of violent behavior. These situations are described. CONCLUSIONS: In the evaluation for risk of violence against physicians or institutions by PWCPs, one needs to understand PWCP-specific situations. Management of potential violent behavior cannot be effective without this understanding.

Millon Behavioral Health Inventory norms for chronic pain patients.

The Millon Behavioral Health Inventory (MBHI) is being used more widely in pain treatment settings; however, normative data on a large sample of chronic pain patients have not been published. In the present study, norms were established for 247 chronic pain patients. The chronic pain patient norms then were compared statistically to norms for non-medical population. Overall, the results showed that the score distributions for chronic pain patients and normals were similar on most MBHI scales. The differences that were found are consistent with other research on pain patients and indicate that chronic pain patients are more likely to be depressed and anxious. Differences in scales between chronic pain patients and controls may be explained by state vs. trait factors. In evaluating chronic pain patients by personality tests, one needs to keep in mind state-trait problems and their potential influence on test results.

Types of pain treatment facilities and referral selection criteria. A review.

Family physicians often come in contact with patients who suffer from chronic pain. These patients present a treatment challenge and may require referral to a pain treatment facility. The purpose of this review is to define and clarify the current concept of a pain treatment facility and delineate the different types of treatment facilities available. Possible selection criteria for referral to such facilities are suggested, with the rationale for the selection of these criteria. The role of the family physician in the treatment by a by a special facility of a patient with chronic pain is discussed. By definition, pain treatment facilities differ. The family physician should be aware of these differences and selection criteria for referral to such facilities.

Identifying patients at risk for loss to follow-up after pain center treatment.

OBJECTIVE: This study was designed to identify, at admission to a pain treatment facility, characteristics of patients who will be lost to follow-up after treatment completion. METHOD: Patients were divided into 3 groups depending on how they responded to the 12-month follow-up. The analysis was a between-subjects design using prospective data collected at a comprehensive pain treatment facility. Low back pain patients (n = 168) received 4 weeks of multidisciplinary pain treatment. The main outcome measure was response/nonresponse to follow-up questionnaires. RESULTS: showed that patients who were later lost to follow-up, or who were reluctant to answer follow-ups, could be predicted at treatment admission by measures of pain and functioning. The prediction equation was validated by a second group of patients, treatment noncompleters (n = 55). CONCLUSION: Chronic pain patients who are more likely to be lost to follow-up can be identified upon admission to a pain facility. Procedures that should decrease follow-up attrition could be implemented at program admission.

Detection of a "faked" strength task effort in volunteers using a computerized exercise testing system.

The objective of this study was to develop an experimental method to separate a "faked" strength effort from a "best" effort in volunteers. Thirty-four pain-free volunteers (18 males, 16 females) performed a shoulder press and pull-down on an isokinetic computerized exercise testing system (CETS), giving a best effort followed by a faked effort. Two months later, a randomly selected subgroup (6 males) repeated the experiment to test the predictive validity of the derived variables. In the statistical analysis, best efforts were first compared with fake efforts by paired ttest for 80 CETS variables for males and females separately. Variables showing a strong difference between the best and faked effort were then selected for further analysis. In the second step of the analysis, the method of multiple correlations (r2 method) was used to reduce the number of redundant CETS variables to five in both the male and female groups. In the third step, a stepwise discriminant analysis was used to select predictor variables for the male and female groups. For the variables selected by the discriminant analysis for both males and females, sensitivities and specificities were calculated. Finally, the developed discriminant formula was used in the predictive validity part of the study to determine the sensitivities and specificities of the developed method. The discriminant analysis selected the following CETS variables for male and female groups, respectively: duty cycle down, work weight/down, peak value up (males); and average power up, 40% repetition down, duty cycle up (females). For males, using their three variables, the discriminant function classified 77.14% of the efforts correctly with 88.9% sensitivity and 64.7% specificity. For females, using their three variables, the discriminant function classified 90.63% of the efforts correctly with 100% sensitivity and 81.3% specificity. In the predictive validity group, the discriminant function classified 75% of the efforts correctly with 83.3% sensitivity and 66.7% specificity. This pilot study indicates that the method developed here may be useful in the experimental study for the discrimination between faked and best efforts on this isokinetic CETS machine. Future studies using this method will need to involve a larger number of volunteers.