Music soothes...

Sedative music reduces anxiety and pain during chair rest after open-heart surgery
Jo A. Vossa, et.al
DOI

Open-heart surgery patients report anxiety and pain with chair rest despite opioid analgesic use. The effectiveness of non-pharmacological complementary methods (sedative music and scheduled rest) in reducing anxiety and pain during chair rest was tested using a three-group pretest–posttest experimental design with 61 adult postoperative open-heart surgery patients. Patients were randomly assigned to receive 30 min of sedative music (N=19), scheduled rest (N=21), or treatment as usual (N=21) during chair rest. Anxiety, pain sensation, and pain distress were measured with visual analogue scales at chair rest initiation and 30 min later. Repeated measures MANOVA indicated significant group differences in anxiety, pain sensation, and pain distress from pretest to posttest, P<0.001. Univariate repeated measures ANOVA (P?0.001) and post hoc dependent t-tests indicated that in the sedative music and scheduled rest groups, anxiety, pain sensation, and pain distress all decreased significantly, P<0.001–0.015; while in the treatment as usual group, no significant differences occurred. Further, independent t-tests indicated significantly less posttest anxiety, pain sensation, and pain distress in the sedative music group than in the scheduled rest or treatment as usual groups (P<0.001–0.006). Thus, in this randomized control trial, sedative music was more effective than scheduled rest and treatment as usual in decreasing anxiety and pain in open-heart surgery patients during first time chair rest. Patients should be encouraged to use sedative music as an adjuvant to medication during chair rest.

And what counts as sedative music?

Sedative music was operationalized as music without lyrics and with a sustained melodic quality, with a rate of 60–80 beats per minute and a general absence of strong rhythms or percussion (Gaston, 1951 and Good et al., 2000). The volume and pitch were controlled so that the music was heard comfortably. Participants who received sedative music selected a tape from a collection prior to chair rest by listening to a 30-s excerpt of each of the selections. The collection consisted of six types of music—synthesizer, harp, piano, orchestra, slow jazz, and flute. Good (1995) developed the selections on the first five tapes in consultation with a music therapist. The synthesizer tape included new age music, the piano tape included music popular in the United States from the 1940s to the 1980s, the orchestra tape was classical music, the harp tape included both popular and new age music, and the jazz tape was slow modern jazz (Good et al., 2000). A tape featuring American Indian flute music was added to provide a culturally acceptable selection for the American Indian population served at the hospital (DeRuyter, 2000 and Good et al., 2000). The music has been shown to reduce the sensation and distress of postoperative pain up to 31% in abdominal surgical patients (Good et al., 1999) and also to reduce labor pain (Phumdoung and Good, 2003).

The availability of choice has got to be key. Put me in a chair with Enya soothing my ears and I'll have a heart attack.*

*I'm actually somewhat serious about this. Several years ago, I donated platelets three times a month for nearly a year. Donation involves being immobile in a bed for 2 hours, so the center kindly provides you with a movie. Trouble is, they provided it whether I wanted it or not; and its a bit hard to remove headphones with a large IV plugged into each arm. They had a closet full of movies to choose from, very few that I could stomach. The discomfort of watching Men at Work for the nth time was far worse than the needles, saline infusions, or ischemic discomfort.

I can only imagine the music selection available in the ICU. Will they let you bring in your own music? Will it have to pass their scrutiny? What if I find electroclash most soothing?

Effects of experimenter characteristics and men and woment's pain reports

More on one of my favorite topics:

The effects of experimenter characteristics on pain reports in women and men
Ibolya Kállai, et.al
DOI

In pain research, one important aspect of pain is its report, i.e. its verbal and behavioral indication towards others. As the report of pain virtually always takes place in the presence of another person, for example a physician or an experimenter, a close examination of the effect this person might have on the report of pain is paramount. In a clinical context, the pain report fulfils a function by communicating the problem to the physician thus facilitating diagnosis and therapy. In the absence of the necessity to deliver a vital message, as is the case in most experimental settings, the subject's pain report is likely influenced by additional parameters (Robinson and Wise, 2003).

Several studies suggest that traditional gender roles influence the verbalization of pain (Levine and De Simone, 1991, Robinson and Wise, 2003 and Sanford et al., 2002). Generally, gender role refers to a society's widely assumed set of characteristics for each sex and may comprise beliefs regarding appropriate pain behaviors. Whereas the stereotypical male role in Western society characterizes men as stoic and intending to impress women with their ability to withstand pain, the corresponding female role expects women to exhibit increased sensitivity in order to evoke protective behavior in men (Levine and De Simone, 1991). Some authors confirmed these expectations investigating the influence of the experimenters' gender in a cold pressor test (Carter et al., 2002, Levine and De Simone, 1991 and Voss, 2001), whereas others found no such effects (Otto and Dougher, 1985). Furthermore, women generally report higher pain levels than men (Fillingim and Maixner, 1995 and Riley et al., 1998).

Apart from gender effects, other characteristics of the experimenter might also influence pain reports. Considering the typical setting of psychological experiments, a factor varying across studies is whether the experiments are conducted by students or members of the faculty. Although it is questionable whether student experimenters obtain the same results as experimenters of a higher professional level, few reports mention the professional status of the experimenter. Student experimenters may be perceived as possessing lower authority or competence compared to faculty members, leading subjects to believe that experiments conducted by students may be less important and/or safe than those carried out by faculty members. If a subject doubts the importance of the experiment or the experimenter's competence, the subject may not give his/her best and may not be willing to endure much pain.

The current study investigates not only gender effects, but also the effect of the experimenter's professional status on the subjects’ pain responsivity. We expected that subjects tested by a professional experimenter would show higher pain thresholds and pain tolerance as well as lower pain intensity ratings compared to subjects who were tested by a student experimenter. Regarding gender, we anticipated female subjects to report pain earlier and to endure it for briefer time periods than male subjects. Further, both male and female subjects were expected to demonstrate higher pain thresholds, higher pain tolerance and lower pain intensity ratings when examined by female than by male experimenters.
[....]
4. Discussion

4.1. Experimenter professional status
As expected, there was a significant main effect on pain tolerance for experimenter professional status. Pain tolerance was significantly higher when subjects were tested by a professional experimenter compared to a student experimenter and more subjects were willing to endure the pain for the full 3 min. Interestingly, this effect was not seen for pain threshold or pain intensity. This suggests that the presence of the professional experimenter did not affect the perception or report of pain, but the will to endure it.

An explanation for this effect might be that the subjects tested by the professional experimenters were motivated more strongly and attributed more importance to the experiment. Further analyses showed that the professional experimenters were perceived as possessing significantly more authority than the student experimenters. This perception of authority may have underlined the importance of the experiment and given rise to more effort on the side of the subjects. Although the higher pain tolerance in the presence of a high professional experimenter could theoretically also be mediated by the perceived competence of the experimenter, leading to greater confidence that the experimental pain-inducing situation is handled with care, we could not find statistical evidence supporting such an interpretation. Further, this effect was not due to the fact that the professional experimenters were liked better than the student experimenters as the student experimenters were rated as significantly more likeable.

4.2. Gender effects
Analysing gender effects, we found an interaction between experimenter gender and subject gender for pain tolerance. As could be expected from the literature, men tolerated pain longer when tested by a female experimenter than by a male one (e.g. Levine and De Simone, 1991). However, contrary to our expectations, women also tolerated pain longer when tested by a male experimenter. According to traditional gender role assumptions (cf. Robinson and Wise, 2003 and Sanford et al., 2002), we assumed that women would show higher pain responsivity, for example lower pain tolerance, when tested by a male experimenter, in order to appear helpless and induce male protection. The interaction observed between experimenter gender and subject gender, however, indicates that it is not only men (as we expected) but also women who display increased pain tolerance when tested by a person of the opposite sex in order to impress this person. For women, this behavior—though gender role related—is not in accordance with the traditional gender role outlined above. One reason for this finding, which is unexpected in the light of previous literature, may be that the female gender roles are in flux at the present time, especially among the student population. A further possible explanation could be that there are cultural differences regarding gender roles that would explain the differences between our German sample and the American samples investigated in previous literature (c.f. Carter et al., 2002, Levine and De Simone, 1991 and Robinson and Wise, 2003). Again, the interaction observed between experimenter gender and subject gender was not found for pain threshold or pain intensity, indicating that the will to endure the pain was affected but not the report or the perception of the pain itself.

Furthermore, we found a significant effect for experimenter gender in pain intensity. Both men and women rated pain intensity higher when tested by female experimenters. This effect is contrary to our expectations, as we assumed that, in accordance with traditional gender roles, both men and women would report lower pain intensity to female experimenters than to male experimenters. One explanation for this unexpected result might be that the pain intensity ratings were collected following the cold pressor task and not while the subjects had their hands immersed in the ice-water. For example, in the case of male subjects, it could be the case that they would rate pain intensity as ‘low’ in front of female experimenters while they are actually experiencing the pain, thereby trying to impress the woman by saying that they do not feel much pain. However, when asked to rate pain intensity after the test has already ended, as was the case in our experiment, they might try to impress the female experimenters by saying that they were able to endure high pain intensities. This result warrants further research.

In our study, we did not find any main effect involving subject gender although, according to previous literature (cf. Riley et al., 1998), we expected that women would report higher pain levels and would be less willing to endure the pain compared to men. Generally, men and women did not differ significantly in their pain thresholds, pain tolerance or pain intensity ratings, even though the descriptive differences pointed in the expected direction.

In summary, our findings indicate that pain responsivity, i.e. the will to endure pain as well as the report of pain, might be influenced in part by the characteristics of the person to whom the pain is expressed. This finding may have consequences for pain research in general and for the interpretation of already existing studies. Inconsistent results of earlier studies should be re-examined with respect to experimenters’ attributes and the relation between experimenter and subject. Additionally, in clinical settings, it should always be remembered that attributes of physicians, therapists and other health-care professionals may have an influence on the pain levels expressed by the patients.

Gender

Sex differences and catastrophizing

Catastrophizing as a mediator of sex differences in pain: differential effects for daily pain versus laboratory-induced pain
Edwards, et.al
DOI

Sex differences have been reported for many pain-related responses. For instance, women are at greater risk for pain disorders such as fibromyalgia (Unruh, 1996). Women also report more widespread pain, more pain-related affective symptoms (Mullersdorf and Soderback, 2000 and Keefe et al., 2000), and more frequent daily pain (Berkley and Holdcroft, 1999, Barsky et al., 2001 and Bassols et al., 2002). Sex differences have also been investigated in laboratory settings, with women demonstrating lower pain thresholds and higher pain ratings across a variety of noxious stimuli (Riley et al., 1998 and Fillingim, 2000). It has been suggested (Fillingim and Maixner, 1995, Fillingim et al., 1999 and Fillingim et al., 1999b) that these findings are linked, with greater pain sensitivity acting as a risk factor for enhanced clinical pain.

Although sex differences are well-documented, explaining these differences is more challenging. While some researchers emphasize socialization (Fearon et al., 1996) or emotional responsiveness (Riley et al., 2001) as potential mechanisms, others have highlighted biological factors (Berkley, 1997) or pain-coping (Unruh, 1996, Fillingim, 2000 and Myers et al., 2003). Indeed, how one copes with pain consistently predicts important clinical outcomes, including pain severity and disability (Turk and Okifuji, 2002). Generally, the most robust predictor of pain outcomes is catastrophizing (Sullivan et al., 2001), defined as a negative emotional and cognitive response to pain involving elements of magnification, helplessness, and pessimism. Catastrophizing is positively correlated with pain and depression, and some laboratory studies show an association with responses to standardized noxious stimuli (Sullivan et al., 2001).

Additionally, women report more frequent catastrophic cognitions (Sullivan et al., 2001), making catastrophizing a potential contributor to sex differences in pain. In a recent osteoarthritis study, women had higher levels of pain, pain behavior, and disability. Moreover, women reported more catastrophizing, which mediated the relationship between sex and pain-related outcomes after controlling for depression (Keefe et al., 2000). A second study reported that during a cold pressor task, females reported more pain and displayed more pain behavior than males, effects which became non-significant when catastrophizing was controlled (Sullivan et al., 2000b).

The literature, however, is inconsistent, with some studies showing no sex differences in catastrophizing (Unruh et al., 1999 and Edwards et al., 2000). Moreover, while pain-related sex differences in the laboratory are often large (Riley et al., 1998 and Fillingim, 2000), sex differences in clinical pain are inconsistent (Turk and Okifuji, 1999). Additionally, catastrophizing as a mediator of sex differences in day-to-day pain among healthy individuals has not been studied. It is important to investigate such questions in non-clinical samples, before sex differences in pain are confounded by additional factors such as sex differences in pain treatment or sex-specific selection biases. Many researchers have also not controlled for depression when evaluating catastrophizing, which is now a standard in the field (Sullivan et al., 2001). Finally, catastrophizing likely depends on contextual factors such as the threat value of pain, which may differ in laboratory settings versus clinical environments. The present investigation, therefore, studied catastrophizing as a mediator of sex differences in both day-to-day pain and experimental pain.
[....]
Discussion
Our results indicate that sex differences in complaints of painful day-to-day symptoms are accounted for by the significant differences between men and women in reports of catastrophizing. However, the sex differences in catastrophizing do not account for the substantially higher threshold and tolerance for thermal and cold pain observed among men.

The present study builds upon prior work by assessing catastrophizing as a mediator of male–female differences in pain responses both inside and outside of the laboratory. Several prior studies have suggested that catastrophizing at least partially mediates observed sex differences in both clinical pain (i.e. arthritis pain) (Keefe et al., 2000) and in experimental pain responses (Sullivan et al., 2000a and Sullivan et al., 2000b). Our results are consistent with those of the former study, and suggest that catastrophizing plays an influential role in shaping sex differences in pain report in both clinical and non-clinical samples. However, it is somewhat more difficult to reconcile our findings with those of Sullivan and colleagues (Sullivan et al., 2000b), who also used a cold pressor task. They assessed pain intensity ratings and a measure of the duration of pain behaviors during the task. Correlations of between 0.33 and 0.53 were observed for the association between catastrophizing scores and pain responses. In contrast, we observed minimal correlations (r=-0.12 for CPTO and catastrophizing). One other recent cold pressor study evaluated threat appraisals (i.e. conceptually similar to catastrophizing) as a potential mediator of sex differences in cold pain tolerance (Sanford et al., 2002). The association between threat appraisals and cold pain tolerance was only marginally significant (r=-0.15); however, controlling for threat appraisals did slightly reduce the significance of sex difference in cold pressor tolerance times. The small magnitude of this association parallels our findings and suggests that catastrophizing's relationship with experimental pain responses may be contingent on the type of response measured, with ratings of pain intensity and observation of pain behaviors (see Keefe et al., 2000), being most subject to influence by cognitive and affective processes.

We should also note that assessment of catastrophizing should include the additional dimensions of rumination and magnification, as measured by the pain catastrophizing scale (PCS) (Sullivan et al., 1995).
[....]
Pain recall is subject to many biases (Haythornthwaite and Fauerbach, 2001 and Stone et al., 2004), and it may be that catastrophizing is more powerful in shaping pain recall than in determining in vivo pain responses. Indeed, in the present study, the CSQ was completed shortly after participants answered questions about recent daily pain, and their responses to questions about catastrophizing may have been influenced by those recently-recalled pain experiences.

The process of catastrophizing is closely tied to the meaning of pain (Sullivan et al., 2001); it seems probable that catastrophic interpretations are more likely to accompany daily pain relative to a brief, controllable stimulus administered in a laboratory, where subjects have foreknowledge about the stimuli (Gracely, 1999). In contrast, clinical pain is more unpredictable and threatening. For example, a study of cancer patients found that those who believed that physical therapy-induced pain was cancer-related showed higher ratings of pain intensity and unpleasantness compared to those who attributed their pain to other factors, highlighting the role of meaning and interpretation (Smith et al., 1998). Another investigation noted that pain intensity ratings are strongly affected by interpretations of stimuli as more or less tissue-damaging, a consideration that would rarely apply to most laboratory settings (Arntz and Claassens, 2004). Finally, a study of fibromyalgia patients reported strong correlations between catastrophizing and clinical pain but no associations with responses to noxious mechanical stimuli administered in a laboratory (Gracely et al., 2004).

Sex-related variation in catastrophizing appears to emerge relatively early in development, probably well before most individuals have had any substantive experience with chronic pain. Catastrophizing is more common among adolescent school girls than boys, and was associated with more pain and pain medication use in a survey of high school students (Bedard et al., 1997). Indeed, this sample consists of healthy college-age students with no history of chronic pain. Unfortunately, while it suggests some consequences of sex differences in catastrophizing, the present study can offer little insight into its causes; such information will require longitudinal studies with long follow-up periods in children and adolescents.
[....]
While sex differences in laboratory pain responses are generally robust, catastrophizing does not appear to play a role in producing these male–female discrepancies. Laboratory pain responses are related to the brain's response to noxious stimulation (Coghill et al., 2003), to quality of life (Edwards et al., 2003c), and can prospectively predict clinical pain (Granot et al., 2003). Illuminating the mechanisms producing sex differences in experimental pain responses may therefore have important clinical implications. The fact that catastrophizing did mediate sex differences in day-to-day pain supports prior work in osteoarthritis patients. Importantly, catastrophizing mediated this association even after controlling for negative mood, highlighting catastrophizing's unique effects. Catastrophizing is observed in community residents who report no current pain (Buer and Linton, 2002), is fairly stable across time (Sullivan et al., 2001), and is a risk factor for worsening pain (Keefe et al., 1989 and Haythornthwaite et al., 2003). As such, it certainly warrants further attention as a marker for individuals at high risk for the onset or worsening of pain, as a target of treatment, and as an important variable in shaping group differences in the clinical experience of pain.

Gender

Fat, protein, and pain

Dietary fat and protein interact in suppressing neuropathic pain-related disorders following a partial sciatic ligation injury in rats
Jordi Péreza, et.al
DOI
Abstract:

Chronic neuropathic sensory disorders (CNSD) of rats receiving a partial sciatic nerve ligation injury (the PSL model) are suppressed by dietary soy protein. Although previously shown to modify nociceptive behavior in acute pain models, dietary fat has never been tested for its putative analgesic properties in chronic pain states. Here we tested the role of dietary fat, protein and fat/protein interactions in the development of tactile allodynia and heat hyperalgesia in PSL-injured rats. Male Wistar rats were fed nine different diets, comprising of three proteins (soy, casein and albumin) and three fats (corn, soy and canola) for a week preceding PSL injury and for 2 weeks thereafter. Rats' responses to tactile and noxious heat stimuli were tested before surgery and 3, 7 and 14 days afterwards. Tactile and heat sensory abnormalities following PSL injury were significantly different among the nine dietary groups. Consumption of corn and soy fats suppressed the levels of tactile and heat allodynia and hyperalgesia, whereas consumption of soy and casein proteins was associated with lower levels of heat hyperalgesia but not tactile allodynia. A significant fat/protein interaction was found for the heat but not tactile stimuli. We conclude that dietary fat is a significant independent predictor of levels of neuropathic sensory disorders in rats and that this effect is accentuated by dietary protein. The mechanisms by which fat suppresses neuropathic disorders have yet to be determined.

Predictors of disability

Self-efficacy, fear avoidance, and pain intensity as predictors of disability in subacute and chronic musculoskeletal pain patients in primary health care
Denison, et.al
DOI

Disability is proposed to be an important outcome in pain research (Deyo et al., 1994), and 30% of persons with neck, shoulder, or back pain may be expected to report limitations in daily life (Picavet and Schouten, 2003). Psychological factors are related to both the onset and development of spinal pain and disability (Linton, 2000). Self-efficacy, i.e. one's confidence in performing a particular behavior and in overcoming barriers to that behavior (Bandura, 1977 and Bandura, 1997), is believed to be an important mediator of disability related to pain. Self-efficacy was found to influence adjustment to a pain condition (Jensen et al., 1991), and pain-related disability (Estlander et al., 1994 and Lackner et al., 1996), to mediate the relationship between pain intensity, disability, and depression (Arnstein, 2000 and Arnstein et al., 1999), to predict lifting capacity (Lackner and Carosella, 1999), and pain behaviour and avoidance (Asghari and Nicholas, 2001) in chronic pain patients.

During the last decade, fear avoidance (Kori et al., 1990 and Vlaeyen et al., 1995) has gained increased empirical support as a mediator of disability in chronic pain (Vlaeyen and Linton, 2000). Empirical support for fear avoidance in relation to disability comes from several studies (Al-Oubadi et al., 2000, Buer and Linton, 2002, Crombez et al., 1999, Fritz and George, 2002, Fritz et al., 2001, Geisser et al., 2000 and Picavet et al., 2002). In a primary health care setting, however, van den Hout et al. (2001) showed that pain intensity and pain catastrophizing were better predictors of disability than pain-related fear. When prediction of disability by both self-efficacy and fear avoidance was examined simultaneously, self-efficacy was found to be the more powerful predictor (Ayre and Tyson, 2001).

Most studies concerning self-efficacy, fear avoidance, and disability have been conducted in secondary or tertiary health care settings where patients are highly selected due to the referral filtering process (Turk and Rudy, 1990). However, most MSP patients are managed in primary health care, and results from secondary or tertiary settings may not necessarily generalise to primary health care patients. Specifically, patients who remain in primary health care may be expected to be less disabled than patients who are referred to specialised pain clinics or rehabilitation clinics. Since self-efficacy may explain why patients persist in confronting daily activities in the face of obstacles such as pain, we argue that it is a more important predictive factor than fear avoidance in primary health care clients. Thus, the purpose of this study was (1) to test the hypothesis that self-efficacy is a better predictor of disability than fear avoidance variables and pain intensity in a primary health care sample of patients with subacute, chronic or recurring MSP, and (2) to replicate the findings in a second sample.
[....]
The results of this study confirmed our hypothesis that self-efficacy is a better predictor of disability than fear avoidance variables and pain intensity in a primary health care sample of patients with subacute, chronic, or recurring musculoskeletal pain. The results were replicated in a second sample. Gender, age, and pain duration were not significantly correlated to any of the variables in the regression model.

Bivariate correlation analyses showed that self-efficacy was significantly, and negatively, associated with disability, which is in accordance with the results reported by Arnstein et al., 1999 and Arnstein, 2000, and Lackner et al. (1996). In both samples self-efficacy showed the highest correlations with disability, as compared to pain catastrophizing and kinesiophobia. Self-efficacy correlated (negative association) with pain catastrophizing (r=-0.44, P<0.001), and kinesiophobia (negative association) in both samples (r=-0.32 and -0.38, P<0.001). The latter finding is consistent with the results of Ayre and Tyson (2001) who found a significant negative correlation between self-efficacy and fear avoidance in a sample of patients with chronic low back pain. However, the squared correlation coefficients, representing 10 and 15% of shared variance, respectively, in the two samples in the present study indicate that these two constructs were not overlapping to a great extent.

The bivariate analyses also showed positive and significant associations of fear avoidance variables with disability. This is in accordance with other studies reporting significant bivariate correlations (positive associations) between pain catastrophizing or pain-related fear, and disability (Crombez et al., 1999, Fritz and George, 2002, Fritz et al., 2001, Koho et al., 2001 and van den Hout et al., 2001).
[....]
The fear avoidance variables did predict a unique proportion of the variation in PDI scores in both samples, albeit considerably smaller than did self-efficacy. One explanation may be that fear avoidance is a more important construct in patients who are more dysfunctional and therefore managed in secondary and tertiary health care settings. Much of the work regarding fear avoidance and disability comes from pain clinic or rehabilitation program samples, e.g. Waddell et al., 1993, Vlaeyen et al., 1995 and Crombez et al., 1999, where patients are highly selected. The primary health care samples in the present study are likely to be more functional and better adjusted than the samples used to develop the fear avoidance construct. van den Hout et al. (2001), using a primary health care sample found, for example, that pain-related fear was a less important predictor of disability than pain intensity and pain catastrophizing. Fear avoidance has, however, been shown to predict disability (Picavet et al., 2002) and activities of daily living (Buer and Linton, 2002) in population-based samples, and to be present in acute stages of low back pain (Fritz et al., 2001). Thus, fear avoidance seems to be present in patients in different stages of MSP and at different levels of health care. Further research involving both self-efficacy and fear avoidance in different types of samples and settings will clarify this matter.

Pain intensity did not emerge as a consistently-significant predictor of disability in the two samples, which is contrary to the results reported by van den Hout et al. (2001). Because van den Hout et al. measured pain by the McGill Pain Questionnaire, which is a measure of both pain intensity and pain quality, the different modes of pain measurement may explain the differing results. Another possible explanation is that all subjects in the study of van den Hout et al. (2001) were sick-listed at entry of the study, as compared to about 37% of the subjects in both our samples (Table 1), indicating that our samples may have been less influenced by pain intensity.

Pain duration did not correlate significantly with any of the variables in the model, although pain duration ranged from 1 month to several years in both samples. Patients who are able to cope with their pain are likely to remain in primary health care (Turk and Rudy, 1990), and for those patients, pain duration may not be of great importance.
[....]
The clinical implications of the results in this study involve the need for primary health care professionals to focus on pain-related beliefs rather than on pain intensity reports in these patients. By relying on knowledge of pain duration and assessment of pain intensity alone to guide management, clinicians are likely to overlook important aspects of disability, and subsequently to engage in ineffective treatment strategies. As an alternative, systematic assessment of self-efficacy beliefs and fear avoidance beliefs regarding activities relevant for daily living would make a better starting point in the management process. Treatment strategies should focus on improving functional abilities related to specific and prioritised activities, using a small-steps approach to ensure success, thus enhancing self-efficacy and reducing fear.

Analgesia in cognitively impaired kids

Analgesia following surgery in children with and without cognitive impairment
Jeffrey L. Koha, et al.
DOI

Abstract:

Both children and adults with cognitive impairment (CI) have historically been excluded from research examining pain. This is unfortunate since patients with CI may be at higher risk for experiencing pain or having their pain undertreated due to the difficulty of pain assessment and communication. There are now several published reports about the general pain experience of both adult and pediatric patients with cognitive impairment. The purpose of this study was to compare the amount and type of pain medication administered in children with and without CI after surgery to ascertain if there were any differences in analgesic administration patterns between these two groups. One hundred and fifty-two children with borderline to profound CI and 138 non impaired (NI) children were recruited to participate. Analgesic administration data include type and amount of opioid, type of non-opioid medication, and prescribed discharge medications. Results of this study show that children with CI undergoing surgery received less opioid in the perioperative period than children without CI. However, children with CI received comparable amounts and types of analgesics in the postoperative period as children without CI.

Models of pain catastrophizing

Do we need a communal coping model of pain catastrophizing? An alternative explanation
Rudy Severeijnsa, et.al
DOI

Undoubtedly, one of the most robust findings in contemporary psychological pain research is the important role of pain catastrophizing. Despite the growing body of research on pain catastrophizing (for an extensive overview see Sullivan et al., 2001), there is still conceptual confusion about the construct, which revolves around the question whether or not pain catastrophizing is to be considered a form of coping. An illustrative example of the polemic around this question can be found in a 1999 issue of Pain Forum (Geisser et al., 1999, Haythornthwaite and Heinberg, 1999, Keefe et al., 1999 and Thorn et al., 1999). Related to this conceptual confusion is the lack of a guiding theoretical framework (Keefe et al., 2004). Sullivan et al. (2001) give an extensive and a thorough review of the literature on pain catastrophizing and discuss several models that can have a heuristic function and may help to sort and understand the research data on pain catastrophizing. One of these models in particular, the communal coping model (CCM) of catastrophizing (Sullivan et al., 2001 and Sullivan et al., 2000) is clearly taking root in pain research lately.

In this topical review, a case is made for placing pain catastrophizing within the transactional stress and coping model of Lazarus and Folkman (1984). It is argued that the CCM in its current formulation might actually contribute to the conceptual confusion around the construct of pain catastrophizing that was mentioned previously. This finally leads to the question of whether we actually need a CCM of catastrophizing.
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In their transactional model of stress and coping, Lazarus and Folkman (1984) make a clear distinction between the concepts of beliefs, appraisal, and coping.

With the concept of beliefs, Lazarus and Folkman (1984) refer to a person characteristic that is an important determinant of appraisal. Particularly important for the present discussion are generalized beliefs about personal control that have to do with feelings of mastery and confidence. They are conceptualized as stable personality dispositions.

According to Lazarus and Folkman (1984), appraisal can be understood as an evaluative process. They distinguish between primary appraisals that involve evaluating a particular event as irrelevant, benign-positive, or stressful with regard to a person's wellbeing and secondary appraisals that involve evaluating a particular event with respect to coping options and their possible effectiveness. Both interact with each other and influence whether and which coping efforts will be attempted.

Finally, coping is defined as both behavioral and cognitive efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person (Lazarus and Folkman, 1984).

In 1995, Sullivan et al. (1995) already discussed that at a descriptive level there are similarities between the three subscales of the pain catastrophizing scale (PCS) on the one hand (i.e. magnification, rumination, and helplessness) and primary and secondary appraisal processes on the other hand. Magnification and rumination may reflect a focus on and evaluation of painful stimuli as extremely threatening whereas helplessness reflects the evaluation of painful stimuli as unable to cope with. Furthermore, people may possess enduring beliefs or schema about the threat value of painful stimuli or their ability to effectively cope with painful stimuli (Sullivan et al., 1995).

[...]

Based on the finding that pain catastrophizing mediates the gender–pain relationship, Sullivan et al., 2000 and Keefe et al., 2000 proposed a communal coping model (CCM) of pain catastrophizing. In this model, pain catastrophizing is conceptualized as being part of a broader, interpersonal or communal coping style in which it serves a social communicative function. At the core of the model is the tenet that dealing with stress within a social, interpersonal, or relational context, for instance by soliciting social support, assistance, or empathic reactions from (significant) others, might be more important than pain or stress reduction per se. To the extent that catastrophizing serves this goal it may be considered adaptive although it has detrimental consequences for the pain problem itself.

However, placing pain catastrophizing within a communal coping framework passes over the fact that pain catastrophizing is a theoretical construct with an explicitly cognitive connotation. Therefore, it is rather confusing to operationalize catastrophizing other than in a cognitive way. Furthermore, these catastrophizing cognitions or appraisals cannot serve a social communicative function in and of themselves because they are not observable. Rather, their sheer existence can only be inferred by asking people to complete the PCS or the CSQ or from the behavior, either verbal or nonverbal, of those who catastrophize about pain. This behavior, of course, may or may not serve a social communicative function. So, pain catastrophizing could only serve a social communicative function indirectly. Again, however, it is quite confusing to define the nature of a process, which is cognitive in the case of pain catastrophizing, in terms of its potential function or one of its effects. Analogously, although one of the effects of pain behavior might be that people become less active and develop a disuse syndrome, this does not mean that pain behavior should be defined in terms of disuse. Therefore, we argue here that the term ‘pain catastrophizing’ should be used in its pure, that is, cognitive meaning. By placing catastrophizing within a coping framework, the conceptual confusion that already exists may even be enhanced.

According to Sullivan et al. (2001), several research findings support a CCM explanation of catastrophizing. For example, Keefe et al. (1997) found that catastrophizing was related to lower spousal ratings of self-efficacy for pain. More recently, some hypotheses, derived from the CCM have been examined in research. Keefe et al. (2003) found that cancer patients who catastrophized about their pain reported receiving higher levels of caregiver instrumental support. Caregivers of these patients reported having higher levels of stress and critical behaviors and rated the patients as having more pain and engaging in more pain behaviors. Giardino et al. (2003) showed that there was a positive association between pain catastrophizing on the one hand and solicitousness and pain reports on the other hand. Perceived solicitousness and the type of social relationship (spouse or partner versus someone else) moderated the association between catastrophizing and pain reports. Finally, Sullivan et al. (2004) found that compared to low catastrophizers, high catastrophizers displayed pain behaviors for a longer duration and used fewer pain coping strategies in the presence of an observer.

Overall, the results of these studies seem to support a CCM interpretation of pain catastrophizing in that they, at least partially, confirm some of the predictions derived from the CCM, and demonstrate that pain catastrophizing has interpersonal correlates. Nevertheless, the question is justified whether the same predictions can also be derived from existing models of pain catastrophizing, in particular the appraisal model of pain catastrophizing for which supporting research data have been found as well.

According to the appraisal model of pain catastrophizing primary appraisal processes (magnification and rumination) and secondary appraisal processes (helplessness) interact and determine whether and which coping efforts will be attempted. Indeed, several studies that have started from the transactional model of stress and coping have found specific relations between appraisals of stressful events and ways of coping (Dunkel-Schetter et al., 1992, Dunkel-Schetter et al., 1987, Folkman et al., 1986, Knussen and Lee, 1998 and Turner et al., 1987). More specifically, researchers have found that threats to one's own physical health were associated with more seeking of social support (Folkman et al., 1986). Also, events that were appraised as highly stressful were characterized by support from significantly more people and by greater amounts of informational and emotional support than were events that were appraised as low in stress (Dunkel-Schetter et al., 1987). Finally, perceived stressfulness of having cancer was associated with significantly greater coping through social support (Dunkel-Schetter et al., 1992).

The point to be made here is that from this perspective and based on these findings, predictions may be made that individuals who focus on their pain (rumination), think that something terrible might happen to them because of the pain (magnification), and feel unable to effectively cope with their pain (helplessness), may adopt a coping style that, either intentionally or not, elicits social support and attention by means of overtly displaying distress, fear, helplessness, or pain behavior. The prediction of the CCM that the presence of other people serves as a discriminative stimulus for these overt displays of distress is not surprising in this context, for what is the use of showing, for example, that you are helpless if there is no one around to respond or to help you?

In a recent study by Sullivan et al. (2004) in which supportive evidence for the CCM is reported, it is proposed in the discussion section that ‘strategies used to maximize the proximity of others may be motivated, at least in part, by low levels of coping efficacy’ (italics by the present authors). However, in our opinion they fail to follow this hypothesis to its logical and ultimate consequence, which is that exactly for that reason it may be unnecessary to hypothesize that some individuals prefer a more communal or interpersonal approach to coping and that catastrophizing plays an important role in communicating this approach. Rather, within an appraisal model of catastrophizing, it is the features of catastrophizing itself that directly impinge on these interpersonal correlates. In this view, the predictions derived from the CCM of pain catastrophizing can also be accounted for by the appraisal model of pain catastrophizing.

Summarizing the previous discussion, some tentative conclusions and recommendations can be made. First, an appraisal model of pain catastrophizing offers an attractive theoretical framework, is supported by research data, and might function as a guide for future catastrophizing research. Second, pain catastrophizing should be defined in terms of its cognitive nature and not in terms of its potential function or effects. Third, the fact that catastrophizing has interpersonal correlates is intrinsic to the very nature of pain catastrophizing and can be attributed to the effects of appraisals of threat and helplessness (that is, low levels of coping efficacy) on coping behavior (that is, overt display of distress and helplessness, as well as pain behavior), which in turn is likely to evoke social attention and support. Finally, to the extent that these conclusions can be validated empirically we doubt that there is a need for a CCM of catastrophizing in which it is hypothesized that individuals who catastrophize about their pain do so because they prefer an interpersonal approach to dealing with painful stimuli. Instead, we would rather argue the opposite, namely that these individuals seek assurance and social support because they focus on their pain, experience their pain as threatening, and feel helpless in dealing with their pain. Of course, further research will have to demonstrate which of these two models, the CCM or the appraisal model, has more merits.

Editorial on headaches and depression in Pain 11(3)

The relation between depression and headache is
complex. In clinical practice depressive mood is frequently
encountered in patients with frequent headaches, including
tension-type headache (TTH), but overt major depression is
rather rare. In a cohort of subjects with TTH of any severity
the incidence of depression was not increased (Merikangas
et al., 1994). There is a bidirectional relationship in lifetime
prevalence between migraine and major depression,
suggesting a shared cause. Severe non-migrainous headaches
(most of which were frequent tension-type headaches),
however, were not predicted by major depression,
while they were themselves predictive of first-onset major
depression (Breslau et al., 2000). It was therefore felt by
some that depression was merely a secondary phenomenon
in disabling TTH, the more so that such headaches can be
ameliorated by tricyclics at low doses supposed to have little
or no antidepressant effect.

The study by Janke et al. (2004) in this issue is of
paramount importance for this discussion as it shows for the
first time that major depression favours the occurrence of
stress-induced headache in subjects suffering from frequent
TTH and that this is associated with increased pericranial
palpation tenderness. Pressure-pain thresholds were also
decreased at an extracephalic site in the depressed TTH
sufferers. The neurobiological mechanisms through which
depression promotes TTH are likely to be central sensitisation
and dysfunctioning of descending pain control pathways.
It cannot be concluded from the study whether
depression per se or increased stress in the depressed subjects
are responsible for the observed changes. From findings with
brain stem reflexes we have previously hypothesised that the
limbic control of descending pain control systems might be
abnormal in chronic TTH patients (Schoenen, 1990).

Fortunately for our PhD students, the study by Janke
et al. (2004) does not answer all questions. For instance,
they were not able to recruit depressed subjects with less
than 12 headaches per year, which by itself suggests that
depression may cause TTH, but leaves open the question
whether depression is able to favour TTH by itself.
Although the study convincingly shows that depression
predisposes to stress-induced headache episodes, it does not
prove that it is the major culprit in frequent or chronic TTH.
It could only be an aggravating factor like for instance
hormonal changes in the perimenstrum (which was not
taken into account in the present study). The fact that
specific serotonin reuptake blockers, though effective
antidepressants, are not useful for chronic TTH (Schoenen,
2000) would not favour a primary pathogenic role for
depression. The subjects recruited by Janke et al. (2004) had
major depression which is not the rule in clinical samples of
TTH patients. It would be interesting to know whether
depressive mood (scores !18 on Beck’s inventory) also
increases onset of TTH following laboratory stress. Finally,
considering the abovementioned bidirectional relationship
between migraine and depression, it seems worthwhile to
perform a similar study in migraineurs in order to determine
if depression favours migraine attacks or certain interval
headaches which can be indistinguishable from TTH.
In summary, despite its limitations this study is a
milestone in headache research as it provides experimental
evidence that depression may be the villain in tension-type
headache, and not just a bystander.

J. Schoenen
Departments of Neuroanatomy and Neurology,
University of Liege, 20,

Grrr....

In the new issue of Philosophy and Public Affairs, David Sussman gives essentially my view on why torture is bad.

torture forces its victim into the position of colluding against himself through his own affects and emotions, so that he experiences himself as simultaneously powerless and yet actively complicit in his own violation....torture turns out to be not just an extreme form of cruelty, but the pre-eminent instance of a kind of forced self-betrayal, more akin to rape than other kinds of violence

Damn, there's one less article I'll be sending out. That said, its worth a read. Check it out if you have access.

FDA OKs Ecstasy study in cancer patients

Dec. 28, 2004 | Washington -- The illegal club drug Ecstasy can trigger euphoria among the dance club set, but can it ease the debilitating anxiety that cancer patients feel as they face their final days?

The Food and Drug Administration has approved a pilot study looking at whether the recreational hallucinogen can help terminally ill patients lessen their fears, quell thoughts of suicide and make it easier for them to deal with loved ones.

'End of life issues are very important and are getting more and more attention, and yet there are very few options for patients who are facing death,' Dr. John Halpern, the Harvard research psychiatrist in charge of the study, said Monday.

The small, four-month study is expected to begin early next spring. It will test the drug's effects on 12 cancer patients from the Lahey Clinic Medical Center in the Boston area. The research is being sponsored by the Multidisciplinary Association for Psychedelic Studies, a nonprofit group that plans to raise $250,000 to fund it.

MAPS, on its web site, touted the study's approval, saying 'the longest day of winter has passed, and maybe so has the decades-long era of resistance to psychedelic research.'

The FDA would not comment, but this will be the second FDA-approved study using Ecstasy this year. South Carolina researchers are studying the effects of Ecstasy on 20 patients suffering from post traumatic stress disorder.

Ecstasy, known scientifically as MDMA for methylenedioxymethamphetamine, is a chemical cousin of methamphetamine and typically induces feelings of euphoria, increased energy and sexual arousal. But it also suppresses appetite, thirst and the need to sleep, and in high doses can sharply increase body temperature, leading to kidney and heart failure, and death.

It peaked in 2001 as a trendy recreational drug used by youth at gatherings called 'raves' and dance clubs.

Halpern, who has done other research on the effects of hallucinogenic drugs, said that some, when used properly, can have medical benefits. He said that unlike LSD, Ecstasy is 'ego-friendly,' and unlike some pain medications it does not oversedate people and make them foggy and unsteady.

Instead, he said, it can reduce stress and increase empathy. There are anecdotal reports, he said, of people dying of cancer who take Ecstasy and they are able to talk to their family and friends about death and other subjects they couldn't broach before.

'I'm hoping that we can find something that can be of use for people in their remaining days of life,' he said. If there are no significant problems, he said broader studies would follow this one.

In addition to FDA approval, the study has also received review board authorization from the Lahey Clinic and Harvard Medical School's psychiatric facility, McLean Hospital. Halpern is awaiting a license from the federal Drug Enforcement Administration.

It's been more than 40 years since Harvard has been the site of psychedelic drug research -- including the infamous LSD studies of Timothy Leary in 1963 and the Good Friday Experiment in 1965, done by Leary's student Walter Pahnke, studying the effects of psilocybin mushrooms on religious people.

But 'this is not about trying to create some sensationalistic storm,' Halpern said. 'This is about trying to help these patients in a meaningful way.'"

New Pain Reliever That Blocks Nerve Channels

From the NYT:

WASHINGTON, Dec. 28 (AP) - The government approved on Tuesday a drug that offers a new way of fighting severe pain, an option for patients who no longer benefit from morphine and other traditional pain medications.

The drug, made by the Elan Corporation, is the first in a new class of drugs that selectively blocks the nerve channels responsible for transmitting pain signals. It will be marketed as Prialt and should be available by the end of January.

'When you've taken all the kinds of pain medication that there is and you still have pain, that is a very frightening situation,' said Dr. Lars Ekman, president of research and development for Elan, which is based in Dublin. 'When you have that kind of pain, there is nowhere to go.'

The drug is part of a new class known as N-type calcium channel blockers. It is known chemically as ziconotide.

The Food and Drug Administration approved the drug for patients who no longer receive relief from morphine and have moved to the next level of treatment, which involves a pump that delivers medicine directly to the area around the spine.

Prialt has been studied in patients with cancer, AIDS and other afflictions that produce chronic pain. More than 1,200 patients took part in three clinical trials.

There are side effects, and the F.D.A. said it would require its strongest warning to appear with the drug. Side effects may include dizziness, drowsiness and altered mental status, with patients confused at times.

Despite the side effects, the drug was approved because there are no other options for these patients and the benefits outweighed the risks, the agency said.

Not NSAIDs too

Mediagenic doctors, start your engines.

A new study has found that Aleve, a popular over-the-counter painkiller made by Bayer, could increase heart problems, and federal officials are warning patients not to exceed the recommended dose of two 200-milligram pills a day or continue therapy for more than 10 days without consulting a physician.

It was the fourth big-selling pain medicine in recent months to be suspected of hurting the heart, and federal drug officials said that similar drugs, like Advil, might also increase heart risks.

The study, sponsored by the National Institutes of Health, was intended to measure whether Aleve and Celebrex, made by Pfizer, might prevent Alzheimer's disease. Nearly 2,500 patients were given one of the two drugs or a placebo and were followed for three years. Those taking Aleve had a 50 percent greater rate of heart problems - including heart attacks and stroke - than those given a placebo. The Celebrex patients saw no increase in heart events.

The latest findings follow an announcement Friday that a different national study found that those given high doses of Celebrex had a 240 percent increase in heart problems, including death. Merck executives withdrew their painkiller Vioxx after a study found that it increased the risk of heart attack and stroke by more than 100 percent. Also, Pfizer announced recently that a study of Bextra found that it increased the risk of heart attacks in those who have had cardiac surgery.

"This illustrates the fundamental dynamic that all drugs have risks," said Dr. Steven Galson, acting director of the Food and Drug Administration's center for drug evaluation and research. "All should be taken carefully."

Federal drug officials said that the entire class of painkillers known as nonsteroidal anti-inflammatories - drugs that include Celebrex, Advil and Mobic - could cause worrisome effects on the heart. Sales of Celebrex, along with other anti-inflammatories like Advil and Mobic, are expected to fall as a result.

"We know that there are other phenomena that occur across these class of drugs, including gastrointestinal bleeding," said Dr. Sandra Kweder, deputy director of the F.D.A.'s office of new drugs. Heart problems "may be another class phenomenon."

Dr. Kweder said that the agency was studying the results of this latest study and "will be assessing what regulatory actions are appropriate over the next day or two." Researchers stopped the study, but patients will be monitored. Link

Seriously, did we really just learn that "All drugs have risks"? Though it is good of the FDA to do so much to quell the panic that we've all now seen on TV and Radio. Hopefully, everyone will flock to Tylenol --the only over-the-counter non-NSAID (its more properly an analgesic)-- and start killing their livers to avoid heart attacks.

These latest revelations do highlight some serious ethical issues about how the FDA tests and approves drugs (in particular how they deal with drugs taken daily for years), but the public reaction does strike me as overblown.
Categories: Legal

Depression, anxiety, and pain

Depression and anxiety associated with three pain conditions: results from a nationally representative sample
McWilliams, et. al
DOI

Numerous studies have found pain conditions to be associated with self-reports of psychological distress and psychiatric disorders. Several important clinical implications of these associations have been noted. For example, information regarding specific patterns of comorbidity could guide clinicians' efforts to detect psychiatric disorders in patients with pain. As well, psychopathology (i.e. depression) has been found to be associated with poor pain-related outcomes such as elevated pain intensity, functional limitations, and non-recovery (see Bair et al., 2003).
[....]
McWilliams et al. (2003) found significant associations between arthritis and each of the mood and anxiety disorders considered. Given the lack of attention to anxiety disorders in the pain literature, it was particularly noteworthy that the associations between arthritis and several of the anxiety disorders (i.e. panic disorder and posttraumatic stress disorder) were stronger than the association between arthritis and depression. Evidence from other epidemiological studies indicates that migraine may also be more strongly associated with anxiety disorders, particularly panic disorder (e.g. Breslau and Davis, 1993 and Swartz et al., 2000) and generalized anxiety disorder (GAD) (e.g. Merikangas et al., 1990), than with depression. The present study utilized data from another nationally representative sample, the Midlife Development in the United States Survey (MIDUS), in an attempt to replicate these earlier findings with arthritis and migraine and to extend this line of investigation to back pain. It was hypothesized that each of these pain conditions would be significantly associated with the psychiatric disorders included in the MIDUS and that each pain condition would be more strongly associated with the anxiety disorders than with depression.
[....]
Discussion
Data from the MIDUS yielded significant positive associations between three pain conditions (arthritis, migraine, and back pain) and common mood and anxiety disorders (depression, panic attacks, and GAD). Multivariate logistic regression analyses indicated that these associations remained after adjusting for a wide range of potential confounding variables including age, gender, education level, race, and the presence of another pain condition. These findings were noteworthy because previous epidemiological studies concerning psychopathology and both migraine (e.g. Merikangas et al., 1990 and Stewart et al., 1994) and arthritis (e.g. McWilliams et al., 2003) have generally not adjusted for comorbid pain conditions.

Medical or health conditions that do not primarily involve pain are also associated with psychopathology (e.g. Wells et al., 1988). A third series of analyses examined whether each pain condition could account for unique variance in the psychiatric disorders beyond that accounted for by the number of other medical/health conditions present. The majority of the associations remained statistically significant, but the association between arthritis and panic attacks and the association between back pain and GAD did not. This pattern of findings raises the possibility that the association between arthritis and panic attacks and the association between back pain and GAD found in Models 1 and 2 reflect a more general association between health problems and psychopathology rather than more specific associations between these respective pain conditions and psychiatric disorders. Several of the other medical conditions included (e.g. recurring stomach problems) likely involved pain, so it is possible that the third set of analyses also adjusted for the presence of other forms of pain. Nonetheless, this procedure was used because the focus of the study was on three types of pain (rather than pain in general) and the goal of these analyses was to adjust for other medical and health conditions regardless of whether they involved some pain.

Consistent with previous studies, depression was significantly associated with each of the pain conditions. Based on previous research demonstrating substantial comorbidity between mood and anxiety disorders (e.g. Krueger, 1999 and Vollebergh et al., 2001), it was expected that anxiety disorders would also be associated with the pain conditions. Furthermore, several studies (e.g. Breslau and Davis, 1993; McWilliams et al., 2003 and Merikangas et al., 1990) have found pain conditions to be more strongly associated with several anxiety disorders than with depression. The present study replicated this pattern of findings and extended it to back pain. The bivariate odds ratios clearly indicated that each pain condition was more strongly associated with the anxiety disorders than with depression. However, this pattern was less consistent in the analyses that adjusted for other medical/health conditions. Three additional logistic regression analyses were used to examine whether the association between multiple pain conditions and psychopathology would be greater than the associations between pure pain conditions (i.e. those with only one pain condition) and psychopathology. The overall pattern was consistent with previous research (e.g. Dworkin et al., 1990) indicating that those with multiple physical complaints have higher rates of psychopathology than those without a physical complaint or those with a single complaint.

There is a paucity of research or clinical literature concerning anxiety disorders in relation to pain conditions. The findings of this and earlier studies suggest that such attention is warranted. More sophisticated approaches to the assessment of anxiety are required in pain-related contexts. For example, a recent issue of Arthritis Care and Research focused on assessment issues included an article on depression (Smarr, 2003), but anxiety was only addressed in an article considering ‘other measures of psychological well-being’ ( Schiaffino, 2003). Furthermore, the anxiety measure selected was the State-Trait Anxiety Inventory ( Spielberger, 1983), which includes numerous depression-related items (see Bieling et al., 1998), and appears to be more accurately described as a measure of general distress. Several self-report measures designed to assess symptoms or constructs directly related to specific anxiety disorders are available. Examples include the Penn State Worry Questionnaire ( Meyer et al., 1990) for GAD and the Mobility Inventory ( Chambless et al., 1985) for agoraphobia. As well, the CIDI-SF could readily be incorporated into assessment procedures and represents a successful compromise between the need for diagnostic-specific assessment procedures and the time constraints found in many contexts.

Temporal relationships between pain conditions and depression have long been of interest (see Fishbain et al., 1997). However, the temporal relationships between pain conditions and anxiety disorders remains largely ignored. Breslau and Davis's (1993) longitudinal study of the association between migraine and psychopathology in a community sample of young adults provides a rare exception to this general rule. They found that individuals who reported having their last migraine a year or more prior to the baseline interview were at increased risk of experiencing first incidence depression and panic disorder at a 14-month follow up. These findings suggest that depression, panic, and migraine share common predispositions and that mood and anxiety disorders are not merely the psychological consequences of a pain condition. Causal relations between anxiety and most other pain conditions have not been investigated.

Theories regarding underlying factors involved in both pain and anxiety disorders have focused on neurochemical mechanisms (e.g. Merikangas et al., 1990). Asmundson et al. (2002) reviewed several potential shared psychological vulnerabilities for posttraumatic stress disorder and pain and noted hyperarousal, hypervigilance, and attentional biases towards somatic cues may be involved in both conditions. These factors have also been implicated in other anxiety disorders, particularly panic disorder, and may be responsible for the associations observed in the present study. Recent conceptualizations of GAD have suggested that worry may be used to suppress somatic anxiety or the hyperarousal associated with perceptions of threat ( Borkovec et al., 2004). It is possible that individuals with pain conditions may use worry as a strategy for reducing somatic arousal associated with pain, and as a result may become prone to developing GAD.

The treatment implications of the associations between pain and psychiatric disorders have focused on pharmacologic interventions (e.g. Stewart et al., 1994). However, in light of their possible shared psychological vulnerabilities, psychological interventions also hold potential for treating comorbid pain and psychiatric disorders. It is noteworthy that psychosocial interventions for psychiatric disorders and pain conditions share several common elements. For example, treatments for depression and pain both focus on increasing activity levels and treatments for anxiety and pain both include strategies for reducing arousal (i.e. relaxation training). It may be possible to develop integrated psychological treatments for both conditions. As well, evidence concerning the temporal relationships between disorders may provide direction in terms of prevention efforts. For example, the findings of Breslau and Davis (1993) suggest that those with a history of migraine would be an appropriate group at which to target anxiety disorder prevention efforts.

Anxiety and headaches

Anxiety sensitivity, fear, and avoidance behavior in headache pain
Norton, et.al
DOI

Abstract
Recent research has implicated anxiety sensitivity (AS), the fear of anxiety-related sensations, as a mitigating factor involved in fear and avoidance in patients with chronic back pain [Understanding and treating fear of pain (2004) 3]. Given reported similarities between individuals experiencing chronic pain and those experiencing recurrent headaches, it is theoretically plausible that AS plays a role in influencing fear of pain and avoidance behavior in people with recurrent headache. This has not been studied to date. In the current study we used structural equation modeling to examine the role of AS in fear and avoidance behavior of patients experiencing recurrent headaches. Treatment seeking patients with recurrent headaches completed measures of AS, headache pain severity, pain-related fear, and pain-related escape and avoidance behavior. Structural equation modeling supported the prediction of a direct significant loading of AS on fear of pain. Headache severity also had a direct loading on fear of pain. Results also revealed that AS and headache severity had indirect relationships to pain-related escape and avoidance via their direct loadings on fear of pain. Headache severity also had a small direct loading on escape and avoidance behavior. These results provide compelling evidence that AS may play an important role in pain-related fear and escape and avoidance behavior in patients with recurrent headaches.
[....]
Discussion
The results of the structural equation modeling provide preliminary, albeit not perfect, support for a similar model to that found by Asmundson and Taylor (1996). Our model, consistent with the Asmundson and Taylor (1996) model, identified AS as having a direct significant relationship to fear of pain in patients with recurrent headaches. Pain severity had a direct significant loading on fear of pain, albeit of a slightly smaller magnitude than AS. Again, this finding was observed by Asmundson and Taylor (1996). As predicted, our model converged with Asmundson and Taylor's in that fear of pain had a very strong direct loading on pain-related escape and avoidance behavior. Contrary to their results, however, we found that pain severity had a small but significant direct loading on pain-related escape and avoidance behavior after accounting for the indirect loading via fear of pain. This discrepancy between our model and that of Asmundson and Taylor (1996) may indicate some differences between the experiences of chronic headache and musculoskeletal pain.
[....]
In conclusion, our results generally support the Asmundson and Taylor (1996) model when employed with a sample of patients experiencing recurring headache. Pain severity and AS both significantly influenced fear of pain, and fear of pain significantly influenced headache-related escape and avoidance behavior. In addition, pain severity had a direct, albeit small, loading on escape/avoidance behavior. These results suggest that treatment strategies that directly target AS may effectively diminish escape and avoidance behaviors in patients seeking treatment for recurrent headache.

Alzheimer's and pain

Pain reactivity in Alzheimer patients with different degrees of cognitive impairment and brain electrical activity deterioration
Benedetti, et. al.
http://dx.doi.org/10.1016/j.pain.2004.05.015

Pain perception and autonomic responses to pain are known to be altered in dementia, although the mechanisms are poorly understood. We studied patients with Alzheimer's disease (AD) whose cognitive status was assessed through the Mini Mental State Examination test and whose brain electrical activity was measured by means of quantitative electroencephalography. After assessment of both cognitive impairment and brain electrical activity deterioration, these patients underwent sensory measurements in which the minimum stimulus intensity for both stimulus detection and pain sensation was determined. In addition, heart rate responses to pain threshold×1.5 were recorded. We found that neither stimulus detection nor pain threshold was correlated to cognitive status and brain electrical activity decline. By contrast, we found a correlation between heart rate responses and deterioration of both cognitive functions and brain electrical activity. In particular, the heart rate increase after pain stimulation was correlated to the presence of slow brain electrical activity (delta and theta frequencies). This correlation was also found for the anticipatory heart rate increase just before pain stimulation. These results indicate that pain anticipation and reactivity depend on both the cognitive status and the frequency bands of the electroencephalogram, whereas both stimulus detection and pain threshold are not affected by the progression of AD. These findings indicate that, whereas the sensory-discriminative components of pain are preserved even in advanced stages of AD, the cognitive and affective functions, which are related to both anticipation and autonomic reactivity, are severely affected. This sensory-affective dissociation is well correlated with the neuropathological findings in AD.

Gender, anxiety sensitivity, and chest pain

Investigating the effect of anxiety sensitivity, gender and negative interpretative bias on the perception of chest pain
Keogh, et. al
http://dx.doi.org/10.1016/j.pain.2004.06.017

Abstract: Research suggests that anxiety sensitivity may be an important component in the negative response to pain sensations, especially those with cardiopulmonary origin. Furthermore, there is experimental evidence to suggest that such effects may be stronger in women than men. The primary aim of the current investigation was to determine the relative roles that anxiety sensitivity and gender have on the pain reports of patients referred to a hospital clinic with chest pain. A total of 78 female and 76 male adults were recruited on entry to a Rapid Access Medical Clinic. All patients had been referred with chest pain, and were administered a range of pain and anxiety measures prior to diagnosis. Results indicate that males were more likely to receive a diagnosis of cardiac chest pain, whereas females were more likely to receive a diagnosis of non-cardiac chest pain. Additionally, anxiety sensitivity was related to pain in women but not men. Finally, evidence was found for the mediating effect of negative interpretative bias on the relationship between anxiety sensitivity and pain. However, this mediating effect was only found in women. These results not only confirm that anxiety sensitivity is related to greater negative pain responses in women, but that this may be due to an increased tendency to negatively interpret sensations.

Gender

Virtual reality analgesia

I've blogged about virtual reality analgesia before. This seems to confirm that it works via attention/distraction.

Manipulating presence influences the magnitude of virtual reality analgesia
Hoffman, et. al
http://dx.doi.org/10.1016/j.pain.2004.06.013

Introduction: Excessive pain during medical procedures performed in unanesthetized patients is frequently reported (Gilron and Bailey, 2003; Karling et al., 2002; Melzack, 1990; Schechter, 1989 and Shang and Gan, 2003) despite the widespread use of analgesic therapies. In clinical settings, side effects of opioid analgesia (e.g. nausea, post-procedure sedation, cognitive dysfunction, and constipation) limit dosage. In contrast, non-pharmacologic techniques typically produce minimal and short-lived side effects, and may serve as valuable adjuncts to traditional pharmacologies. One such non-pharmacologic technique is distraction, which has been shown to help reduce procedural pain in several settings ( Fernandez and Turk, 1989 and Tan, 1982).

Researchers have recently explored the use of immersive virtual reality (VR) as a pain control technique that can be used in combination with traditional pharmacologic therapies. Subjective reports of pain during a variety of painful medical procedures in the clinical setting have been shown to drop approximately 40–50% when patients are distracted by immersive VR (Hoffman et al., 2000a; Hoffman et al., 2000b; Hoffman et al., 2001a; Hoffman et al., 2001b; Hoffman et al., 2004a and Steele et al., 2003).

We theorize that VR analgesia works via an attentional mechanism. Humans have a limited amount of conscious attention available (Kahneman, 1973). Pain requires conscious attention ( Chapman and Nakamura, 1999 and Eccleston and Crombez, 1999). VR systems provide computer-generated multi-sensory input (sight, sound, and more rarely touch, taste and/or smell). Such converging sensory input, and the interactive nature of the experience help give patients the illusion of going into the virtual environment, which can make the virtual world presented difficult for the user's brain to ignore. We theorize that the more intense the patient's illusion of going inside the virtual environment, the more his/her attention will be drawn into the virtual world ( Hoffman, 1998 and Hoffman et al., 2003a), leaving less attention available to focus on pain.

In the present study, some subjects (High Tech VR) used VR hardware (VR helmet, headphones and headtracking system) designed to elicit a strong illusion of VR presence. Others (Low Tech VR) used VR hardware designed to elicit a less compelling illusion of VR presence (see-through VR glasses, no headphones, no headtracking). Regardless of the mechanism of VR analgesia, we predicted that (1) subjects' illusion of ‘going into’ the 3D virtual world (i.e. VR presence) would be greater for the High Tech VR group, and (2) the High Tech VR group would experience more pain reduction than the Low Tech VR group. And we predicted (3) the amount of VR presence reported would be positively and significantly correlated with the amount of pain reduction in VR. In essence, we predicted a measurable dose (increasing VR presence) response (pain reduction) relationship.
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Discussion:
In the current study, we compared the relative effectiveness of Low Tech VR vs. High Tech VR distraction on pain ratings during brief thermal pain stimuli. Subjects showed the predicted dose–response relationship: higher VR presence and more pain reduction in the High Tech VR group than in the Low Tech VR group, and a significant positive correlation between subjective presence ratings and amount of VR pain reduction. The results of the present study and preliminary clinical results (Hoffman et al., 2000b and Hoffman et al., 2001a) are consistent with the notion that pain and VR compete for attention. Although the present study does not specifically identify the mechanism of VR analgesia, we speculate that the more attention is directed towards VR, the less attentional resources are available to process incoming nociceptive signals, and the less pain is consciously experienced.

To date, research exploring VR analgesia has used a within-subjects design (Hoffman et al., 2000a; Hoffman et al., 2000b; Hoffman et al., 2001a; Hoffman et al., 2001b; Hoffman et al., 2004a and Hoffman et al., 2004b), such as comparing pain during 3 min of physical therapy without VR to pain during 3 min of physical therapy with VR within the same physical therapy session ( Hoffman et al., 2000b). Potential nuisance variables such as plasma opioid level or how much sleep the patient had the night prior to the study were all controlled using such a within-subject design. One potential limitation of the within-subjects design is that subjects receive (and are thus aware of) both the experimental and control conditions. In the current study a double-blind, between-groups design was used to help reduce demand characteristics.

Eccelston and Crombez (1999) claim that pain is unusually attention grabbing, making it difficult to distract attention away from pain. Similarly, McCaul and Malott (1984) have proposed that distraction works for mild to moderate pain, but is much less likely to reduce extreme pain. In contrast, preliminary clinical results show that VR is able to distract severe burn patients experiencing extreme pain during wound care ( Hoffman et al., 2000a) suggesting that in comparison to VR, pain does not appear to have privileged access to attentional resources. Why VR is able to compete with extreme pain for attentional resources is an important research question. The present results suggest that the illusion of going into the virtual environment may help explain why VR is so effective for reducing various components of the pain experience.

In a previous VR study not involving pain, Hoffman et al. (2003a) tested the fundamental assumption that VR requires conscious attention. Healthy volunteers monitored a string of numbers from a tape recorder for three odd numbers in a row while in VR (helmet worn and turned on) and without VR (helmet worn but turned off). Participants showed a significant reduction in performance on a divided attention task (accuracy in identifying the consecutive odd numbers) while in VR (74% correct) compared to the control condition (95% correct), and they also estimated that the amount of time they were able to attend to the task of monitoring the numbers was significantly higher with no VR than with VR (96 vs. 65%, respectively).

In the present study, compared to the Low Tech VR group, subjects in the High Tech VR group reported a significant increase in how much fun they had during VR. Pain reduction in VR was correlated with how much fun subjects reported having, and is consistent with severe burn patients who report having fun during wound care and physical therapy in High Tech VR (e.g. Hoffman et al., 2004a). In the present study, increasing the ‘immersiveness’ of the VR hardware also led to higher VR presence ratings and was correlated with pain reduction. Studies exploring medical applications of VR exposure therapy for treating anxiety disorders have also described manipulations of the immersiveness of the VR hardware that increased the illusion of presence and increased treatment effectiveness/clinical outcome ( Hoffman et al., 2003b). We predict that further increasing the immersiveness of VR systems in future studies will further increase the participant's illusion of presence in VR, and may increase the magnitude of VR analgesia. Future laboratory and clinical studies should systematically explore (1) the addition of converging sensory input from visual, sound, tactile, smell and vibrotactile (e.g. surround sound) stimulation, (2) increased interactivity between the participants and the virtual world, and (3) which components of the VR environment (including both hardware and software, and individual differences) contribute to the sense of presence and analgesia. Some manipulations that increase presence may also increase simulator sickness (e.g. going faster through the virtual canyon). Care should be taken to minimize simulator sickness in these more immersive VR systems, especially when used adjunctively in clinical studies in patients at risk for nausea from pharmacologic (opioid) analgesics.

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VR is a promising non-pharmacologic analgesic, especially for patients who must undergo brief painful procedures. Results from the current study suggest design guidelines for VR analgesia systems. Specifically, highly immersive combinations of VR hardware and software that maximize the user's illusion of presence in the VR environment will likely enhance the effectiveness of virtual reality as a non-pharmacologic analgesic. Selecting participants who have a pre-disposition to feel high presence in VR may also be possible in some applications. Furthermore, we speculate that patients may respond better to some virtual worlds than others. Since excessive procedural pain is a widespread problem for the medical community, and these preliminary results provide additional support for the notion that VR might prove valuable for pain control, additional research on this topic is warranted.

Chronic pain and frequent use of health care

Chronic pain and frequent use of health care
Blyth, et. al
http://dx.doi.org/10.1016/j.pain.2004.05.020

Abstract: Little is known about the relationship between chronic pain status and overall use of healthcare. We examined whether disabling chronic pain was associated with more frequent use of healthcare in three settings: primary care, emergency departments, and hospital admissions. We used data from Computer-Assisted Telephone Interviews (CATI) of 17,543 residents in New South Wales, Australia aged 16 and over who were randomly sampled using a population-based two-stage stratified sample and random digit dialling methods. The overall response rate was 70.8%. Compared to chronic pain respondents with no or limited pain-related disability, those with most pain-related disability reported more: primary care visits in the last 2 weeks and last 12 months (adjusted mean number of visits 0.59 vs 0.40 and 10.72 vs 4.81, both P<0.005); hospital admissions (0.46 vs 0.18, P<0.005); and emergency department visits (0.85 vs 0.17, P>0.005). In modelling, having chronic pain per se, or having chronic pain with any level of activity interference predicted health care use after adjusting for age, gender, self-rated health, psychological distress, comorbidity and access to care. Higher levels of pain-related disability predicted health care use more than other pain status variables. There was a strong association between pain-related disability and greater use of services. Further work is needed to understand the nature of this association. Given the fluctuating course of chronic pain over time, there is a significant segment of the population that may be at risk of developing higher levels of disability associated with increased use of services.

Effects of exposure on perception of pain expression

Effects of exposure on perception of pain expression
Prkachin, et. al
http://dx.doi.org/10.1016/j.pain.2004.03.027

I don't normally quote this much from an article, but this one is interesting. Take note my simulation friends.

When a sufferer displays pain, the responses of others can vary. Common affective responses may be sympathy and empathy, but they can include fear, or even pleasure in the other's suffering. Behaviorally, observers often provide assistance or seek ways to soothe the other's suffering; however, they may also criticize, note the evidence of suffering but say nothing or not notice at all. All but the last alternative presupposes that the observer has engaged in some perceptual processing of the event (Prkachin and Craig, 1994). Differences in these responses may affect the sufferer. For example, there is evidence that health-care practitioners underestimate the suffering of pain patients ( Marquié et al., 2003). Such ‘miscalibration’ can affect treatment decisions, thereby influencing the individual's quality of life. Likewise, operant theorists suggest that the manner in which others respond to evidence of pain can set the stage for chronic pain or stoicism ( Fordyce, 1976).

The study of judgments of facial expressions of pain offers a way to understand the perception of the suffering of others. Facial expressions provide evidence about pain that is valid (Craig et al., 2001) and graded in intensity ( Prkachin, 1992 and Prkachin and Mercer, 1989). Observers are sensitive to the information contained in the display ( Prkachin and Craig, 1985 and Prkachin et al., 1994); however, there are marked individual differences in their judgments. Some of these differences may be attributable to experience. For example, Prkachin et al. (2001) studied how people with different experience perceived shoulder-pain patients' facial expressions. Observers generally underestimated pain (relative to the ratings of the sufferers themselves). Compared with people who had little experience with pain patients, health-care workers showed greater underestimation. Relatives of pain patients showed less.

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There is also evidence that certain types of experience alter participants' decisional biases about pain expression. Prkachin et al. (1983) showed that providing observers with information that others should be hypersensitive to pain increased their general tendency to impute pain. Lundquist et al. (2002) showed that information that a person being judged was behaving in accordance with medical advice led judges to impute greater pain.

In the present study, we were interested in whether we could adduce evidence for selective adaptation to pain expression. We hypothesized that increasing exposure to pain expression would be associated with reduced sensitivity. Signal detection methodology was employed in order to map effects on perceptual sensitivity and decisional bias.

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Results
The expectation that selective adaptation to pain expression by overexposure would result in diminished sensitivity to pain expression was not supported. Instead, high levels of exposure were associated with significant alterations in observers' criteria for indicating that a particular expression showed pain. With increasing exposure to displays of strong pain, false alarm and hit probabilities decreased in a parallel fashion, indicating that observers became more conservative in their pain judgments. To our knowledge, this is the first experimental demonstration of a quantitative shift in criteria for judging pain expression. The findings provide evidence of an adaptation-level effect (Helson, 1964 and Rollman, 1979) in the judgment of pain expression. Adaptation-level refers to the observation that, in psychophysical judgment tasks, the evaluation that an observer makes of a stimulus may depend on the context in which judgments are made. Rollman (1979), for example, demonstrated that judgments of the amount of pain induced by electric shocks were influenced by the level of comparative shocks presented at the same time. When a relatively weak stimulus was judged in the presence of a weaker stimulus, participants gave higher ratings than they gave to stronger stimuli judged in the context of even stronger stimuli. In the present study, participants were less willing to judge moderately painful expressions as painful when they had been exposed to a large number of even more painful expressions than when they had been exposed to a relatively smaller number. The significant linear reduction in false alarm and hit rates was suggestive of a ‘dose-dependent’ relationship.

This unexpected finding may bear on the observation that, relative to people with little experience with pain sufferers, health practitioners who routinely deal with pain patients provide lower judgments of the magnitude of pain when relying on the same behavioral information (Prkachin et al., 2001). There are a variety of possible interpretations of this difference, including divided attention, cognitive differences attendant on training and differential experience. The present findings suggest a relatively parsimonious interpretation of the effect. If one is exposed to evidence of considerable pain in relatively large amounts and if an adaptation-level effect is operative, then high-intensity expression may become the standard against which pain in others is evaluated, and other expressions will be ‘downgraded’ accordingly.

The second finding of note was that female observers were better able to detect the presence of pain expression than men. Though novel to the pain expression field, there is a literature that documents female superiority in decoding nonverbal cues (Brody, 1985 and Hall, 1978). The present study is consistent with that literature, which notes a particular advantage for females in decoding cues of negative emotional states. Though significant, the implications of the difference documented in the present study may be limited due to the fact that the effect size was quite small. Nevertheless, in circumstances in which it may be desirable to select individuals who decode pain expression well, such as in decoding studies or pain assessment, there may be an advantage in selecting females.

A third finding that warrants emphasis is the high level of acuity displayed by participants, regardless of experimental condition. Average values of the discriminability measure varied from 0.91 to 0.94 on an index on which a value of 1.0 indicates perfect performance. These levels of performance appear quite impressive when considered in relation to the facts that the test stimuli displayed facial behavior categorized as moderate in intensity and they were displayed for only 1 s. Clearly, under the conditions maintained in the present study, people are highly sensitive to changes in facial behavior indicative of pain. This degree of acuity appears likely to reflect the kind of non-conscious automatic activation of evaluative processes (such as trait judgments) that characterizes the perception of complex social behaviors, (Bargh and Ferguson, 2000). No doubt this speaks to the adaptive nature of sensitivity to pain expression, an ability that is likely to contribute to the fitness of both the sufferer and the observer ( Fridlund, 1994 and Williams, 2002)

Pain shrinks the brain

Curious. But until they say something about the effects of the brain-shrink, not all that useful.

Pain causes an unexpected brain drain, according to a new study in which the brains of people with chronic backaches were up to 11 percent smaller than those of non-sufferers.

People afflicted with other long-term pain and stress might face similar brain shrinkage, said study leader A. Vania Apkarian of Northwestern University.

The results suggest those with constant pain lose gray matter equal to an oversized pea for each year of pain. Gray matter is an outer layer of the brain rich in nerve cells and crucial to information and memory processing.

The results don't reveal why the brain shrinks, but it might involve degradation of neurons, which are the signal transmitters of the mind and body.

"It is possible it's just the stress of having to live with the condition," Apkarian told LiveScience. "The neurons become overactive or tired of the activity."

Another possibility is that people born with smaller numbers of neurons are predisposed to suffering chronic pain. But some of the differences measured "must be directly related to the condition," Apkarian said.

The research involved a one-time brain scan of 26 people who'd had unrelenting back pain for at least a year (and in one case for up to 35 years), along with a pain-free control group. Pain sufferers had lost 5 to 11 percent of gray matter over and above what normal aging would take away.

"People who have had pain for longer times have had more brain atrophy," Apkarian said.

No attempt was made to correlate brain size to brain function. It is possible that some of the shrinkage involves relatively noncrucial tissue -- other than neurons -- and that some of the effects are reversible if the pain is eliminated, Apkarian and colleagues write in the Nov. 23 issue of the Journal of Neuroscience.

Apkarian said other varieties of pain might cause a similar atrophy of gray matter, and he plans to study that possibility in future studies.

"Suffering of pain is fundamentally an emotional condition," Apkarian said. "Different types of pain will have different types of emotional parameters, which will probably result in different types of atrophy -- different amounts and in different brain regions." Link

Living with pain

Another great bit from the UCLA online exhibit (and apologies to my readers whom this bores --as you well know, until fame, I use this blog to record tidbits that interest me for further use).

Since 1973, the multidisciplinary pain clinic has come into its own. Many clinics now offer a variety of therapeutic approaches to effective pain management, including physical therapy, acupuncture, TENS (transcutaneous electronic nerve stimulation), hypnosis, and behavioral modification based on the methods pioneered by Bonica's colleague, Wilbert Fordyce. However, not all patients have access to good pain clinics and, in the US, many pain therapies are not covered by insurance.

Richard Sternbach, of the Pain Treatment Center at Scripps Clinic and Research Foundation in La Jolla, offered 7 steps on how to live despite pain in his 1977 pamphlet (How Can I Learn to Live With Pain When It Hurts So Much?, revised in 1983):

1. Accept the fact of your pain
2. Set specific goals of work, hobbies and social acitivities towards which you will work
3. Let yourself get angry at your pain if it seems to be getting the best of you
4. Pace your activities
* Get in shape, and keep fit
* Learn to relax, and practice it
5. Time your medications, then taper off them
6. Have family and friends support only your healthy behavior, not your invalidism
7. Be open and reasonable with your doctor