Forensic pain medicine has provided an interesting survey of medico-legal practice patterns among pain specialists (1). Members of the New England Pain Association responded to a 20-item questionnaire addressing specific areas of practice including the completion of disability forms, letters, reports to lawyers, depositions, testimony in court, record reviews and return-to-work forms. Respondents were asked to distinguish the medico-legal activities for their patients from those that occurred for third parties.  The participants who responded included pain specialists from a range of disciplines represented by the membership of this regional pain society. The response rate was 67% with a total of 144 surveys returned.

Harold Merskey

Patterns of Forensic Practice

BACKGROUND: There is growing interest in computer-delivered psychological interventions for a number of clinical conditions, including pain.OBJECTIVES: This study tests the effectiveness of a new computer-delivered pain-management program using a laboratory pain paradigm.METHODS: One hundred twenty undergraduate students were randomly assigned to either the computerized pain-management group or the distraction control group. Subjects underwent a cold-pressor task and were asked to continuously rate their subjective pain experience.RESULTS: Women receiving the computerized pain management intervention were able to tolerate the cold-pressor task longer than those in the control group. No effect was found for men. Subjective pain ratings were consistently lower during the cold-pressor task for subjects in the computerized pain-management group regardless of sex. Subjects receiving the computerized intervention reported feeling more comfortable and relaxed than control subjects during the cold-pressor task.CONCLUSIONS: Findings indicate that further investigations of the program used in this study are warranted to determine its potential clinical utility and that of similar computerized interventions for pain.

Jeffrey J Borckardt

Jarred Younger

Justin Winkel

Michael R Nash

Darlene Shaw

The Computer-Assisted Cognitive/Imagery System for Use in the Management of Pain

Previously, the subjective dimension of suffering from chronic pain has only infrequently been reported in the literature. However, in recent years qualitative psychosocial research has added new perspectives that describe how suffering from chronic pain affects life. The present paper refers to a qualitative study on the subjective experience of women diagnosed with chronic musculoskeletal pain. In a model for life adjustment, turning points and passages are described in three stages. In Stage I, there was increasing pain, disability, and physical and mental exhaustion. Alongside frustration and chaos there was a struggle to restore daily life; therefore, the picture of a healthy future was still intact. Acknowledging that pain may not be temporary marked the transition into Stage II, which was characterized by sorrow and loss, and the picture of the future faded. Once given an explanation of pain (a 'pain diagnosis'), a new understanding developed, with gradual improvement of coping skills. Adjustment eventually progressed into Stage III with the constructive use of past experiences, and competence and control increased. A new picture of the future emerged that could be handled. However, living with pain still required regular maintenance work.    The outcome of qualitative investigations, including the one presented here, is discussed along with certain clinical implications. The following clinical implications are reviewed in the present study: distrust from health professionals may obstruct the adjustment process, prolong sick leave and hinder rehabilitation; providing the patient with a diagnosis (eg, an explanation of pain mechanisms) will facilitate life adjustment; acknowledging the individual experience of suffering from chronic pain will make concepts related to pain behaviour, secondary gain and sick role liable to question; and vocational rehabilitation measures should be harmonized with the actual stage of life adjustment.

Ann-Christine Gullacksen

Jan Lidbeck

The Life Adjustment Process in Chronic Pain: Psychosocial Assessment and Clinical Implications

OBJECTIVE: To describe the impact on delegates of attending the Canadian Pain Society's annual meeting in Toronto during the severe acute respiratory syndrome (SARS) crisis in May 2003.METHODS: A prospective survey design was used. Surveys were sent to all delegates (n=432) who attended the conference, and 294 delegates responded (68% response rate). The survey was developed to determine the level of concern about travelling to Toronto; the adequacy of screening measures; the level of stress about attending; and the occupational consequences of attending.RESULTS: Fifty per cent of the participants were not concerned about travelling to Toronto, while the other 50% expressed some concern ranging from mild to serious. Concerns included being exposed to SARS and fear of transmitting it to others upon return. Reasons for attending the conference despite concern included a desire for continuing education, decrease in the number of reported SARS cases, and perceived minimal risk. Almost one-half (n=140) felt the screening measures at the conference were adequate, while 4% felt they were inadequate and 9% somewhat adequate. Delegates (n=99) suggested that temperature-taking (32.2%), improved screening vigilance (14.4%), SARS screening forms checked daily (9.1%), strictly controlled entry (8.1%) and adopting hospital screening procedures (7.1%) should have been instituted.CONCLUSION: Health care professionals planning conferences in this era of new respiratory diseases can benefit from understanding the responses of delegates who attended conferences during outbreaks. Clear communication about the potential risks and benefits, as well as instituting full screening precautions, will help to allay concerns.

Jennifer Stinson

Colin JL McCartney

Andrea Leung

Joel Katz

Impact of Attending a Healthcare Conference in Toronto During the Severe Acute Respiratory Syndrome Crisis: Survey of Delegates

The primary objective of the present study was to determine how simulated severe cervical pain affects cervical motion in patients suffering from two distinct chronic cervical disorders: whiplash (n=25) and degenerative changes (n=25). The second objective was to derive an index that would allow the differentiation of maximal from submaximal performances of cervical range of motion. Patients first performed maximal movement of the head (maximal effort) in each of the six primary directions and then repeated the test as if they were suffering from a much more intense level of pain (submaximal effort). All measurements were repeated within four to seven days. In both groups, there was significant compression of cervical motion during the submaximal effort. This compression was also highly stable on a test-retest basis. In both groups, a significantly higher average coefficient of variation was associated with the imagined pain and it was significantly different between the two clinical groups. In the whiplash group, a logistic regression model allowed the derivation of coefficient of variation-based cutoff scores that might, at selected levels of probability and an individual level, identify chronic whiplash patients who intentionally magnify their motion restriction using pain as a cue. However, the relatively small and very stable compression of cervical motion under pain simulation supports the view that the likelihood that chronic whiplash patients are magnifying their restriction of cervical range of motion using pain as a cue is very low.

Zeevi Dvir

Noga Gal-Eshel

Boaz Shamir

Evgeny Pevzner

Chava Peretz

Nachshon Knoller

Simulated Pain and Cervical Motion in Patients with Chronic Disorders of the Cervical Spine

The Canadian Collaborative Acute Pain Initiative, established in 2002, is a voluntary, multidisciplinary consortium of acute pain health professionals from across Canada whose goal is to improve acute pain management through discussion and consensus. The group met in January 2002 to define strategic areas related to the treatment of acute pain. The areas identified were: the definition of pain; the epidemiology of pain; the concept of an 'ideal' acute pain management service; education; therapeutic options; symptom management; and research and safety. In November 2002, a second meeting was held to develop objectives and recommendations for the management of acute pain based on the defined areas. The outcome of these discussions is summarized in this paper.

David H Goldstein

Jacqueline Ellis

Robert Brown

Rosemary Wilson

John Penning

Kenneth Chisom

Elizabeth VanDenKerkhof

members of the Canadian Collaborative Acute Pain Initiative

Meeting Proceedings: Recommendations for Improved Acute Pain Services: Canadian Collaborative Acute Pain Initiative

The pathophysiology of the pain associated with complex regional pain syndrome, spinal cord injury and diabetic peripheral neuropathy is not known. The pain of complex regional pain syndrome has often been attributed to abnormal sympathetic nervous system activity based on the presence of vasomotor instability and a frequently reported positive response, albeit a temporary response, to sympathetic blockade. In contrast, the pain below the level of spinal cord injury and diabetic peripheral neuropathy are generally seen as deafferentation phenomena. Each of these pain states has been associated with abnormal sympathetic nervous system function and increased peripheral alpha-1 adrenoceptor activity. This increased responsiveness may be a consequence of alpha-1 adrenoceptor postsynaptic hypersensitivity, or alpha-2 adrenoceptor presynaptic dysfunction with diminished noradrenaline reuptake, increased concentrations of noradrenaline in the synaptic cleft and increased stimulation of otherwise normal alpha-1 adrenoceptors. Plausible mechanisms based on animal research by which alpha-1 adrenoceptor hyperresponsiveness can lead to chronic neuropathic-like pain have been reported. This raises the intriguing possibility that sympathetic nervous system dysfunction may be an important factor in the generation of pain in many neuropathic pain states. Although results to date have been mixed, there may be a greater role for new drugs which target peripheral alpha-2 adrenoceptors (agonists) or alpha-1 adrenoceptors (antagonists).

Robert W Teasell

J Malcolm O Arnold

Alpha-1 Adrenoceptor Hyperresponsiveness in Three Neuropathic Pain States: Complex Regional Pain Syndrome 1, Diabetic Peripheral Neuropathic Pain and Central Pain States Following Spinal Cord Injury

Sydenham was the leading English physician of the 17th century and probably to the present time. He was using a well tried remedy. It had been known by then for about 4000 years, frequently mentioned by Hippocrates, and recognized in use in medieval Europe where it probably came through Arabic traders and was well established in use in Paris by the 12th century (2). Professional concerns up to the time of Sydenham were not about addiction. As can be seen from his text, they were about whether the drug was available in adequate preparations, whether there was any difference between opium and other narcotics, particularly comparing the natural juice with "its artificial preparations" (1) (all of which he thought to be about equal in effect), whether it was stimulant or restorative and invigorating, and whether it was being properly used for all the conditions in which it could be helpful. Addiction, dependence and insanity are not mentioned, although the fact that it could occasionally promote excitement ("frenzy") was known.

Opium the Best Remedy

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Pain Research and Management publishes research focusing on laboratory and clinical findings in the field of pain research and the prevention and management of pain.

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Chief Editor&nbsp;Professor Valeriani specialises in clinical neurophysiology with a particular interest in pain and headaches in children and adults, and is currently a neurologist who works at the Bambi Gesu Children’s Hospital in Rome.

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Pain Research and Management - Table of contents 2004

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Pain Research and Management publishes research focusing on laboratory and clinical findings in the field of pain research and the prevention and management of pain.

Pain Research and Management