Guest guest Posted August 7, 2012 Report Share Posted August 7, 2012 > Message: 4 > Date: Tue, 5 May 1998 03:16:40 +1000 > > Subject: The Denial of Chronic Pain > > This was sent to my CFS/FM mailing list. > It's quite long, but it's certainly well worth reading if you can manage > it. > Thankyou, Ken for your note about opiate-phobic doctors ... I'm sorry that > you're in the same boat as me ... but then again, there's a certain relief > in not feeling quite so alone in this " abandonment to pain " treatment. > Kit. > > ---------- > From: Ted Shaw[sMTP:tedshaw@...] > Sent: Saturday, 11 April 1998 13:34 > To: ozme@... > Subject: The Denial of Chronic Pain > > " The Denial of Chronic Pain " by W Teasell > > http://www.pulsus.com/pain/02_02/teas_ed.htm > > W Teasell MD FRCPC > > There is a current disconcerting trend towards dealing with chronic pain > and its subsequent disability by denying its reality. The reason for this > has primarily been cost containment and cost reduction. The monograph on > Back Pain in the Workplace probably best reflected this philosophy wherein > pain was defined as activity intolerance and disability as unemployment > (1). > Recently Bill 99 in the Ontario legislature has put forward changes in the > Workers' Compensation Board's provision that, in essence, limit patients' > medical and compensation entitlements to anywhere from six to 13 weeks > depending on the nature of their job. Responsibility for rehabilitation and > getting the employee back to work would be transferred to the employer. > Undoubtedly, accommodations by employers are essential in enabling injured > workers to return successfully to some form of employment. However, under > the new proposal, the employer is only responsible for trying to provide > suitable or comparable work, and the temptation to deny workers' injuries, > particularly in nonunion environments, will no doubt be high. > > This approach is a radical departure from previous policies. Models of > chronic pain management through denial are based on the proposition that > chronic pain occurs as a consequence of compensation and inappropriate > treatment. Moreover, they emphasize the outmoded concept that soft tissue > injuries heal after six weeks, and they cling to increasingly irrelevant > behavioural models of chronic pain. > > The irony of these developments is that they come at a time when we > understand the physiological basis of chronic pain better than ever before. > As well, the concept that chronic pain is largely secondary to compensation > or psychological factors has been largely refuted. Scientific evidence of a > physiological causation for ongoing chronic pain is well recognized (2-4), > and even the biopsychosocial model recognizes the importance of organic > factors in chronic pain. > > Chronic pain disorders generally develop after a repetitive low impact type > of trauma or a single high impact trauma. Much of the debate regarding > persistent pain revolves around the normal anticipated time for > musculoligamentous healing to occur. There has long been a misconception > that all injuries should heal after six weeks. This rationale is based on a > few animal studies and the clinical experience that the majority of > injuries > do improve within six weeks (5). However, clinical experience and follow-up > studies (6,7) clearly demonstrate that not all patients necessarily get > better and that there is a significant subset who continue to suffer from > chronic symptoms. Some become disabled, depending on both pain intensity > and > psychosocial factors, such as the type of employment in which they are > involved. > > Ironically, in sports medicine it is well recognized that many professional > and nonprofessional athletes have longstanding injuries that are soft > tissue > in nature, which do not get better with time or which require many months > of > therapy and abstention from sports. Such injuries have terminated many > promising careers. The legislation in Bill 99 for the Workers' Compensation > Board of Ontario proposes standards for injured workers that could not be > met by many professional athletes, despite that they are highly motivated > and in top physical shape, have the best medical care and trainers and > receive full compensation even when injured. Fortunately, such individuals > are not included in this proposed legislation, which, if extended to > prominent athletes, would result in a public outcry. > > The evidence that chronic pain has an organic etiology is growing and has > become increasingly compelling. In the area of whiplash injuries, the work > of Barnsley and associates (4) in Australia has been particularly > interesting in that they were able to demonstrate that when local > anesthetics are used to block cervical facets joints, a majority of > appropriate patients experience reduction in their pain far in excess of > that from placebo injections. In addition, Lord et al (8) have shown in a > controlled trial that percutaneous neurotomies denervating these same facet > joints will significantly reduce or eliminate the pain of these individuals > for longer than six months. It is interesting that this highly impressive > research is largely ignored outside of, and to some extent within, the > academic community (5,9). > > There is also impressive evidence of significant biochemical abnormalities > in disorders such as fibromyalgia; three independent studies demonstrated > levels of substance P in the cerebral spinal fluid that were two to three > times those in controls (10-12). As well, we know that, based on animal > data, there is significant evidence of neuroplasticity in the spinal cord > in > response to pain stimuli, which could account for the clinical picture of > regional pain syndromes (3,13). In these conditions, neurotransmitters such > as substance P have also been implicated. More recently, altered regional > cerebral bloodflow has offered opportunities to document a physiological > concomitant of the patient's pain experience (14). Despite this impressive > collection of physiological evidence about pain, the scientific evidence > does not appear to be reaching legislators or clinicians who seem > determined, based on ideology, to impose draconian alternative paradigms to > deal with chronic pain and, in particular, its associated disability. > > To justify such an approach, psychosocial factors are often implicated as > causative. However, a wave of recent research has demonstrated that > psychological factors are more secondary to pain than causative (7,15-17). > The high incidence of psychological problems seen in tertiary care clinics > reflects tertiary care selection biases, and the literature, which largely > arises from such clinics, clearly also displays this bias (18). In fact, > the > problem may be more related to the chronic pain patient's unwillingness to > accept (and subsequently adapt to) their pain and its limitations (19). > Psychological difficulties occurring as a consequence of the pain and > subsequent disability are often misinterpreted as causative. > > Individual coping mechanisms vary but this is true in any medical disorder. > Patients with rheumatoid arthritis can have significant psychological > difficulties, and it has been suggested that psychological factors > contribute to rheumatoid arthritis pain and functional disability, > independent of disease activity (20,21). Among spinal cord injured patients > with pain, over one-third of those who stopped working after the spinal > cord > injury said it was because of their pain and not their paralysis (22). > Interestingly, pain was regarded by these patients as a significant cause > of > work disability, even when the individual had a more 'acceptable' > alternative explanation (ie, paralysis) for work disability. It also > suggests that in some patients, pain is regarded as more disabling than > paralysis/paresis. > > The controversy about chronic pain and disability is inevitably tied to > perceived secondary gain and the availability of compensation. Recent data > suggest that compensation is important, particularly in terms of the number > of claims, but that its importance has been overrated in terms of pain > because it accounts for only a small degree of the variance seen (6% in one > meta-analysis [23]). Its effect on claims is gradational, an expected > relationship. On the other hand, 'secondary gain' is a vague term that has > never been well explained (24). Anybody who treats these patients regularly > realizes that the concept of secondary gain also has to be coupled with > secondary losses, and most of these patients continue to have pain despite > that secondary losses clearly exceed secondary gains (24,25). > > It is most disconcerting that the patients who will be affected by changes > in legislation are those shown to be at highest risk of disability - namely > those in lower socioeconomic groups, in particular those who are poorly > educated, who lack transferrable skills, are older and who are more likely > to perform heavy or repetitive physical labour (26,27) - most of whom would > be classified as 'blue collar' workers or the 'working poor'. Many are > immigrants with limited communication skills and/or working women who > appear > to be more susceptible to developing conditions such as repetitive strain > injury, fibromyalgia and myofascial type pain. Attempts to deal with > chronic > pain disability as a social problem will serve only to target individuals > who are especially vulnerable to withdrawal of support. This vulnerability > is further enhanced by significant changes in the availability of work for > individuals without specific technical skills and a decreased willingness > on > the part of employers to accommodate or compromise the workplace for > injured > workers. This is not only true for chronic soft tissue type pain but also > is > reported in conditions such as rheumatoid arthritis (20). > > Canada is becoming increasingly less sympathetic towards the weak, the > poor, > the injured and the disadvantaged. This Darwinian mindset sees such > individuals as a drain on society and, in particular, contrary to the > economics of profitable business. Certainly the cost of disability is an > important factor that must be considered. However, we seem to have crossed > a > threshold where it is increasingly acceptable to demonstrate a lack of > empathy or compassion for anybody who is injured and, in particular, those > who have chronic pain. Governments not only fail to display compassion for > injured workers, but displaying such compassion is seen as weakness for not > staying the course of significantly reducing direct costs. As health care > professionals and researchers we have an obligation to point out to our > politicians and society in general that there is a significant human cost > to > proposed policy changes. Short-changing people when they are most > vulnerable > is going to increase suffering markedly while simultaneously swelling the > welfare roles and transferring the problem to other jurisdictions. Although > such measures may well force some individuals to return to work who might > not have otherwise done so, the fact is that the vast majority of > individuals are likely going to end up without resources at a time when > they > need them the most. Knowing what we now know about chronic pain, such an > approach clearly strains the ethical responsibilities we have for > individuals in our society who are limited by chronic pain. > > -------------------------------- > > REFERENCES > > 1. Fordyce WE, ed. Back Pain in the Workplace. Seattle: IASP Press, 1995. > > 2. Merskey H. Regional pain is rarely hysterical. Arch Neurol > 1988;45:915-8. > > 3. Coderre TJ, Katz J, Vaccarino AL, Melzack R. Contribution of central > neuroplasticity to pathological pain: review of clinical and experimental > evidence. Pain 1993;52:259-85. > > 4. Barnsley L, Lord S, Bogduk N. Comparative local anaesthetic blocks in > the > diagnosis of cervical zygapophysial joint pain. Pain 1993;55:99-106. > > 5. Spitzer WO, Skovron ML, Salmi LR, et al. Scientific monograph of the > Quebec Task Force on Whiplash-Associated Disorders: redefining " whiplash " > and its management. Spine 1995;20(Suppl):1S-73S. > > 6. Mendelson G. Not " cured by a verdict " . Effect of a legal settlement on > compensation claimants. Med J Austr 1982;2:219-30. > > 7. Radanov BP, Sturzenegger M, DeStefano G, Schindrig A. Relationship > between early somatic, radiological, cognitive and psychosocial findings > and > outcome during a one-year follow-up in 117 patients suffering from common > whiplash. Br J Rheumatol 1994;33:442-8. > > 8. Lord SM, Barnsley L, Wallis BJ, Mc GJ, Bogduk N. Percutaneous > radiofrequency neurotomy for chronic cervical zygapophyseal joint pain. N > Engl J Med 1996;335:1721-6. > > 9. Ferrari R, AS. The whiplash syndrome - common sense revisited. J > Rheumatol 1997;24:618-22. > > 10. Vaeroy H, Helle R, Forre O, Kass E, Terenius L. Elevated CSF levels of > substance P and high incidence of Raynaud's phenomenon in patients with > fibromyalgia: new features for diagnosis. Pain 1988;32:21-6. > > 11. IJ, Orv MD, Littman B, et al. Elevated cerebrospinal fluid > levels of substance P in patients with fibromyalgia syndrome. Arthritis > Rheum 1994;37:1593-601. > > 12. Mountz JM, Bradley LA, Modell JG, et al. Fibromyalgia in women. > Abnormalities of regional blood flow in the thalamus and the caudate > nucleus > are associated with low pain threshold levels. Arthritis Rheum > 1995;38:926-38. > > 13. Mense S. Referral of muscle pain. Am Pain Soc J 1994;3:10-2. > > 14. Bradley RA, Alberts KR, Alarcon GC, et al. Abnormal brain regional > cerebral blood flow (rCBF) and cerebrospinal fluid (CSF) levels of > substance > P (SP) in patients and non-patients with fibromyalgia (FM). Arthritis Rheum > 1996;39:S212. > > 15. Gamsa A. Is emotional status a precipitator or a consequence of pain? > Pain 1990;42:183-95. > > 16. Gatchel RJ, Polatin PB, Mayer TG. The dominant role of psychosocial > risk > factors in the development of chronic low back pain disability. Spine > 1995;20:2702-9. > > 17. Bogduk N, Lord S, Wallis B. The treatment of psychological distress in > patients with chronic neck pain after whiplash. 1997 Spine Society of > Australia Scientific Meeting, Gold Coast, Queensland, Australia, May 1997. > > 18. Crook J, Tunks E. Defining the " chronic pain syndrome " : An > epidemiological method. In: Fields HL, Dubner R, Cervero F, eds. Advances > in > Pain Research and Therapy, vol 9. New York: Raven Press, 1986:871-7. > > 19. Reitsma B, Meijler WJ. Pain and patienthood. Clin J Pain 1997;13:9-21. > > 20. Reisine ST, Grady KE, Goodenow C, Fifield J. Work disability among > women > with rheumatoid arthritis. Arthritis Rheum 1989;32:538-43. > > 21. Reisine S, McQuillan J, Fifield J. Predictors of work disability in > rheumatoid arthritis patients. A five year follow-up. Arthritis Rheum > 1995;38:1630-7. > > 22. Rose M, JE, Ells P, Cole JD. Pain following spinal cord > injury: > results form a postal survey. Pain 1988;34:101-2. > > 23. Rohling ML, Binder LM, Langhinrichsen-Rohling J. Money matters: A > meta-analytic review of the association between financial compensation and > the experience and treatment of chronic pain. Health Psychol > 1995;14:537-47. > > 24. Fishbain DA. Secondary gain concept. Definition problems and its abuse > in medical practice. Am Pain Soc J 1994;3:264-73. > > 25. Freeman DW. Sick rule dynamics and chronic back pain in the injured > worker. Seventh World Congress on Pain, Paris, France. 1993;315:108. (Abst) > > 26. Leavitt F. The physical exertion factor in compensable work injuries. A > hidden flaw in previous research. Spine 1992;17:307-400. > > 27. Yelin EH, Henke CJ, Epstein WV. Work disability among persons with > musculoskeletal conditions. Arthritis Rheum 1986;29:1322-33. > > -------------------------------- > > Department of Physical Medicine and Rehabilitation, University of Western > Ontario and London Health Sciences Centre, London, Ontario > > Correspondence: Dr W Teasell, London Health Sciences Centre, 339 > Windermere Road, London, Ontario N6A 5A5. Telephone , fax > , e-mail robert.teasell@... > > Received for publication June 27, 1997. Accepted July 4, 1997 > > -------------------------------- > > --------------------------------------------------------------- > Ted Shaw - tedshaw@... Phone/Fax (079) 381 277 > 28 Street Mt. , Queensland Australia 4714 > Home Page: http://www.networx.com.au/mall/cfs > --------------------------------------------------------------- > > [ To unsubscribe, mail ozme-request@... with " unsubscribe " ] > [ in the message body ] > [ For other help, mail majordomo@... with a body of " help " ] > > Quote Link to comment Share on other sites More sharing options...
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