Chronic low back pain patients around the world: cross-cultural similarities and differences.

OBJECTIVE: The current study sought to determine whether there were any significant cross-cultural differences in medical-physical findings, or in psychosocial, behavioral, vocational, and avocational functioning, for chronic low back pain patients. DESIGN: Partially double-blind controlled comparison of six different culture groups. SETTING: Subjects were selected from primarily ambulatory care facilities specializing in treating chronic pain patients. PATIENTS-SUBJECTS: Subjects consisted of 63 chronic low back pain patients and 63 healthy controls. Low back pain patients were randomly selected from six different culture groups (American, Japanese, Mexican, Colombian, Italian, and New Zealander). Ten to 11 were gathered per culture from a pool of patients treated at various pain treatment programs. Likewise, 10 or 11 control group subjects were obtained from each culture from a pool of healthy support staff. MAIN OUTCOME MEASURES: The Sickness Impact Profile and the Medical Examination and Diagnostic Information Coding System were used as primary outcome measures. RESULTS: Findings showed that (a) low back pain subjects across all cultures had significantly more medical-physical findings and more impairment on psychosocial, behavioral, vocational, and avocational measures than controls did; (b) Mexican and New Zealander low back pain subjects had significantly fewer physical findings than other low back pain groups did; (c) the American, New Zealander, and Italian low back pain patients reported significantly more impairment in psychosocial, recreational, and/or work areas, with the Americans the most dysfunctional; and (d) findings were not a function of working class, age, sex, pain intensity, pain duration, previous surgeries, or differences in medical-physical findings. CONCLUSIONS: It was concluded that there were important cross-cultural differences in chronic low back pain patients' self-perceived level of dysfunction, with the American patients clearly the most dysfunctional. Possible explanations included cross-cultural differences in social expectation; attention; legal-administrative requirements; financial gains; attitudes-expectations about usage, type, and availability of health care; and self-perceived ability and willingness to cope.

Patterns of conscious failure to provide accurate self-report data in patients with low back pain.

Assessment and treatment responses were compared in 17 subjects with chronic low back pain assessed as showing at least one clear consciously produced inconsistency in statements and/or behaviors during their participation in an interdisciplinary treatment program and 143 subjects assessed as showing no such inconsistency. Numerous statistically significant differences emerged: Inconsistent subjects were more likely to have pending litigation and to be assessed by staff as showing a higher degree of focus on pain and more dramatized complaints, lower levels of medical findings and attention and interest in treatment, and poor compliance with treatment and assessment procedures. In addition, these subjects reported lower levels of physical activity and generally more inconsistent or negative responses to lumbar sympathetic injections with fewer expected changes in physical sensations. Though not definitive, these results suggested a syndrome of characteristics among such subjects which are similar to those proposed as likely characterizing malingerers. The need for a particularly careful validation of self-report data in patients showing many of these characteristics was emphasized.

American and Japanese chronic low back pain patients: cross-cultural similarities and differences.

The study compared and contrasted medical, psychological, social and general behavioral functioning of American and Japanese low back pain patients and normal controls. The Sickness Impact Profile and a standardized Medical Examination Protocol for Pain instrument were used to assess all subjects. Findings showed that the American and Japanese low back pain patients had similar and significantly higher medical-physical findings than their respective controls. Likewise, the American and Japanese low back pain patients showed significantly greater psychological, social, and general behavioral dysfunction compared to control subjects. Finally, despite similar medical and physical findings, the Japanese low back pain patients were significantly less impaired in psychological, social, vocational, and avocational functioning than the American low back pain patients. It was concluded that there were significant cross-cultural differences between the American and Japanese low back pain patients, primarily in the psychosocial and behavioral areas. However, given the small sample size, any conclusion should be considered with caution; replication is needed before more definite conclusions are possible.

Nerve blocks and chronic pain states--an update. 1. Basic considerations.

Appreciation of the extremely complex nature of pain has resulted, regrettably, in diminished use of nerve blocking to manage chronic pain states. Nevertheless, clinical use of these time-honored techniques remains popular in clinical anesthesia for surgery, in obstetrics, and in the control of pathogenic pain resulting from injury or disease. Patients with chronic pain are best assessed by cross-matched analysis of medical, emotional, and social factors.

Nerve blocks and chronic pain states--an update. 2. Clinical indications.

With the unfortunate exception of the differential spinal block, diagnostic nerve blocking has become somewhat obsolete with the development of newer, more sophisticated diagnostic technology. Therapeutic nerve blocks remain useful in treating patients with various terminal cancers, some forms of back pain, tic douloreux, causalgia, reflex sympathetic dystrophy, and many trigger point syndromes. For dysfunctional and pain-disabled patients (rated as class 1 or 3 on Emory Pain Estimate Model), block therapy must be structured in comprehensive pain rehabilitation programs.

Chronic pain as a learned experience: Emory University Pain Control Center.

Chronic pain is often a conditioned socioeconomic disease. A majority of chronic pain patients show pain behavior in excess of biomedical findings and disability ratings out of proportion to their actual physical impairment. Biomedical data and pain behavior are independent variables, as the latter is heavily controlled by socioeconomic factors. The diagnosis of chronic pain patients requires evaluation and matching of both variables. When disability claims are present, a comprehensive vocational evaluation should be performed and matched with biomedical and behavioral findings. The Emory Pain Estimate Model for diagnosis of chronic pain states is discussed briefly and techniques of vocational evaluation are presented also. The structure of the Emory Pain Control Program and data from treatment outcome are presented and discussed.

The "learned pain syndrome": decoding a patient's pain signals.

Learned pain is a distinct entity with its own set of symptoms, diagnostic criteria, and treatment methods. Recognition of the condition by health professionals is necessary for proper patient management and will facilitate further research and appropriate training.

Chronic pain states: their relationship to impairment and disability.

Chronic pain patients (101) were assigned ratings of impairment and disability and were assessed for organic pathology and pain behavior through comprehensive testing procedures. As predicted, higher ratings of impairment and disability were significantly associated with higher levels of both physical pathology and pain behaviors. These results indicate that conditioning and pathologic processes significantly influence impairment and disability ratings. Many patients showed higher disability than impairment ratings, which suggests the possibility of gainful employment in less demanding jobs. However, the current disability system rewards sickness and dysfunction and discourages patients from resuming work.

Compensation for work-related injuries and rehabilitation of patients with chronic pain.

A group of 61 patients with problems of chronic pain were managed though a rehabilitation program based on the principles of operant conditioning. Of these patients, 35 were receiving compensation for work-related accidents, and 26 were receiving no financial compensation for their chronic pain. Of the patients not receiving compensation, 69% (18) made significant increases in their functional performances, while only 43% (15) of the compensation group made similar increases.