A comparison of anatomical pain sites from a tertiary care sample: evidence of disconnect between functional and perceived disability specific to lower back pain.

Heterogeneity has been identified within chronic musculoskeletal pain (CMP) patient samples; however, investigations have typically focused on psychological constructs or coping (e.g., pain-related anxiety, catastrophizing) in this regard. Furthermore, studies to date have included either samples presenting with a specific anatomical site (e.g., only lower back pain) or a mix of anatomical sites (e.g., lower back, shoulder, or leg pain) as the primary pain complaint, without making comparisons based on the anatomical site of reported pain. For example, patients with chronic lower back pain (CLBP) may differ from those with chronic upper or lower extremity pain (ULEP) in presentation, recovery trajectory, and psychological variables. The current investigation explored whether systematic differences existed between patients participating in a multidisciplinary reconditioning third-party-payer program who have CLBP relative to patients with ULEP. Patients included those with CLBP (n=23; 35% women) or ULEP (e.g., arm, shoulder, leg, knee; n=28; 29% women). The ULEP group began and finished the program with more pain-related anxiety, more catastrophic thoughts, and more fearful cognitions than the CLBP group. There were no significant correlations between functional deficit and perceived levels of disability or associations between group and return to work status; however, there was an unexpected significant interaction between group and perceived disability. Specifically, CLBP patients reported increasing perceived disability despite improvements in functional deficit, whereas ULEP patients did not. These findings suggest a disconnect between perceived disability and function that may be specific to lower back pain. Implications and directions for future research are discussed.

Waddell's symptoms as correlates of vulnerabilities associated with fear-anxiety-avoidance models of pain: pain-related anxiety, catastrophic thinking, perceived disability, and treatment outcome.

INTRODUCTION: Fear-anxiety-avoidance models of chronic pain emphasize psychological constructs as key vulnerabilities for the development and maintenance of disabling chronic pain. Complementarily, Waddell described physical signs and symptoms thought inconsistent with anatomic and pathologic disease patterns that might function as indications of pain-related psychological distress. Research has not supported using Waddell's signs due to low inter-rater reliability and limited associations with psychological distress; however, these findings are equivocal. Similarly, theorists have suggested that endorsement of Waddell's symptoms may indicate psychological distress; however, the precedent research has not included the psychological constructs described in fear-anxiety-avoidance models as vulnerability factors for the development and maintenance of chronic pain. METHODS: Participants for the current study were patients (n = 68; 35% women) with chronic low back pain involved in a multi-disciplinary work-hardening program provided by a third-party insurer. Patients endorsing more than two of Waddell's symptoms were compared with those who did not on demographic variables as well as established self-report psychological measures, measures of perceived disability, functional capacity, and treatment outcome. RESULTS: Patients endorsing more than two of Waddell's symptoms reported higher levels of depressive symptoms, pain-related anxiety, fear, catastrophizing, and pain intensity. Unexpectedly, there were no significant differences in functional capacity. Similar differences were found between those who did and did not return to work. CONCLUSIONS: While Waddell's symptoms must still be interpreted judiciously, they may provide much needed cross-disciplinary utility as indicators that more detailed psychological assessment is warranted. Comprehensive implications and directions for future research are discussed.

Waddell's symptoms as indicators of psychological distress, perceived disability, and treatment outcome.

INTRODUCTION: Waddell's signs and symptoms have been described as patient presentations not within usual anatomic patterns of injury pathology. Waddell's signs were thought to indicate psychological distress and were termed "non-organic findings"; similarly, Waddell's symptoms were described as inappropriate and attributable to psychological features. Endorsement of more than two of Waddell's symptoms is thought to be associated with psychological distress, disability, and poor treatment outcomes; however, this has not been empirically assessed. METHODS: The current study used a sample of patients (n = 108; 30% women) involved in a multi-disciplinary work hardening program provided by a third-party insurer. Patients who endorsed more than two of Waddell's symptoms were compared with those who did not on demographic variables as well as self-report measures of psychological distress, disability, and treatment outcome. RESULTS: Patients who endorsed more than two of Waddell's symptoms reported higher levels of psychological distress, perceived disability, pain intensity, and pain durations. Moreover, consistent with previous research on Waddell's symptoms, patients endorsing more than two symptoms were also less likely to return to work. CONCLUSIONS: Waddell's symptoms were associated with increased perceived disability and pervasive pain interference. Patients who endorsed more than two symptoms were significantly less likely to return to work than those who endorsed zero, one, or two symptoms. Patients who endorsed more than two symptoms may indeed be affected by factors beyond tissue pathology that nonetheless warrant clinical attention. Waddell's symptoms appear to have promise as a quick indicator of treatment complexity and outcome.