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Medically incongruent back pain presentation : an indication of physical restriction, suffering, and… Reesor, Kenneth Alan 1986

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MEDICALLY AN  INCONGRUENT  INDICATION AND  OF  BACK  PHYSICAL  INEFFECTIVE  PAIN  PRESENTATION:  RESTRICTION,  COPING  WITH  SUFFERING,  PAIN  By KENNETH M.A.,  The  U n i v e r s i t y of  B.A. (Hons.),  A  THESIS THE  ALAN  The  SUBMITTED  British  University  IN  FOR  OF  Columbia,  of  PARTIAL  REQUIREMENTS DOCTOR  REESOR 1984  Alberta,  1980  FULFILLMENT  THE  DEGREE  OF  PHILOSOPHY  in THE  FACULTY  OF  GRADUATE  D e p a r t m e n t of  We a c c e p t t h i s to the  THE  Psychology  thesis  required  UNIVERSITY  OF  as  conforming  standard  BRITISH  September (c)Kenneth  STUDIES  Alan  COLUMBIA  1986 Reesor  OF  In presenting this requirements  for  thesis  freely  fulfilment  an a d v a n c e d d e g r e e a t t h e  of B r i t i s h Columbia, I it  in partial  available  agree t h a t  for  scholarly  the L i b r a r y  r e f e r e n c e and s t u d y .  understood t h a t financial  copying or p u b l i c a t i o n of  Psychology  The U n i v e r s i t y o f B r i t i s h 1956 Main Mall V a n c o u v e r , Canada V6T 1Y3 Date  I  further this  thesis  this  It  is thesis  g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n  permission.  Department o f  s h a l l make  p u r p o s e s may be g r a n t e d by t h e h e a d o f my  d e p a r t m e n t o r by h i s o r h e r r e p r e s e n t a t i v e s . for  the  University  agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying o f for  of  September 22,  1986  Columbia  Abstract Chronic that  low b a c k  is d e e m e d  known  incongruent  organic  (CLBP) p a t i e n t s w h o d i s p l a y o r r e p o r t  pain  impairment  and anatomically and expected  non-conforming  symptomatology  to have a p o o r e r outcome to medical t r e a t m e n t use h e a l t h c a r e to contrast physical  incongruent  assessment  at a b a c k  a videotaped  task.  Videotaped  of cognitions  independently  during  of pain g r o u p  variables  MANOVAs  effects  the  pain  status.  to 2 X 2 (pain  and only  disincentives,  physical  examination  pain  effects groups  or medication  measures  patients,  iii  -  which  with  completed  and  and  pain transcribed  coded  measures group  and  by  other  sex)  While t h e r e w e r e minimal  effects  No  on d e m o g r a p h i c ,  pain  but  self  were  no  for  pain g r o u p .  limitation  as  battery,  movements  pressure  were  consumption,  of p h y s i c a l  -  for  40  in  a psychometric  Dependent  in t h e s e a n a l y s e s ,  financial  patients,  induction  analyses.  between  sample  sequence of motor  univariate  emerged  patient  to  sought  anatomically  an e x p e r i m e n t a l  t h e r e w e r e a n u m b e r of s i g n i f i c a n t differences  investigation  behavior observations  were subjected  and appropriate  interaction  pain  and  and/or  pain  pain clinic,  found  non-organic  A t o t a l o f 80 C L B P  p a i n a n d 40 ' c o n t r o l '  have been  to  multiple  symptoms, CLBP  relative  rehabilitation,  present  either  a control  a n d an a s s e s s m e n t w i t h  induction  patient  with  were absent.  examination,  positions,  The  inappropriate  drawings  incongruent'  p a r t of t h e i r  reports  multiple  pain  these criteria  a physical  excessively.  CLBP p a t i e n t s w h o d i s p l a y e d  signs,  'medically  resources  and  pain  sex,  history,  report  higher  in  and the  incongruent higher  pain g r o u p .  ambulatory/postural cognitions physical  during  emerged  as s i g n i f i c a n t l y but  e m e r g e as s i g n i f i c a n t . during  discriminator cognition  between  in C L B P  the  reported  introduced  analysis  physically  These  conceptualized to cope w i t h  results  as b e i n g  their  pain  in  patients  patients  differences  the failed  sense  highlight  the  of  role  incongruent  interventions  pain  iv  -  and overwhelmed  condition.  in  of pain  may  c o g n i t i v e mediation of  ineffective  to  important  medically  based  on  fail  pain  also s u g g e s t t h a t t h e s e p a t i e n t s  chronic  -  When  revealed that  results  who present with  because d y s f u n c t i o n a l  n o t be a l t e r e d .  pain  t a s k was t h e most These  received  dysfunctional  group.  incongruent  and self-report  the groups.  idea t h a t  more  as a c o v a r i a t e  from control  A discriminant  received  more  than the control  behavioral  also  and depression,  displayed  variables,  different  patients  with these patients  attempts  and  was  the experimental  and s u p p o r t  be b e t t e r  of p a i n ,  pain experiences  on t h e d e p e n d e n t  pain g r o u p  intensity  pain b e h a v i o r ,  cognitive variables,  control  ratings  impairment/limitation  MANCOVAs  may  incongruent  scores on measures of pain  h i g h e r global j u d g m e n t  signs  The  may  their  CONTENTS Abstract  iii  INTRODUCTION  1  LITERATURE REVIEW  6  M e d i c a l l y I n c o n g r u e n t Pain P r e s e n t a t i o n I d e n t i f i c a t i o n of M e d i c a l l y I n c o n g r u e n t Pain P a t i e n t s P s y c h o s o c i a l M o d u l a t i o n o f Pain C o g n i t i o n a n d Pain A f f e c t a n d Pain O v e r t B e h a v i o r a n d Pain Conclusions M u l t i d i m e n s i o n a l A s s e s s m e n t o f Pain C o g n i t i v e A s s e s s m e n t in Pain E x p e r i m e n t a l Pain I n d u c t i o n w i t h Pain P a t i e n t s O v e r t , N o n v e r b a l , B e h a v i o r a l A s p e c t s of Pain Assessment with Verbal Descriptors Conclusions C h r o n i c Low B a c k Pain B a c k g r o u n d to t h e Problem Prevalence Etiology Treatment S u b g r o u p s of C L B P Patients Conclusions Hypotheses and Design . .  METHOD  10 13 18 19 23 25 27 29 31 36 39 41 42 43 43 43 44 45 47 50 50  55  Subjects Equipment Procedure S e l f - r e p o r t Measures O s w e s t r y Low B a c k Pain D i s a b i l i t y Q u e s t i o n n a i r e M c G i l l Pain Q u e s t i o n n a i r e Beck Depression I n v e n t o r y Coping Strategy Questionnaire Pain D r a w i n g I n a p p r o p r i a t e S y m p t o m Scale D e s c r i p t o r D i f f e r e n t i a l Scales Physical Examination Non-organic physical signs Organic signs Physical Impairment Index R e l i a b i l i t y of Physical Examination F i n d i n g s Experimental Assessment Procedure  -  v  -  55 58 59 61 61 61 62 62 63 63 64 64 64 65 66 66 69  O b s e r v a t i o n a l A s s e s s m e n t of Pain B e h a v i o r s Reliability of Behavioral Measures Pain I n d u c t i o n P r o c e d u r e Cognitive Assessment Reliability of the Cognitive Measures D e t e r m i n a t i o n of M e d i c a l l y I n c o n g r u e n t Pain G r o u p Statistical Analyses  69 69 70 71 72 73 76  RESULTS  78  Group Differences: Patient Characteristics Principal Component Analyses: Cognitive and Behavioral Measures C o p i n g S t r a t e g y Q u e s t i o n n a i r e Scales Pain B e h a v i o r s Group Differences: Cognitive Measures Group Differences: Behavioral Measures G r o u p D i f f e r e n c e s : S e l f - R e p o r t M e a s u r e s o f Pain a n d Depression D i s c r i m i n a n t F u n c t i o n A n a l y s e s of Pain P r e s e n t a t i o n  78 83 83 85 86 89 92 95  DISCUSSION  97  C o g n i t i o n a n d M e d i c a l l y I n c o n g r u e n t Pain I n t e r p r e t i v e Issues Implications f o r Patient Management C o g n i t i v e / B e h a v i o r a l T r i a l s in t h e A s s e s s m e n t of Pain Conclusions  .  97 102 105  Chronic 108 110  112  REFERENCES Appendix  A:  Information  and  Appendix  B:  Coping  Appendix  C:  Pain  Appendix  D:  Inappropriate  Appendix  E:  Descriptor  Appendix  F:  Examination  Appendix  G:  Non-Organic  Strategy  Consent  Form  136  Questionnaire  138  Drawings  140  Symptoms  Differential  142  Scales  Checklist  143  144  Signs  146  - vi  -  Appendix  H:  Physical  Appendix  I:  Video Observation  Impairment  Index  149  Instructions  151  Appendix J :  Pain  Appendix  K:  Video Scoring  Preparation  155  Appendix  L:  Pressure  Procedure  156  Appendix  M:  Structured  Appendix  N:  SISP S c o r i n g  Behaviors  Pain  153  Interview  Schedule for  Pain  158  Key  161  TABLES  1.  Percentage  2.  Reliability  3.  Means a n d  4.  Reliabilities  5.  O c c u r r e n c e of C r i t e r i a W i t h i n  Each G r o u p  74  6.  Incongruent  N u m b e r of C r i t e r i a  75  7.  Relationships  8.  Percentage Breakdown Variables  9.  MANOVA  Breakdown of t h e  Pain  Patients  Among  Pain  Patient Sample  . . .  58  Physical  . . .  67  by  Group:  Signs  Behaviors  of t h e C o g n i t i v e  Incongruent by  in t h e  and Organic  of t h e  Frequencies  Summary  History  Diagnoses  Non-organic  Reliabilities and  of  Pain  70 Categories  . . .  Indicators  Categorical  75  Patient 79  Table for  Demographic  and  Pain  Variables  10.  Means a n d  11.  Relationships Pain  12.  Principal Component Questionnaire  73  .80  Univariate Between  Analyses:  Patient  Physical  Severity  Characteristics and  . . . .  81  Incongruent 83  Analyses  of t h e  Coping  Strategy 84  -  vii  -  13.  Relationships (CSQ)  Between  Factors  Coping  and  Strategy  In V i v o  14.  Principal  Component  15.  MANOVA  and MANCOVA  Questionnaire  Categories  Analyses of t h e Summary  Pain  85 Behaviors  Table for  Cognitive  Measures 16.  Means a n d  17.  MANOVA  87  Univariate Analyses:  and MANCOVA  Cognitive Variables  Summary  Table for  Means a n d  19.  Relationship  20.  MANOVA  89  Univariate Between  Analyses: Severity  and MANCOVA  Behavioral  and  Summary  Pain  Variables  Behaviors  Table for  Univariate  91 92  Self-Report  Measures  93  21.  Means a n d  22.  C l a s s i f i c a t i o n of Pain G r o u p M e m b e r s h i p w i t h Discriminant Function Relative O r d e r i n g of D i s c r i m i n a t i n g V a r i a b l e s  23.  88  Behavioral  Measures 18.  86  Analyses:  - viii  Self-Report  -  Measures  94  the 96 96  ACKNOWLEDGEMENTS Many people c o n t r i b u t e d d i r e c t l y o r i n d i r e c t l y to this w o r k . I am v e r y g r a t e f u l f o r t h e i r a s s i s s t a n c e . F i r s t , I'd l i k e t o t h a n k D r . Ken C r a i g f o r h i s a d v i c e , c o m m e n t s , s u p p o r t , a n d e x p r e s s e d c o n f i d e n c e in m y r e s e a r c h a b i l i t i e s f r o m the projects' inception to its completion. I'd also l i k e t o t h a n k my research committee, D r s . Keith Dobson, Bob Knox, and Ralph H a k s t i a n , for t h e i r v a l u a b l e advice a n d comments t h r o u g h v a r i o u s stages of t h i s r e s e a r c h . S e c o n d l y , I'd l i k e t o t h a n k t h o s e p e o p l e at t h e B a c k Pain C l i n i c a n d t h e P s y c h o l o g y D e p a r t m e n t at S h a u g h n e s s y H o s p i t a l , w i t h o u t w h o s e s u p p o r t t h e r e w o u l d be no s t u d y . In p a r t i c u l a r , Dr. Peter Wing, Faith, Elsie, and Dr. D a v i d Lawson f o r a d m i n i s t r a t i v e s u p p o r t , space, and e q u i p m e n t . A n u m b e r of physiotherapists h e l p e d in t h e d a t a collection (B. Barr, C. Carson, K. G r e e r , L. H e n d r y , L . H o b d a y , B . K e l l y , & L. P e r e p e l k e n ) as d i d a n u m b e r o f p h y s i c i a n s a n d p s y c h o l o g i s t s ( D r s . D . D o b s o n , I . G u m m e s o n , K. Hatelid, C . S o l y o m , I . T s a n g , & J . W h i t e ) t o w h o m I am m o s t g r a t e f u l . Special t h a n k s t o A v i s B e r n s t e i n f o r ali h e r h e l p . Third, I'd l i k e t o t h a n k t h o s e r e s p o n s i b l e f o r m a i n t a i n i n g m y emotional w e l l - b e i n g d u r i n g v a r i o u s phases of t h i s d i s s e r t a t i o n : Bill and Rosie (for e v e r y t h i n g ) , my fellow g r a d u a t e s t u d e n t s , and my colleagues at t h e Rehab C e n t r e . F i n a l l y , I ' d l i k e t o t h a n k m y w i f e S u e , as m y d e s i r e t o j o i n h e r b a c k in O t t a w a was t h e s o u r c e of m y d r i v e a n d m o t i v a t i o n t o complete t h i s w o r k .  -ix-  INTRODUCTION Chronic  low b a c k  pain  leading causes of p h y s i c a l CLBP  sufferers  demand on CLBP  for their  individuals  (Nagi, health  patients pain  psychological  Riley,  (Flor  have  (Loeser,  1980).  impairment  (Sternbach  & Timmermans,  intense  (Leavitt,  Garron,  investigations without  1979b;  resources  at a  functional  disease or  heavy  identified  injury  causes  as i m p o r t a n t for the  to  60% o f account  and  determinants  identification  in  of  intervention  that when  efforts  1979),  without  use d i f f e r e n t  (Hendler,  have failed to f i n d  Sternbach,  patients  D'Angelo,  & Bieliauskas,  (Heaton,  compared to patients  1982;  1979), 1980).  and  1979),  report  However,  differences  & Garron,  1974).  -  1. -  to  between  1979a;  of  describe  endorse  more life  a number  i m p a i r m e n t on measures Leavitt  disturbed  adjectives  & McNeil,  with  diagnostic  t e n d to be more p s y c h o l o g i c a l l y  detectable organic  adjustment  1984).  it has been e s t i m a t e d t h a t o v e r  impairment,  Garron,  symptomatology  (Leavitt,  & Turk,  Yet despite the  from medically-based  have f o u n d  identified organic  pain  1973).  the  1984).  e v i d e n c e of  their  CLBP or other  a n d as m a r k e r s  unlikely to benefit  care  Therefore functional  have been  CLBP  Investigations clearly  & Newby,  (Flor  health  no d i a g n o s a b l e m e d i c a l  factors  & Turk,  and disability  without  care services,  t h e maintenance of patients  limitation  has been f o u n d t o be one o f  have been f o u n d to utilize  rate t w i c e t h a t of impairments  (CLBP)  more  stress  of  patients  with  and  psychological Leavitt  & Garron,  2 The  lack of consistent  assumptions has been  about  undetected  (i.e.,  1977),  k i n d of c o n c e p t u a l i z a t i o n  identifiable organic patients  involvement with  reciprocal  Genest,  be p r e s e n t  Thus,  An identify (i.e., Main  of o r g a n i c i t y  to the  the behavioral  1982).  inconsistent  & Cleeland,  examination  1983).  situation  o r t i m e f r o m an e x p e c t e d 'inappropriate  illness  1984).  patients  CLBP  CLBP  is t h e  findings)  physical  that  with  with  use of  pathology  (Waddell,  who present with  report  pain  Bircher, such  patients,  clinical in  pattern  described  Finlayson,  incongruent  1984a;  (Teske,  in t h e  has been  criteria  suggest  not conform  basis  to  Craig,  indicatiors  does  Brena,  inclusionary 1977;  &  reliability  criteria  r e p o r t of pain may  pain that  exists,  (Fordyce,  many chronic  impairment  to by  Meichenbaum,  (Chapman,  pathophysiological  behavior'  patients  low i n t e r r a t e r  Behavior or verbal  suggesting  is  psychological  (Turk,  that  and the verbal  with  but  problem  use of e x c l u s i o n a r y  For example,  expression  While  exclusive category  has been f o u n d  approach  examination  of  indicators).  is p r e s e n t  clear organic  the two  alternative  & Waddell,  Daut,  between  1978).  scores,  impairment  Considerable  & Loeser,  test  Diagnosis  on t h e basis  recognize that  even when  incongruent'  simplistic  have been maintained o r mediated  DeLateur,  'medically  suffering  fails to  i t is n o t s u r p r i s i n g  concerning judgements Holcomb,  patients  another more important  factors.  interactions  1983).  such  pathophysiology  p r o b l e m may  or functional may  of  be d u e to  pain conditions  impairment are not a mutually  whose pain  psychological  in p a r t  lack of o r g a n i c  may arise w h e r e  (Chapman,  may  a 'non-organic'  identification  criteria  false positives  this  identifying  based t h e  exclusionary  findings  as  & Main,  pain-related  3 behavior or  report,  (Waddell et a l . , (Dzioba  1984),  & Doxey,  modalities  have a greater  such  1984),  and a poorer  the  harmful  mediation of these c l e a r as t o w h a t management.  (Lehmann,  individuals  interventions.  role c o g n i t i v e ,  behavioral, patients'  The central  who do not,  to discover  stressors Anger,  respond to physically  with  chronic  found pain  pain conditions  between behavior  Alternatively, provided maintain tissue  illness  medically  and  symptomatology  it has  been  proposed  by the environment some C L B P  behavior  (Fordyce,  of t h e b e h a v i o r a l  clear  however  it has  is  the  not  been  behavior  which  incongruent  processes pain  Shared  reinforcing disincentives,  and pain  report  if t h e r e  and  associated  variance  has  been  inappropriate  1982). consequences attention)  independent  I t has also been  perspective that  the  behavior.  have been  & Waddell,  that  may  modalities.  a n d o c c u r r e n c e of  (Main  CLBP  with  and account for  psychological  1984a).  pain  was to compare  (financial  1979).  crucial  or  have on  correlates  and depression  (Craig,  1983).  has been  presentation  based treatment  measures of depression  pathology  adherents  anxiety,  pain  psychological  dysfunctional  may come t o m a i n t a i n  demoralization,  not been  investigation  incongruent  k i n d of  above,  has  relief  a r e l i k e l y t o lead t o e f f e c t i v e  aim of t h i s  patients  As suggested  What  pain  unnecessary,  Further,  medically  failure to  these patients  pain experience.  who display  rehabilitation  & Spratt,  influences  patients  this  Russell,  to costly,  targets  utilization  and  and affective  intervention  promote and maintain  care  response to physical  the value of i d e n t i f y i n g  so as n o t t o e x p o s e t h e s e potentially  health  a poorer outcome to s u r g e r y  as a c u p u n c t u r e  Clinically,  level of  of  may  originating  argued  by  is no  pain  4 behavior,  there  perspective More wherein  is n o p a i n  ignores  statements  (Fordyce,  the subjective,  recently  thoughts,  problem  a cognitive  noxious  experiential  model of pain  interpretations,  related to  1978).  events  has b e e n  pain and  in t u r n  Considerable  support  investigations populations pain,  contribute  with  have demonstrated of  that  noxious  detectable organic  stimulation,  (Weisenberg,  impairment  perceived  distortion  in t h e  have been  and poorer  in C L B P  and symptomatology  measures  that  reflected  or  CLBP  et a l . ,  (Rosenstiel  patient  induced intensity control,  readily  perceive  (Schmidt,  events  Medically  the  1983)  and  (Lefebvre,  affective  distress  incongruent  have been f o u n d to be associated physical  pain with  functioning  1982).  cognitive coping  dysfunctional  activity  during  cognitions pain,  and  and  1985).  pain and  & Keefe,  or  reduce  without  greater  toward  from  patients  of b a c k - p a i n - r e l a t e d  patients.  1983).  has come  control,  in c o n t r o l l i n g  to  maintain  of p e r c e i v e d  non-patients  excessive attention  It was p r o p o s e d t h a t effective  as c e n t r a l  as f r o m p a i n  increasing  s h o w n to be associated w i t h  adjustment  & Waddell,  or  1977).  cognitions  self-  of t h e p e r c e i v e d  were f o u n d to more  interpretation  behavior  (Main  as w e l l  pain.  using experimentally  lack of s e l f - e f f i c a c y  presence of c a t a s t r o p h i z i n g  (Turk,  in p a i n  reduction  intensity  m u s c u l a r f a t i g u e as p a i n t h a n  Further,  1981)  Studies  exaggeration  attenuating  the tolerance to pain  distress  volunteers,  1984).  and coping  attenuate,  role of cognition  non-patient  lack of cognitions  normal  for the  (Weisenberg,  consequences  to affective  of  articulated  are viewed  t h e p a i n e x p e r i e n c e a n d can come t o e n h a n c e ,  extreme  components  expectations,  sensory  This  lack  characterized  of pain  5 patients  that  processes  displayed  incongruent  were thought  the accompanying  to amplify  emotional  underlying  assumption  expression  and emotional  1976;  Turk,  et a l . ,  as a s e n s o r y , 1983),  Keefe,  Brown,  incongruent behavior,  pain  a lower  intensity  of  rated  coping during methodology both  induced  pain  to p r o v i d e  pain,  and  a greater  greater  report  pain  of c o g n i t i v e  follows  et a l . ,  (Melzack 1982;  of  distress,  the pain  and  higher  cognitive about  the  & Turk,  1981),  (Rosenstiel  activity 1983)  for the cognitive  & Genest,  conceptualized  to i d e n t i f y  pain  investigation.  &  during  were  employed  variables  under  1981).  has a d d r e s s e d  The  Beck,  (Keefe,  (Genest  during  1981; T u r k ,  Glass,  (cf.  dysfunctional  during  and  pain  frequency  affective  with  to  phenomenon  1982) was e x p e c t e d  validity  background" literature to this  has been  behavioral  of c o g n i t i o n  & Turk,  review which  pain  assessment approach  cognition  unstructured  (Merluzzi,  pain  pain  of d i s t r e s s .  since t h e r e are questions  self-report  (Genest  and  in a s s o c i a t i o n  Further,  cognitive  is p r i m a r y  associated with  as d i s p l a y i n g  some c o n v e r g e n t  investigation The  affective,  pain tolerance,  of assessing  1983)  and expression  Since c h r o n i c  & Ziesat,  patient  pain.  retrospective  Keefe,  experience  a multidimensional  These  and distort these patients'  experience  1983).  Scott,  behavior.  here was t h a t c o g n i t i o n  cognitive,  & Wall,  pain  in m o r e d e t a i l  the  LITERATURE  P a i n h a s b e e n d e f i n e d as " a n experience associated with described S t u d y of  Pain,  1979).  sensory  stimulation  soldiers wounded the  potential  damage"  This  is n o t a l w a y s e q u i v a l e n t  unpleasant  actual or  in t e r m s of s u c h  REVIEW  definition  for  acknowledges  between  the extent  can be  persist  surgical,  or  Fordyce,  1976).  effected pain  medical,  (Sternbach,  and physical  phantom  substrates  limb p a i n ,  amputees  where  The  extremity  cognitive-evaluative  components  c o m p o n e n t of p a i n  nonetheless influences  is m o d i f i e d (Turk,  by  et a l . ,  is a h i g h l y  of  dramatic  Further,  tissue  repair  The dissociation illustrated  pain  has  the can  been  between  in t h e case of half of  localized  pathophysiology  & Wall,  in  and  of p a i n  1983).  salient dimension, affective,  Presenting  not only tissue damage b u t  how  motivational-affective,  (Melzack  1983).  1955).  conceptualization  cognitive,  noxious  all  their  1983).  tissue  sensory-discriminative,  the  experience  Observations  is p e r c e p t u a l l y  a broader  or the  estimated that over  & Wall,  between  has p r o m p t e d  encompasses  reflect  (Melzack  'desynchrony'  experience  pain t h a t  for  of t i s s u e damage a n d  natural  is p o i g n a n t l y  it has been  may e x p e r i e n c e  amputated  sensory  1974;  (Beecher,  or  pain  have illustrated  amount of pain e x p e r i e n c e d after  that  o f an i n j u r y  example,  emotional  Association  resulting from tissue damage.  in b a t t l e ,  and  tissue damage,  (International  to the severity  lack of c o r r e s p o n d e n c e  even  sensory  a variety  - 6 -  and  pain that  and  While  the  somatic  input  behavioral  complaints of pain of dimensions of  can  suffering  7 (Weisenberg, and the  1980).  reciprocal  Recognition  determinism  of t h e m u l t i d i m e n s i o n a l  among these  significance f o r t h e development of Physical/somatic less e f f e c t i v e strongly  approaches  when  maintain  affective,  and  o b s e r v e d t o become e s p e c i a l l y 1980).  The distinction  crucial  (Sternbach,  closely a f u n c t i o n whereas  1978).  of  of o r g a n i c  pain  pathology  p e r s i s t e n c e of pain models are b e t t e r  (Keefe,  acute pain  such  can,  intake,  in e f f e c t , Chronic  months  perpetuate pain  (Bonica,  described  1978).  in t h e c h r o n i c  pain  in  duration,  as p a i n w h i c h  that  evidence  and  but  less  pain  since  (Crue,  1975),  after  initially  6  since t h e r e  has sometimes i t is p e r h a p s  in a d e v e l o p m e n t a l  these  1980).  persists  criterion  for  demands,  is s p e c i f i c t o t h i s  as a s t a t i c s y n d r o m e  disease  Treatments  (Bonica,  is  more  medical o r  in c h r o n i c  and disability  only  as  from job and personal  pain  which  limited  condition.  chronic  along multiple dimensions,  (Bonica,  pain t h e r e f o r e  Therefore  is an a r b i t r a r y  stage  be  been  acute pain problems,  pain condition  as a t e r m i n a l  have  to the duration  contraindicated  This  can  in t h e a b s e n c e o f  Although  conceptualized  1980).  'chronic'  1982).  withdrawal  illness  input  as p a i n p e r s i s t s  no l i m i t a t i o n  has b e e n d e f i n e d  (Sternbach,  no c h a n g e span  have been  relief.  influences  influences  may e x i s t  the chronic  as b e d r e s t ,  obvious  has b e e n d e s c r i b e d  for conceptualizing  understanding  behavioral  and  pain  et a l . ,  pain  sensory  or tissue damage and  and with  useful for  analgesic  'acute'  condition  has  pain  experience.  prominent  Acute  injury  the chronic  pain  or  behavioral  between  for  noxious  affective,  or modulate the  Cognitive,  strategies  to a l t e r i n g  cognitive,  influences  n a t u r e of  is  time  been better  process  occurring  may be associated  with  8 injury  or tissue damage.  develop  into a chronic  characterized  by  in m e d i c a t i o n  intake,  Pre-chronic  pain  stages,  condition,  a temporary  decrease  p r e s e n c e of a n x i e t y ,  autonomic  arousal  (Keefe,  the other  hand,  have been  is u n c o n t r o l l a b l e ,  preoccupation  with  pain and bodily  decreased  autonomic  Persistent  pain  progressive occupational There  arousal,  has b e e n  and  is c o n s i d e r a b l e  (Bonica,  pain.  In o t h e r  across  Patients with  demoralization,  depression,  maladjustment,  and vocational  no i m p a c t o n p s y c h o l o g i c a l , (Sternbach,  1974).  attention  health  against  of  an " i l l u s i o n  Personality  homogeneity"  (cf.  chronic pain  pain  that  spasm,  endurance. leads  to  and  by  invariant as  severe  presentation  h a v e come t o  (1976)  among c h r o n i c  pain  of p a t i e n t s 1982)  showing  adjustment  Fordyce  & Heilbronn,  is n o t  the  psychosocial  and vocational  Thus,  and  have been d e s c r i b e d  to a clinical  characteristics  Blumer  concerns  force that  more of t h e f o r m e r  care p r o v i d e r s .  and emotional  prone personality'  social o r  and  interpersonal,  dependency,  Undoubtedly  of  strength  characterized  failure,  long-term  muscle  in t h e p r o g r e s s i o n  chronic  drug  a  on  depression,  constant  malefic'  words,  presentation  by  phases,  1974).  variability  impact of c h r o n i c  ranging from a clinical  as a  of t h e p e r s o n a l ,  lives of p a t i e n t s  sufferers.  reduced  described  deterioration  to cope,  complaints,  increased  Chronic  use of m e d i c a t i o n ,  passive attemps  active  and  as c h a r a c t e r i z e d  habitual  increase  be c o n t r o l l e d ,  1980).  not  as  temporary  muscle spasms,  & Williams,  described  of decreased a c t i v i t y ,  the pain  in a c t i v i t y ,  beliefs t h a t t h e pain will  Block,  may o r may  have been d e s c r i b e d  attempts to cope,  pattern  which  has  cautioned  patients.  attributed  may  the  reflect  to a  'pain  changes  9 resulting from prolonged exposure to pain, suffering, and distress (Sternbach, The determining  1974).  type of underlying pathophysiology  is extremely important in  the nature of pain sensations and  cannot be overlooked  attempts to understand the chronic pain experience.  in  Turk, et al.  (1983) have distinguished three basic types of chronic pain. These included:  (a) chronic, acute,  recurrent pain (e.g. migraine headaches,  trigeminal neuralgia); (b) chronic persistent, benign pain characterized by a constant presence of varying intensity (e.g. low back pain);  and  (c) chronic, progressive, malignant pain (e.g. cancer). Pathophysiological processes with subjective and  have been proposed to reciprocally interact  interpersonal factors to contribute to the clinical  presentation and the individuals' experience  of pain (Dubuisson &  Melzack, 1976). To summarize, in the case of chronic pain, originating tissue damage and  nociceptive stimuli may  come to have a decreasing  importance as pain persists in spite of attempts to cope. However, as previously suggested, there is considerable variation among pain sufferers in the extent to which complaints are congruent with pathophysiology.  For a portion of patients, behavior  displayed that is  disproportionate or deviant given the underlying organic impairment, suggests that their complaints are more a function of intrapersonal or interpersonal variables. The  purpose of this investigation was  factors that may  to determine some of the  account for pain complaints in chronic pain patients  whose symptom picture lacks correspondence to underlying anatomy and  disease c o u r s e . addressed  The first  section  that follows  some a s p e c t s o f a n a t o m i c a l l y  to identifying  'psychogenic'  second section,  been d i s c u s s e d .  manifestations  independent  In t h e t h i r d  measurement of c o g n i t i v e , associated with  incongruent  some o f t h e p s y c h o s o c i a l  modulate pain experience  pain,  some i n v e s t i g a t i o n s  section,  behavioral,  have been  factors  of t i s s u e  review  pain.  which  approaches  In  the  m a y come  pathophysiology  some a p p r o a c h e s and affective Finally,  factors  has  pain and  of c h r o n i c  reviewed.  of p s y c h o s o c i a l  in t h i s  in C L B P  to  to have  the  phenomena in t h e  last  patients  section,  have  been  discussed.  Medically  Incongruent  Pain p a t i e n t s 'illness  behavior'  aches and  Pain  Presentation  w h o come t o c l i n i c a l  such  symptoms,  sympathy  (Bellisimo  described  as a g l o b a l  as l o o k i n g  construct  behavior  reflecting  need f o r  behavior  is n o t t h e  same as t h e  Therefore, receiving  illness  others  be learned  roles,  and overt  behavior  may  ill,  (Mechanic,  1976).  in a s o c i o c u l t u r a l  Illness  behavior  action  underlying behaviors  Thus, context  has  about  accepting been  symptom  of medical  perception,  services, 1976).  disease process,  communication  in w a y t h a t  it  behavior  (Craig,  1983;  be  disease. in  the  recognized  reflecting Fordyce,  is  function  to assume will  and  Illness  aimed at a l l e v i a t i n g  In o r d e r  illness  and  (Mechanic,  serve a vital  behave  display  complaining  encompasses  recovery.  individuals  ordinarily  medication,  utilization  remedial  care and facilitating  ' s t a t u s ' of b e i n g by  covert  sick  which  interpretation,  hurt,  taking  1984).  symptom  associated with  like they  ceasing w o r k , & Tunks,  attention  pain 1976).  may  Illness  behavior  inappropriate, course.  in c h r o n i c  given the  underlying  Crue  (1975),  for  t y p e s of pain  related  illness  example,  signal of s o m a t o p a t h o l o g y , pathology  that  knowledge,  cannot  and  (c)  pain  presentation:  (b)  behavior  principles course.  localized, related when  of t h i s  of p a i n ,  of  illness  illness  behavior  and persistent  Pain reflect  reports  underlying  healing process origin,  such  problems,  and  made b e t w e e n  report  known  relects  report that  (Pilowsky,  remote  in  as  with  and/or  and  normal  disease  inconsistent  diffuse,  and  poorly  of p a i n .  abnormal' symptoms,  with  Pain-  especially health  anxiety,  documentation  and  1984). indicative of persist  as r e f l e c t i n g  gain'.  have prompted 'psychogenic'  pain that beyond  somatic e x p r e s s i o n  'secondary  pain  behavior  anatomical  and descriptions  diagnostically  illness,  illness  behavior  is v a g u e ,  behaviors  may be t r e a t e d  'somatogenic'  therapeutic  demonstrable  conform to t h e  impairment or that  incongruent  in  appropriate  consistent with  behavior  illness  organic  malingering,  as a s i g n a l o f  of disease d e s p i t e medical  as p s y c h i a t r i c  non-anatomical,  discussion,  preoccupation  reassurance to the c o n t r a r y  three as a  is t o o m i n o r o r t o o  has been d e s c r i b e d  conviction  between  no  or  disease  pain expression  associated with  perceptions  i t is a s s o c i a t e d w i t h  and  due to inadequacies  pain t h a t  symptom  and exaggerated  appropriate  problem.  and symptom  Incongruent  (a)  expression  a problem that  and perceptions  physiology  pain  expression  time to account f o r t h e pain For t h e purposes  pathophysiology  makes a d i s t i n c t i o n  be a l l e v i a t e d  somatic problem or w i t h  reflects  pain may be c o n s i d e r e d  Such  of  the  some  not normal  other  psychological  explanations  a distinction  pain.  do  Sternbach  to  of  be  (1974,  p.  12 21)  uses t h e t e r m  understood  psychogenic  in p s y c h o l o g i c a l  psychogenic  pain  than  (i.e.,  has p e r v a d e d (Sternbach, cognitive,  artificial,  undifferentiated. involvement present  and  'physical'  et a l . ,  have  (Bellisimo  even  1983).  when  between  indicated that  £• T u n k s ,  1984).  (cf.  to assume t h a t  Waddell  & Main,  'psychogenic'  mutually  exclusive.  function  of t w o p o t e n t i a l l y  and  However,  i t is e v e n  even with  'physical',  can be u s e f u l f o r  'somatogenic'  conceptualizing  predicting  outcome.  determining  be  psychological  etiology  is  also  t h e c o n c e p t of  an  and  variables,  'physical'  'abnormal'  significant  There  complementary  same  rare to f i n d one w i t h o u t  Considerable  1984).  tend to  clear organic  'psychological'  somewhat  levels of t h e  considerable  Consistent with  biochemical,  may be  perspective, that  (i.e.,  (i.e.,  reflect different  sufferer's  has been f o u n d t o e x i s t  impairment  components  I t has been o b s e r v e d  determinism  some w r i t e r s  behavior  from the  can be p r e s e n t  (Turk,  interactive  other  and behavioral) sensory)  dichotomy  practice  'psychological'  and  sequelae  reflecting  simple  into  as b o t h t o a l a r g e d e g r e e  phenomena w h i c h ,  this  assessment  of  1978).  pain  mechanical,  better  to physical  (Merskey,  questioned,  is  The definition  of a d i s t i n c t i o n  and clinical  Separating  affective,  structural,  has been  research  1978).  pain a t t r i b u t e d  and validity  in p a i n  much  language".  muscle tension)  While t h e usefulness dualism  refer to "pain which  physical  has also i n c l u d e d  of emotional f a c t o r s  mind/body  pain to  is,  illness  organic  therefore,  pain  processes,  no  categories  chronic  the  pain  reason are  as a  psychological'  patient treatment  and  and  One  reason f o r  exploring  the  psychogenic/somatogenic  is t h a t m i s c o n c e p t i o n s  a p p e a r to be associated w i t h  pain  (Reuler,  & Nardone,  that  regardless of  should This  type'  explain  of p a i n ,  1982).  i t is a s s e s s e d ,  nonetheless,  some p a t i e n t s ,  is s o m e h o w t h e p a t i e n t ' s control.  understanding contribute  psychological real?",  an  a pain  hysterical  Development essential, avoiding  not only  pain  variables  patients  are associated with  for  issues  identifying have been  Identification The  (Keefe,  d e g r e e of ' a b n o r m a l ' , have its o r i g i n s  common  referral  (Greisak,  this  processes questions  these patients  pain  In o r d e r  discussed  identifying  are  of  that for pain  faking?",  patient  assessment but  pain,  for  conceptualizations  to determine reliable and  required.  Several  are  about  what valid approaches  below.  Incongruent chronic  'incongruent',  or  Pain  pain  Patients.  patients  'psychogenic'  necessity  or  1984).  accurate  incongruent  the under  as " I s t h e person  &  to  be a lack  more effective t r e a t m e n t s ,  1982).  in t h e p r a c t i c a l  such  "Is  in c h r o n i c  of Medically  p r a c t i c e of  be i n v o k e d  p r o b l e m may simply  and promoting  (Main  a n d t o some e x t e n t  personality?",  creating  "imaginary".  may be made t h a t  have been o b s e r v e d  and advances for  must  warned  pain'  connotations  construct  based  has  'psychogenic  of t h e p s y c h o l o g i c a l  reaction?"  (1974)  is a n y w a y  responsibility  Thus,  prone  misconceptions  chronic  criteria  pain.  consultation  "Is this  "Is this  pain  the attribution  and appreciation  to chronic  label  has p e j o r a t i v e  Part of t h i s  non-organic  Sternbach  the  Since a psychological  pain f o r  the patient's  and  how  1980).  not be used to imply t h a t t h e  Waddell,  pain  Girard,  distinction  of  as h a v i n g  some  pain appears  to  identifying  patient  14 groupings  appropriate  interventions.  for  One problem with  condition  is t h a t o f t e n ,  practice,  diagnosis  by  inclusionary  radiologic,  conventional  laboratory,  physical  is a s s u m e d .  Craig,  examination, despite  T h e fallacy of this  may arise when o r g a n i c  pathology  literature  exclusionary  1959;  objective disease are not p r e s e n t , etiology  research  has been made b y (Engel,  surgical  t h e diagnosis of a p s y c h o g e n i c  in b o t h t h e  criteria  medical or  1984b).  pain logic  is t h a t  rather  than  Therefore, indicators  report,  but  clinical  criteria  Or other  is p r e s e n t  and  pain  a  when of  psychologic  'false  positives'  undetected  (Chapman,  1977). Psychometric organicity  test efforts  have produced  because of  unreliability  reliabilities  of  examination  ratings  operational  equivocal  of o r g a n i c i t y ,  (e.g.,  definitions  mean  1982).  was f o u n d  Therefore,  with  chronic  This  is e s p e c i a l l y  have serious  pain  is a s u b j e c t i v e other  for  behaviors  inter-judge  evidence.  1974)  of  enhanced  than  relying  have  patient  and  management  'psychogenic'  is t h e r e f o r e  of  Chapman  (1977)  When  et  intuitive  pain arises  has p r o p o s e d  al., process  judgement. pathology  (Nachemson,  on  the  organic  (Waddell  dependent  only  u s e d as  the assessment on  partly  medical  1978).  were  reliability  of  Interrater  since failure to detect organic  in a s s e s s i n g  experience  behavioral  patient  rather  important  The difficulty  F o r d y c e et a l . ,  is a n e e d t o o b j e c t i f y  patients  implications  (Sternbach,  have been f o u n d to  to be s i g n i f i c a n t l y  there  on t h e basis  based on j u d g e m e n t  r=.58;  the  groups  patient groups.  data,  of d i s t i n c t  basis of global j u d g e m e n t s , indicators  results  in i d e n t i f y i n g  and diagnostic test  modest agreement  to differentiate  can  1976).  because self-report that for  pain or the  15 diagnosis  of  'psychogenic'  psychological  test  disease w h i c h present.  to i n j u r y 1959).  scores,  or  Nemiah,  involvement deviation  & Barry,  that  findings,  from expected  with  a significant  differences  in t h e  of t h e p r e s e n t i n g  pathology.  Chapman,  and  patients:  chronic  Brena,  categories of pain high  'pain  behavior'  high  'pain  display  report  and  behavior'  low ' p a i n  behavior'  high and  compensation Stegal,  reactions etiology  (Engle, have  (Brown,  McGill  by  (1981),  sufferers  been  Barr,  pain  neurologic,  was associated greater  1979).  and compensation  with  status  organic  high  'pain  who  low display  and pain verbalizers  who  So c a l l e d  'pain  based on p a t i e n t  self-  activity,  radiologic  disability.  the association  is i r r e l e v a n t  four  who display  pain amplifiers  t h e p r e s e n c e of  However,  or  to  was based on a  reported  patient  have described  reducers  a rating  and  pain  who display  Pain Q u e s t i o n a i r e ,  Tissue pathology  and with  chronic  a n d low t i s s u e p a t h o l o g y .  determined  (MMPI,  & Chyatte,  behavior'  pain  of p a i n  low t i s s u e p a t h o l o g y ;  behavior'  levels).  behavior'  disproportionate  pain complaints  tissue pathology;  j u d g e m e n t of e x a m i n a t i o n , 'pain  reactions  'appropriateness'  Decker  tissue pathology;  was a c t u a l l y  measures  medication  of  have been made t o o p e r a t i o n a l i z e  reflect  and  be  decisions  psychological display  should  organic  1954).  'inappropriateness'  behavior'  and attention  anatomical  in t h e i r  abnormal  o r e v i d e n c e of an  has been t o look f o r  as m o r e ' d r a m a t i c '  Attempts 'types'  interview  least,  m e t h o d of m a k i n g d i a g n o s t i c  Pain p a t i e n t s  described  at t h e v e r y  could alter consciousness  Another  psychological  pain,  and  physician's findings.  High  financial (Brena, between  Chapman, high  to t h e question  of  'pain  16 whether  'appropriateness'  have challenged problematic  not yet  patients  patients organic  Thus,  the empirical  exaggerated  patients  to organic  determining  and associative examinations,  a poorer  In C L B P incongruent  prognosis  Waddell  during  deviate f r o m anatomical  endorsement anatomy or  of s y m p t o m s disease course  (reports  al., model  signs"  to have,  et al.  (Main  by  affective  on t h e b a s i s  of  indicators.  "organically for  exaggerated  retrospective  have  clinical  1981). operationalized  indicators.  examination  (Waddell,  & Waddell,  associative  Both the  (1980)  are exaggerated  are  an  (Hendler,  an o r t h o p e d i c  pain  and the c r i t e r i a  on  surgery  objective  identifiable  affective or  and psychometric  principles  which  no  of p a i n  not specified.  for  pain:  was d e t e r m i n e d  p a i n on t h e basis of o b j e c t i v e elicited  but  since the criteria f o r  were found  populations,  include behaviors which  symptoms  pain were  patients  et  of t h i s  unspecified  pain maintained  positive objective  exaggerated  basis),  and  involvement  is p r o b l e m a t i c  lesions w i t h  grounds  category  and appropriate  patients  r e p o r t of  t h e presence of p s y c h i a t r i c  defineable  pain  Psychological  approach  and  Kremer,  validity  r e p o r t of pain  impairment),  (exaggerated  1985;  a similar f o u r  incongruent  (have a non-exaggerated basis),  compensation  established.  has p r o p o s e d  reflecting  investigations  and empirical  1985).  ( h a v e an i d e n t i f i a b l e o r g a n i c  disturbance).  This  methodological & Vannucci,  (1981)  disproportionate pain  between  Brand,  been a d e q u a t e l y  conceptualization  Recent  Richlin,  et a l . ,  Hendler  pain  pain on b o t h  Handlin,  1983; Melzack has  the simplistic association  chronic  (Dworkin,  is w e l l o p e r a t i o n a l i z e d .  et a l . ,  These  procedure 1980)  and  and do not c o n f o r m  1984a).  Another  to  indicator  17 of  incongruent  and  pain  non-anatomical  (Ransford,  routine  has been  patients  & Mooney,  proposed  is  exaggerated  produce to illustrate t h e i r  1976).  a d v a n t a g e of b e i n g  sex d i f f e r e n c e s  women t e n d i n g Waddell,  to display  1984b).  The  t o be m o d e r a t e l y  All of these c r i t e r i a  pain  have  reliable and easily assessed  with  independent CLBP incongruent  of medical  representation endorsement)  the  during  spinal  manipulation, with  Bircher,  multiple  incongruent physical exercise,  pain  and  bedrest)  moderate or Finlayson,  signs.  1984).  (chemonucleolysis,  and medication) incongruent  was f o u n d pain  signs,  to  weakly  to  be  medically  symptom treatments  physiotherapy,  to a back  pain  incongruent  pain  Further,  success  t o be p o o r e r f o r  treatment  to  1980).  supports,  admission  signs than  Successful  shown  1982),  more specific  little d i s p l a y of  pain  &  non-anatomical  orthodic  & Main,  has b e e n  a l a r g e amount of  received  upon  (Main  and appeared  inappropriate  have been f o u n d  incongruent  interventions  multiple  signs,  injections,  men  & Waddell,  et a l . ,  as d i s p l a y i n g  and  signs  1980),  (Waddell,  than  with  measures of t e n d e n c y  (Main  et a l . ,  non-organic  lumbar  response to treatment display  behavioral  been f o u n d to have  analgesics,  (Waddell,  identified  have been f o u n d  symptoms  self-report  (Waddell,  in p a i n d r a w i n g s ,  (i.e.,  patients  with  diagnosis  (i.e.,  had  and  and depression  t h e MMPI  pain  presentation  more signs  correlated  patients  in p a i n  presence of t h e  somatic complaints  correlated  with  that  examination.  Slight  report  drawings  Carins,  demonstrated  than  presentation  clinic  rates  patients  those who display outcome to  lumbar  surgery,  no  various graded  r a n g e f r o m 4-48% f o r  a n d f r o m 54-94% f o r  who  patients  patients  in  18 without  incongruent  patients  displaying  obtain  less p a i n  stimulation  pain  medically  operationalization  Ransford  by  incongruent  pain  mediators  of  Psychosocial  Modulation  prolong  better  pain  of  suffering  demonstrated  factors  behavior  and distress  described  associated with  processes  who present with  cognitive, sensory  research  affective,  aspects  examining  and behavioral  of p a i n .  Central  maladaptive cognitive coping, heightens  expressions  who manifest  methods determining  potential  pain.  above and chronic  investigate  the  and  validity.  psychosocial  or  serve  to  p a i n . While  pain t h e r e  interactions  between  and their  affective  is c h a r a c t e r i s t i c Elaboration  is t h e  idea  distress  of c h r o n i c  of t h i s  has  i n f l u e n c e on  investigation  increases  there  psychological  incongruent  factors  to t h i s  which  of p a i n ,  incongruent  Waddell,  may come t o d e t e r m i n e  to empirically  been considerable  in  pain  Pain  illness  individuals  by  signs,  reliability  some o f t h e  have been few a t t e m p t s in  physically  non-organic  described  an  expression.  of p s y c h o l o g i c a l  incongruent  in  Vague,  his colleagues  has a d d r e s s e d  incongruent  A number maintain  b e c a u s e of  and  nerve  p r o p o s e d t h a t allow f o r  pain.  report  to  1983).  may be p r e f e r r e d to t h e  Brena  Similarly,  have been f o u n d  & Spratt,  p a i n as r e f l e c t e d symptom  1984).  and transcutaneous  incongruent  colleagues  section  pain  have been c r i t e r i a  incongruent  Hendler or  The following  Russell,  of medically  and their  described  there  exaggerated  and  & Doxey,  incongruent  (Lehmann,  To summarize,  drawings,  (Dzioba  relief from a c u p u n c t u r e  (TNS)  incongruous,  signs  pain  hypothesis  the that  and patients follows  19 discussion  b e l o w o f some e x p e r i m e n t a l  cognitive,  affective,  and  behavioral  Cognition  and Pain.  Cognitive  perspectives  search, pain.  selection, The  and  emphasize the  investigations  of  dispositional  variations  t o be r e l a t e d to e x p e r i m e n t a l been associated w i t h with  threatening  tendency making  interpretations to affect  or appraisals  p r e s e n c e o f an i n t o l e r a n t In s t u d i e s  either the  where  intensity  & Schwartz,  & Seidner,  1973)  suggestions  and  to intellectualize (Davidson  Gervasi,  parameters,  pain tolerance.  pain  report  model  from  produces  subjects  than  higher 1971)  and  instructions  increased tolerance to electric  shock  the  that  (Blitz  and  characteristics  the  in  1973).  cognitive h a v e also  painful (Bowers,  been  presence of a  pain while  they  perceived  has  cope  1970),  For example,  in c o g n i t i v e c o p i n g shock  found  pain tolerance  longer cold p r e s s u r e  those without  have been  the opposite effect  perceived  intensity  Some  & Holzer,  induced  in  populations.  & Bobey,  of w h i c h  of  pressure,  and actively  stimulus  o r t i m i n g o f an a v e r s i v e ,  were able to tolerate Tursky,  Greater  of pain are a f u n c t i o n ,  experimental  t o l e r a n t model d e c r e a s e s  1978).  pain tolerance.  (Alder,  of e n v i r o n m e n t a l  heat,  non-clinical  from external  perceptual judgments  (radiant  processes  stimulation  t o be i n d e p e n d e n t  Manipulation  found  external  information  the experience  in c o g n i t i v e  the tendency  of  pain.  has been e s t a b l i s h e d  pain  with  investigations  role of s e n s o r y  in p a i n  induced  shock)  in  in d e t e r m i n i n g  processes  muscle ischemia, or electric general  mediators  interpretation  role of c o v e r t  experimental  and correlational  could  the (Craig,  control  stimulus, 1968;  Staub,  exposure  control.  strategies  & Dinnerstein,  they  (Kanfer  Analgesic have 1971).  Further,  with  expectancies Leventhal,  experimentally (Hall  1983)  & Stride, h a v e also  manipulation  of c o g n i t i v e  hyperalgesic  affects  oxide  in  1954)  pain,  after  resulted  have  involved  processes  Thomme  douloureux'  'too intense'  in t h e  attending  cognitive  experience and  correlated  with  and  suggesting  incongruent  and  nitrous LeResche,  and pain  may be v i e w e d he o r  pain  recently,  Indicators  (1968)  Craig  belief  processes  behavior  security  (Main  and  of  disease  al.,  affective  consequences.  meaning  associated  independence, & Tunks,  et  1982),  behavioral  (Bellisimo  be  (Pilowsky,  The  lost  has  pain  patients.  with  or  and  shown to  & Waddell,  individual,  has  (1984b)  the  are associated with  in p a i n  as a t h r e a t t o t h e  have been  the  excessive'  systems,  pain populations  display  and  described  by  of c o n v i c t i o n  preoccupation  also has a f f e c t i v e  physical  activity  in  Engle  the more complex Szasz  memory,  a role  pain c o n d i t i o n .  can o p e r a t e to m a i n t a i n  s h e is n o w d i s a b l e d ,  and  as p l a y i n g  ideational  of p a i n ,  in c h r o n i c  pain  that cognitive  disturbance to chronic  and  depression  the  More  processes,  behavior.  somatic f o c u s i n g  financial  &  The  analgesic  Chen,  a career characterized  to his p a i n .  appraisals  pain  recognized  pain experience.  as h a v i n g  how attentional  distorted  that  (Dworkin,  of t h e c h r o n i c  in t h e d e s c r i p t i o n  'psychic'  1977),  both  o f t h e same d o s e s o f  long been  (1959) o b s e r v e d t h a t t h e more complex  and/or  Blanchard,  pain tolerance.  has p r o d u c e d  stimulation  the maintenance or exacerbation  outlined  of  1983).  Cognitive factors  imagery  (Ahles,  in i n c r e a s e d  administration pulp  the manipulation  and attention  expectancies  response to tooth  & Clark,  induced  and  1984).  attributed Pain  meanings has  lost  21 Considerable cognitive and  research  processes  interpretation  1980;  Mechanic,  relationship  and structures of physical  1976;  between  interpreting,  cognitive  the  system that  limit s u f f e r i n g "  may be a c r u c i a l  person  copes w i t h  persons' and  systems that  coping  have  reported  behavioral  (Girodo  using  modification  covert  patients  fail  processes that  as p a i n ,  perceived  symptoms symptoms.  "to develop  more  threat  to cope,  & Lazarus,  in i n d i v i d u a l s  (Beck,  1976).  (reinterpretation  hypnosis)  have become i n c r e a s i n g l y  threat, Belief  consequences  Therefore,  pain may  strategy  (Copp,  have been  strategies  the  1980).  most people s u f f e r i n g  suffering  How a  beliefs  determine  1977).  strategies  of  a  reasonably  on  of t h e  and t h e emotional  some s o r t o f c o g n i t i v e  processes  is d e p e n d e n t  of control o v e r  & Wood,  chronic  consequences  (Roskies  appraisals  pain management  surprisingly,  reacting to physical  in c o p i n g w i t h  such  perception  attempts  for  pain.  influence cognitive  In t h e i r  have  element  available to cope  processes  seem t o be a  p.314).  a stressor,  pain and the  & Nerenz,  perceived  arise from the perceived  about  Meyer,  There would  pain  the  understanding  has a r g u e d t h a t t h e a m o u n t o f  appraisal of t h r e a t ,  resources  peoples'  in a t t e m p t t o a l l e v i a t e  coping  1979,  (1984)  take  understanding  'schema' people  some c h r o n i c  allows f o r  control  1982).  and emotionally  that  guide  (Leventhal,  k i n d of mental  (Pinsky,  Weisenberg  symptoms  actions t h e y  proposed  which  Pennebacker,  monitoring,  and the consequent I t has been  has b e e n d i r e c t e d t o w a r d  pain  symptoms,  in a d d i t i o n  1974).  described (Turk  as t a r g e t s 1983).  not  for Cognitive  dissociation,  in t h e t r e a t m e n t  pain  to  Therefore,  et a l . ,  distraction,  popular  from chronic  and  self-  22 management of both 1983;  Turner  & Chapman,  pointed out, Patients  coping  cope will  1982).  strategies  must believe:  capable of  they  using coping  1977)  Individual pain  are  skills or  strategies;  n u m b e r of studies  in c o p i n g ,  variables.  demonstrated  CLBP  depressed  overgeneralization,  abstraction)  do n o n - d e p r e s s e d  patients  LBP patients with  non-pain  demonstrating dysphoric  made specific e r r o r s  that  mood  A couple of between tasks  cognition  have been  in C L B P However, impaired  and  in c o m p a r i s o n  coping. are  attempts  self-efficacy  to  (cf.  to cope w i t h  among C L B P Lefebvre  or  patients  patients.  A self-  errors'  selective  Although only the  depressed  depressed  CLBP experiences.  processes  in  has  and  was c o n s i s t e n t  in c o g n i t i v e  on  make more c o g n i t i v e  concerning  research  behavior  processes.  (1981)  personalization, CLBP  pain  of c o v e r t  investigations  As  in  are associated  have illustrated the  and t h e m u s c u l a t u r e of C L B P shown  has  with  1976).  recent  non-pain  return  this  distortions  (Beck,  (1984)  that they  and  also make more c o g n i t i v e e r r o r s ,  populations,  al.,  successful  attempts  adjustment,  patients  (catastrophizing,  non-pain  person  differences  r e p o r t measures of c o g n i t i v e  than  et  and that t h e i r  reflect the operation  have found  that  for  In o t h e r w o r d s , the  Turk,  pain.  differences may  1982;  as W e i s e n b e r g  not s u f f i c i e n t  whether  of t h e i r  patients  (Tan,  have the skills to cope;  determines  avoid exacerbations  pain  However,  h a v e some e f f e c t o n p a i n .  Bandura,  chronic  acute and chronic  to increase patients  (Flor,  to n o n - p a i n  to baseline  EMG l e v e l Turk,  controls,  patients.  relationship  Mental  in p a r a v e r t e b r a l & Birbaumer, CLBP  patients  stress  muscles  1985). show  EMG l e v e l s a f t e r t h e e n d o f t h e t a s k .  In  23 another  investigation,  CLBP  were compared to matched physical  exertion  matched  exertion  non-pain  Despite the interventions  1985).  cognitive assessment  (Turk  et a l . ,  (described  processes  self-control physiological  1983).  However,  model,  that  in o r d e r  A f f e c t and Affective 1984a).  In  in  over  to test  there  damage  chronic  of p a i n a n d thoughts,  related to pain implied  (b)  are  to  the  feelings,  (Turk, by the  et  al.,  cognitive  mediate i n c o n g r u e n t and  to  pain  to pain management  reappraisal  processes  in  have been few attempts  employed by  hypotheses  pain,  measured.  can a c c e n t u a t e o r a t t e n u a t e with  experimentally  of p o s i t i v e emotive increased  imagery  1966).  & Schachter, associated with  induced  (Horan  pain  (Craig,  pain,  the  & Dellinger,  pain tolerance while manipulations  (Nisbett  represent  to  Pain.  processes  (Craig,  more likely  and despite advances  approaches  responses  and anxiety  and anger  of  i n d i c a t i v e of t i s s u e  dysfunctional  increase apprehension  closely  1983)  need to be i d e n t i f i e d  investigations  manipulation resulted  and  maladaptive cognitive  the cognitive targets  were  levels  cognitive-behavioral  spontaneously  reconceptualization  and  and  of  below)  foster  behavior,  patients  findings  controls.  T w o goals of c o g n i t i v e  d e v e l o p m e n t of  CLBP  as d i s t r e s s i n g  sufferers. (a)  major pathological  p a t i e n t s on c o n t r o l l e d  recent development  in p a i n  study the covert  without  non-pain  (Schmidt,  rate the physical than  patients  Chronic  depression  1984a;  have been  has been  to  designed reduce  reported  and to a lesser e x t e n t ,  Sternbach,  f a i l u r e of p h y s i c a l ,  pain  shown  1974).  behavioral,  Such  1974) to  tolerance to  be  anxiety,  affective  and cognitive  has  states  fear, may  pain-coping  24 mechanisms hostility, Rachman  resulting  and  in g r e a t e r  interpersonal  & Phillips,  processes,  are intimately  usually  involved  conceptualized  dimension  system that  physiological  processes  pain conditions Leventhal  1979;  states  condition  independently  have been  1976;  The  as a l o o s e l y c o u p l e d , with  cognitive,  & Hodgson,  may o r may  (Lethem, Melzack  Slade, & Wall,  with  proposed  of o r g a n i c  aspects  partially and  I t is i m p o r t a n t of these  not c o v a r y Troup,  when  Emotional  chronic 1983; distress  anticipation,  (Craig,  1984a).  to modulate the chronic impairment  to  processes  & Bentley,  1983).  heightened  not  affective  behavioral,  1974).  are  of  or  pathology  Thus, pain  (Blumer  &  1982).  While d e p r e s s i o n associated with depression  has been t h e most common a f f e c t i v e  chronic  and chronic  Bonica  (1985)  to pain.  and m o n i t o r i n g of pain  affective  pain  estimates  Fordyce,  and expressive  interactive functioning  as a s s o c i a t e d  rumination,  Heilbronn,  and  since t h e y  & Everhart,  vigilance,  (Rachman  are assessed  has b e e n d e s c r i b e d  1984a;  dependency,  t h e e x p e r i e n c e of p a i n , t h e y  antecedents  interacts  independent  in t h e pain e x p e r i e n c e  chronic  with  has b e e n c h a r a c t e r i z e d  recognize the  (Craig,  like cognitive  as c a u s a l  independent  and  manipulation  frustration,  1980).  While a f f e c t i v e pain,  helplessness,  (1977)  found  patients  as h i g h  reviewed  pain and f o u n d  pain, pain  research has been  that only  relationship  inconclusive.  a small s u b s e t ,  were depressed whereas  as 85% ( L i n d s e y  & Wykoff,  o v e r 35 i n v e s t i g a t i o n s that  on t h e  between  Pilowsky,  Chapman,  approximately  others 1981).  exploring  state  have  of  reported  Romano a n d  depression  because of a lack of a d e q u a t e l y  10%,  and  controlled  Turner chronic  studies  25 it was  not possible to determine w h e t h e r  prevalent or  in c h r o n i c  pain  healthy controls.  manifested pain or  itself  These authors  dysfunctional processes  mediates  both  medical  patients  depression  concurrently few  more  with  patients  the onset  developed  of  pain  depression. above,  (Lefebvre,  It was  was a c t u a l l y  chronic  suggested that  Relatively  dysphoric  cognitive appraisal  incongruent  in o t h e r  ways:  a f t e r t h e o n s e t of p a i n .  As mentioned  1982).  than  in t w o d i f f e r e n t  a f t e r t h e onset of  with  patients  depression  pain  1981).  dysphoric  has been  and maladaptive  Depression  behavior  hypothesized  mood  and  mood a n d  cognitive  has been f o u n d  symptom  here that  associated  report  pain-related  incongruent  with  coping  to be  associated  (Main  £• W a d d e l l ,  cognitive  activity  pain.  Overt Behavior and Pain. Studies the  intensity  of e l e c t r i c  with  of pain  shock  facial expression Patrick,  experimentally  Craig,  is c l o s e l y  has been and facial  & Prkachin,  in p r e s s ) .  changes  expression.  among subjects  shocked while alone. tolerant  Kleck  Environmental  et a l .  (1976)  who were observed  model b y  (Prkachin,  Currie,  from subjects the  on t h e  relative  & Craig,  that  Intensity basis  & Kleck,  of  1970;  manipulations to  found  produce less  judged  while shocked than  Subjects who were shocked  p r e s e n c e o f an i n t o l e r a n t  indices.  (Lanzetta  h a v e also been f o u n d  model w e r e d i s t i n g u i s h a b l e  facial movements  have demonstrated  related to non-verbal  muscle movement  pain tolerance  discomfort  pain  s h o w n t o be d i s c r i m i n a b l e  designed to alter in f a c i a l  induced  those  in t h e p r e s e n c e of a shocked  in  infrequency 1983).  the of  discrete  26 Environmental maintain  behavior  impairment or 'pain  contingencies  associated with  pathology.  behavior'  chronic  Fordyce  initially  respondent  unconditioned  association  with  instrumental starts  and  maintained  by  in t u r n  physical  activities.  observer  events  (von  1978;  attention  awards,  from significant incentives,  sometimes  hypothesized  result  1959)  behaviors  care-taking  such others such  r e f e r e d t o as  to similarly  1978)  attention  (Block,  Kremer,  as d i s a b i l i t y secondary pain  comes t o (1976).  'behavior'  Pain of  behaviors  communicating in  the  Pain b e h a v i o r  and  (Redd,  demonstrated  1980)  & Gaylor,  have  as  responses  has b e e n  payments, gain',  be  restriction  has also been  as s t a f f  reinforce  behavior  and sympathetic  & Winget,  were  were  people since  1984).  as  movement),  increase distress  responsibilities  pain  through  Pain  Fordyce  for other  and may  and  behaviors  in a v o i d a n c e a n d  & McMillan,  Blackwell,  contingencies  Financial  to  means to elicit  1976; Wooley,  to be u n d e r  according to  Johnson,  a n d to f a c i l i t a t e a v o i d a n c e of (Fordyce,  pain  'pain'  as p o s t u r e o r  pain a r e also a means of  Engle,  Baeyer,  an i n s t r u m e n t a l  pain  consequences.  has c o n s e q u e n c e s  and express  (Craig,  by their  was p r o p o s e d  Pain b e h a v i o r  distress  Operant  organic  experience,  stimuli that,  (such  that  were conceptualized  Respondent  cues  of  that  response to tissue damage then  contingent  used to avoid  neutral  reinforced  behavior  Pain b e h a v i o r s  responses.  as a r e f l e x i v e  has a r g u e d  responses to painful  as f a c t o r s  independent  as a s u b j e c t i v e  or operant.  previously  became c o n d i t i o n e d  pain  (1978)  a r e t h e same s i n c e ,  must be i n f e r r e d f r o m b e h a v i o r . being either  have been p r o p o s e d  shown  or  1980).  litigation been  (Brena  & Chapman,  27 1981) a l t h o u g h problematic  the  interpretation  since other variables  compensation  status  potential for  reinforcing  that chronic  pain  originating of such  al.,  contingencies  across  displays  Zr F e i n b e r g ,  Consistent with  which  pain may be m a n i f e s t  their  greater  chronic  The  nature  may that  very  pain behavior  individuals  pain may e x a g g e r a t e  behavior  may become s e l e c t i v e l y  pain fail to elicit desired  in  levels of p e r c e i v e d  (Wooley et a l . ,  1978).  In t h i s  way,  reinforced  responses  from  'reality'  of t h e pain  distress,  (Steger,  increasingly  physical, have  salient displays  providers. to  who  illness  dramatic'  in a t t e m p t s  failed.  patients  help-eliciting  health-care  (Leavitt,  whose  resources  as l e s s  may also become more e x a g g e r a t e d  of t h e  of  behavior  ranges from  the  hypothesized  1983).  in p a i n  and cognitive coping  behavior  behavior  i t is  environment  of pain to absence of o v e r t  behavioral,  fail to cope w i t h  variation  with  because of  independently  (Fordyce,  is  1980).  Incongruent pharmacological,  Nonetheless,  in a p a t i e n t s '  individuals,  in p a i n  associated  contingencies,  nociception  account for the considerable  exaggerated  others  1983).  can be m a i n t a i n e d  tissue damage and  status  may be s p u r i o u s l y  environmental  behavior  has been o b s e r v e d  Fox,  (Kremer'et  reinforcing  partially  of compensation  of  Pain  convince  1985).  Conclusions. It was between  proposed  patients  with  in t h i s  pain deemed  deemed c o n g r u e n t  or  pathophysiology.  Differences  cognitive,  behavioral,  investigation,  appropriate  incongruent  given  nature  to be m a n i f e s t e d  processes,  differences  and those with  the degree and  were expected  and affective  that there were  described  pain of in  above,  the that  modulate pain.  Specifically,  these patient groups coping activity induced  pain  that  would  during  better  pain e x p e r i e n c e .  spontaneously  noxious  T h e presence of cognitions lack of s p o n t a n e o u s l y  with  Maladaptive  greater  input or  coping the  coping  of t h e c o g n i t i v e  identification  incongruent  pain  and  1983). the  were associated  presentation.  t o be a s s o c i a t e d  pain  of  et a l . ,  activity  behavior,  with  and  of  hypotheses  incongruent  pain  was d e p e n d e n t patients  on  more  accurate  as d i s c u s s e d  previously,  reliable a n d a c c u r a t e assessment of t h e p s y c h o l o g i c a l  t h e pain e x p e r i e n c e .  Recent advances  influences  on pain  (Melzack,  has a d d r e s s e d  of c o g n i t i o n ,  affect,  1983b;  some o f t h e  and  behavior  Turk  affective,  et a l . ,  1983).  issues and approaches in  mediators  h a v e been made in  assessment and measurement of t h e c o g n i t i v e ,  section  lack  strategies  coping  strategy  cognitions  accentuate (Turk  with  strategies  the pain experience  cognitive  of  cognitive  work  p r e s e n c e of  pain tolerance  displays  in  Experimental  the  between  disturbance.  A t e s t of t h e s e  on  (b)  c o g n i t i v e c o p i n g was p r o p o s e d  i n t o l e r a n c e of p a i n , affective  and  that worsen  anatomically  primarily  pain tolerance than  reduced  generated  differences  no o n e c o g n i t i v e  sensory  as c h a r a c t e r i s t i c  exaggerated,  (a)  generate;  are associated with  hypothesized  that:  in i n c r e a s i n g  serve to magnify  control  the  that  manifest themselves  has s u g g e s t e d  is c o n s i s t e n t l y subjects  it was e x p e c t e d  pain.  and of  the  and  behavioral  The  following  to  assessment  29 Multidimensional  The indicates  A s s e s s m e n t of  lack of c o r r e s p o n d e n c e the  necessity  Multidimensional address  cognitive,  1982).  affective,  sensory,  self-report,  writers  Turk,  preferred  et a l . ,  approach  among c h r o n i c different  pain  factors  traditional  methodology chronic  patients, that  for  indices of p e r s o n a l i t y  approaches  underlie  1985).  by  approaches)  implying  for  such  specifically  motor  1982).  (Keefe,  methods  et  al.,  has been  understanding associations  the  differences between  the  experience. pathological  and  tendencies  expressive that  aspects  of  traditional  have little face v a l i d i t y to be s e n s i t i v e to  (Keefe et a l . ,  assessment may  a psychological  (Keefe,  assessment  example,  pain experience  social-  may be too limited a  experiential  argued,  not designed  individual  or  are t r a i t o r i e n t e d ,  it has been o b s e r v e d t h a t resentment  pain  and  refine assessment  and the complex  et  noxious  included overt  differences  and  contribute to the  understanding  and are  need to  Keefe  following  be assessed:  responses  to  as w e l l a s  1982;  conceptual-judgemental,  Multidimensional  assessment  have attempted  Keefe,  have  pain  assessment.  included the  should  to s u b g r o u p  subgroups  p a i n . " I t has been  assessment  pain  for operationalizing  that  Psychometric (i.e.,  example,  and physiological  1983).  to  modulate  components  1977;  assessment targets  sensitivity  that  pain assessment  have pointed to t h e  and demonstrate  approach  behavioral,  for  chronic  Operationally,  behaviors,  1982;  (1977),  along which  factors  (Chapman,  motivational-emotional,  cultural.  Various  and  components  Chapman  dimensions  between  of a m u l t i f a c e t e d  models of c h r o n i c  pathophysiological al.,  Pain  1982).  provoke  processess Further,  hostility  etiology to t h e pain  for  and  (Leavitt,  30 Diagnostic information  assignment  r e l e v a n t t o an i n d i v i d u a l ' s  'hypochondriasis' viewed  as b e i n g  patient's  pain  & Waddell,  are empirically  reliability  and validity  especially  useful  pain  patient  providing  pain that  and the overt been  assumption  intensity  (and  behavioral  actual ongoing  There  and  (Viernstien,  psychopathology. descriptive  1982),  While  they  proponents  and may  be  traditional about  different  have not been  treatment  such  adequate  information  1974),  useful  strategies  by)  aspects of p a i n .  individual  in  designed  the sensory  Self-report  behavior  it has b e e n a r g u e d t h a t  & Turk,  to chronic  1981; Nisbett  populations  the  private self-report  to distinguish  contingencies, pain  have  because of  that  a n u m b e r of f a c t o r s ,  and environmental  and are p a r t i c u l a r  is d i f f i c u l t  experience,  measures  pain  however,  with  affective  has access t o t h e s e  reason to believe,  (Genest  associated  the cognitive and  are modified  Further,  1983).  have demonstrated  instances  rationalizations  report  a  point out that  patients  lies in t h e d i f f i c u l t y  overt or covert  intake,  is i n f l u e n c i n g  of  been  pain  post-hoc  medication  has  chronic  in t h e a s s e s s m e n t of c h r o n i c  is  and  hand,  and q u a l i t y ,  that only the  experiences.  and meanings  a measure  pain.  problem  used commonly  For example,  of w h a t  relevant to planning  modify  limited  On t h e o t h e r  (Sternbach,  coping with  provides  1982).  have p r o v i d e d  Part of t h e  processes  in most  in d e t e c t i n g  information  measuring  derived  subgroups  to facilitate  pain.  v a g u e as an e x p l a n a t i o n  assessment f o r  assessment tools  scores  has m u l t i p l e c o n n o t a t i o n s  (Main  of p s y c h o m e t r i c devices  based on t e s t  &• W i l s o n , such  as  can d i s t o r t (Kremer  of  from 1977).  mood, self-  et  al.,  31 On t h e o t h e r  hand,  nonverbal  and behavioral  indices  may  be  e q u a l l y o r m o r e s e n s i t i v e t o some a s p e c t s o f t h e p a i n e x p e r i e n c e less s u b j e c t t o d i s t o r t i o n promising  (cf.  Craig  assessment approach  sampling of c o g n i t i v e a c t i v i t y more sensitive retrospective and  perhaps  indicator accounts  Thus,  covert  (b)  as m e n t i o n e d  processes  observable  has  events.  that accompany assessment  found that  pain  was  that  support  worsen  related to anxiety  than  (Turk,  et a l . ,  self-report  1983)  indices.  by the  and  of c o p i n g  predicted  and  cognitive tolerance  sufferers  activity  private,  pain  of non-  processes  therefore  report.  during  pain  Rosensteil on t h e i r  emotional  and other  and  have Keefe  adjustment,  to  Unexpectedly,  been (1983)  Coping  psychometric  notion that the tendency  and depression.  the  in t e r m s  and the covert  usually  behavior,  classes  problem of m e a s u r i n g  items e n d o r s e d  history  events  the pain experience. .  pain  related to CLBP.  the  vivo'  may also be a  attempts to cope w i t h  t o be d e p e n d e n t on v e r b a l  patient  This  'in  increase or decrease  describing  derived from  beyond  the  have proposed two broad  (a)  hampered  measures  Questionnaire  findings  can  (1983)  are subjective  cognitions  factors  ratings  Their  been  has t e n d e d  used to assess  above,  levels  than other  The experience of,pain  pain  Self-report  Strategy  cognitions  pain.  pain experience pain  Another  involves  of e n v i r o n m e n t a l  cognitive acitivity:  and  1983).  Pain.  activity  et a l . ,  below  induced  different  in  covert  Turk,  of p a i n - r e l a t e d  However,  under  manipulations  suggest that  experience,  during  of t h e clinical  Assessment  Experimental  to pain.  described  less s u b j e c t t o d i s t o r t i o n  Cognitive  activity  & Prkachin,  and  and  variables.  catastrophize this  study  also  32 found that  higher  endorsement  'suppression' factors impairment.  were  Perhaps this  accounts of c o g n i t i v e that coping  skills  expectancies  reflected  se a r e  that they  items on t h e  related to greater  processes  per  One problem  of  will  n o t as i m p o r t a n t  in m e a s u r i n g  hence  or descriptions are v o l u n t a r y attribution that  an  actor's  of t h o u g h t or  cognitive events  actor'  an  'observer'  (Genest  & Turk,  Kahneman  and T v e r s k y of causal  Nisbett  w h o does  heuristics  1973),  connections  that the  used to explain  events.  information  report will  to d i s t i n g u i s h  post  Even the  'actual' t h o u g h t  not  lack  hoc  process  relevant  verity.  of  through  reasons  (Mahoney,  social  an  demonstrated  & Ross,  access t o  reports 1980).  process of  the  of  are not  covert  According  to  making  to t h e e v e n t .  and  To the  extent  representative,  i t is n o t a l w a y s  thoughts  more  desirability  from accounts  1974).  that  c a u s e a n d c a n b e no  Therefore,  verbalizing  is  explanations  From  (1977)  have direct  the event  rationalizations  process  self-report  be assessed  1977).  all i n f l u e n c e  the  and  1983).  as c a u s a l  and Wilson  possibility  d e p e n d s on t h e a v a i l a b i l i t y  of  the verbal  & Wilson,  1981; Nisbett  representativeness heuristics  events  or mistake actual  (1972;  belief  is t h a t  cannot  Demand c h a r a c t e r i s t i c s ,  processes  retrospective  may be i n a c c u r a t e f o r  (Nisbett  may o v e r l o o k  and availability  observations  patterns  perspective,  cognitions.  influences,  of c o g n i t i v e  involuntary  theory  accurate than  reports  in  et a l . ,  and  functional  1980) o r t h e  as t h e  (Turk,  d e p e n d e n t on a n u m b e r of p r o c e s s e s w h i c h introspection,  inherent  £• R o s s ,  be e f f e c t i v e  coping'  self-reported  distortion  (Nisbett  'cognitive  of  'actual'  can change  possible covert the  33 Genest and T u r k certain  conditions,  a n d bias  explanations feelings data.  of b e h a v i o r  While t h e r e  through  events  of  They  reports  verbal  coping  pain,  beliefs,  a b i l i t y to cope w i t h  through  strategies  cognitive errors)  during  1983).  antecedents, exacerbate  chronic  (Rollman,  The  distress,  1983).  pain or  pain  open-ended  1983)  where  in v i v o b y  fashion or t h r o u g h  experimentally  self-report  controlled  for  Validity  of  convergent  1981).  (such  as  have been  self-statements, suggested  of  and valuable  (Genest  as  response in  & Turk,  events that  to  planning  (cf.  and  behavior  stimuli.  is  events  1981;  Turk,  affective  serve to maintain  Hollon  & Kendall,  means of a ' b e h a v i o r a l  structured  noxious  reflection  asking  analysis of t h e c o v e r t  behaviors  cognitive  as  One way to elicit such t a r g e t s  and consequent related  and  covert  using multiple  i d e a h e r e is t o d e l i n e a t e c o g n i t i v e  mediators,  et a l . ,  in  by  may be p r e d i c t i v e  t h e e x p e r i e n c e of pain  has been a c c o m p l i s h e d  (Turk,  which  causal  minimizing  and  & Genest,  a cognitive affective-functional  that occur et a l . ,  Glass,  cognitive activities  assessment t a r g e t s  treatment  This  (Merrluzzi,  reflecting  strategies,  important  assessment of  as o p p o s e d t o q u a n t i t a t i v e j u d g e m e n t s .  assessment methods  as  there  can be dealt w i t h  questions,  by  that  of t h i n k i n g  s u g g e s t e d t h a t t h e biases  c o g n i t i v e assessment may also be e n h a n c e d  Behavior  of t h i n k i n g  random sampling of s e l f - r e p o r t ,  non-quantitative  distortion  have argued  reports  to the direct  use of o p e n - e n d e d  under  influence and  importance that  are limitations  the  cueing,  verbal  and treating  Genest and T u r k  can be limited b y  have argued that,  can be m i n i m i z e d .  between t r e a t i n g  as b e h a v i o r a l  processes,  however,  reactance to environmental  in s e l f - r e p o r t  are differences  (1981),  inventories  in  1981).  trial'  is a s s e s s e d e i t h e r response  or  in  an to  34 T h e goal of t h e c o g n i t i v e assessment of pain  sufferers  traditional  psychometric  to identify  controlling  modified.  hypochondriasis, D'Zurillia, of  individual's The  Scott  stimulation (1983)  to the  conversion  found  reaction)  1972; which  strategies  strategies  w e r e as g o o d as t h o s e p r o v i d e d  tolerance ended  relationships  have been f o u n d .  interview  induced  between  pain.  significantly found that  and asked Ratings  correlated self-report  pressor task were  Alder  subjects  of s u b j e c t s ' with  half t h e  h a v e not been  cognitive/affective and  Lomazzi  what they  (1972)  reconstructions  of t h e  that  when  studies, by  the  experimentally activity  and  u s e d an  open  strategies  Genest pain  & Mann  High  pain  the  were (1978)  experience  r e l a t e d t o t o l e r a n c e on t h i s t a s k .  exposed  investigations  d i d to cope w i t h  use of c o p i n g  pain tolerance.  illustrated  manipulations.  spontaneous  manipulated,  in u n d e r  the  have found  with  strategies  advantage  & Goldfoot,  r e v i e w of e x p e r i m e n t a l that  &  1981).  Kanfer  strategies  When c o p i n g  (Goldfried  has been  of c o g n i t i v e  experimenter.  pain,  be  to a  has t h e  of t h e e x p e r i m e n t a l  in t h e i r  and  (e.g.,  & Kendall,  use t h e i r own c o p i n g  regardless  to  and of e l u c i d a t i n g  s> C o o p e r ,  the  t h e a i m is  individual,  approach  (Hollon  1977),  in  psychiatric  In t h e f o r m e r ,  assessment approach  & Barber,  to noxious  to t h e  structure  analysis  (Barber  spontaneously  et a l .  pain,  experience  investigations  analysis  t h e a i m is c l a s s i f i c a t i o n  treatment targets  individuals  Turk,  model,  i m p o r t a n c e of t h i s  1978;  models.  particular  The functional  individual  Scott,  in c o n t r a s t  static personality  idiosyncratic  in v a r i o u s 1966;  variables,  psychogenic  1969).  identifying  or  stands  assessment  In t h e d i a g n o s t i c  diagnostic category  affective-functional  during  tolerance  35 subjects they  indicated  more power to persevere  could control  their  likely to catastrophize pain.  Spanos,  reports  Radtke-Bodorik,  'Catastrophizers' to the  increased  distraction,  showed second  immersion,  Although  and  'in  vivo'  and Jones  incremental  reported  Hutchings  under  pain. pain',  pain' to other  painful  stimuli,  a n d also ' c o g n i t i v e l y  of t h e  sample w e r e  Interestingly, anything  when  pain more than  cognitive  self-report  self-report.  In t h e  rated  the  data from Spanos  subjects pain,  the  behavioral  as i n c l u d i n g  coping  to cope w i t h  show was  imagery,  only  (1983)  et a l .  what  'compare  can be used  (1979)  were asked  women. to  'misleading' study  if t h e y  reported  the  their  roughly  some s o r t o f c o p i n g  half  threshold  The  redirect  potentially  pain  pain.  non-dysmenorrheic trials  with  exposed  r e p o r t of  ischemic  to 'exacerbate the  erroneous  as  on pain  in t h e i r  tended  accurate  did  increase  induced  the groups  did differ the  the  groups  distinguish  such  from  assessment approach  dysmenorrheic  with  immersions.  pain tolerance  employed  and  between  they were doing while experiencing  Assessment  their  categorized  women to a muscle-ischemic  while  the groups  attention' away from the  (1979)  'non-catastrophizers'  cognitive  Denney,  no d i f f e r e n c e  or tolerance measures,  could control  t h e m a g n i t u d e of t h i s  non-dysmenorrheic  t h e r e was  more  self-statements.  Arberger,  cognitions  were  repeated cold water  while  Further,  relaxing  populations,  and analysed  after  convinced  subjects  that they  n u m b e r of c o p i n g cognitions  and  dysmenorrheic  doubts  no e v i d e n c e of  I n an e x a m p l e o f a n clinical  low t o l e r a n c e  Ferguson,  questions  pain tolerance.  related to the  while  and express  to open-ended  the first  pain,  and were more  or half  strategy.  had  that they  done had.  Therefore their  a n u m b e r of  own c o g n i t i o n s .  predicting (1973)  subjects Subjects  how d i f f e r e n t  induced  were given (involving  pain with  instructions  more e f f e c t i v e . most e f f e c t i v e ,  yet  the dissociative Thus,  a blood  in d i s t r a c t i o n  to sensations)  Most subjects ratings  stragegy  cognitive  cognitive  the  Further,  (Weisenberg, been  1977).  investigated  cognitive to pain  using  processes  (cf.  selectively  Covert  Chapman, search  for  Olson  (1980),  lower  pain thresholds  pain. were to  They  found  1978).  that  improve  in  with  that the  treatment.  would  be  as t h e  indicated  one  that  appears  own conclusions  important  Pain  trials  about  also  behavioral  have  data  on  Patients.  have been f o u n d in  relevant  non-clinical to chronic For  mediator of a  Hypervigilant  pain  controls  with  pain  have  'hypervigilance' may a c t i v e l y Grimm,  sufferers  pressure  lower the threshold  be  populations  Malow,  dysfunction  to  example,  individuals  i n d i c a t i v e of p a i n .  non-pain  which  cuff  pain methodology.  myofascial  than  also f o u n d  subjects  important  sensations  strategies  below.  phenomena  m a y b e an  subjects  the experience of pain  pairr t h r e s h o l d  induced  after  effective.  n u m b e r of variables  related to pain tolerance and  in  Johnson  strategy  pressure  providing  Induction  A considerable  cuff  cognitive/behavioral  p a i n t o l e r a n c e as h a s b e e n d e s c r i b e d  Pain  pressure  blood  was t h e most  t h e a d v a n t a g e of s i m u l t a n e o u s l y  Experimental  pain.  and asked to predict  'sampling' d u r i n g  activity.  affected  chose the distraction  with  concerning  to be i n a c c u r a t e  and dissociation  to be a more a c c u r a t e data s o u r c e t h a n their  conclusions  h a v e also been f o u n d  cognitive activities  ischemic  attention  made misleading  the  less  and and  reported  induced likely  they  37 However, that chronic controls  in c o n t r a s t t o t h i s  pain  sufferers  (Rollman,  1977).  'compared' to internal research  employing  supported found  this  higher  non-pain findings greater  When e x t e r n a l l y  in s u p p o r t o f t h e  investigations induction  to test  Because v a r i a b i l i t y s h o w n t o be a f u n c t i o n  treatment  characteristics.  unsuccessfully  treated  ischemic t e c h n i q u e to d e r i v e  patients' after  patients'  back  pain tolerance.  treatment.  (1981)  pain,  intolerant  patients  who were  pain,  ischemic  procedure,  raising,  and altered f l e x o r - e x t e n s o r  demonstrated  chronic  (1981)  has  in  suggested  studied.  pain  processes.  pain tasks  has  i t is n o t s u r p r i s i n g  pain  (1974)  that  to  sensitivity  patients,  but  to  not  in  has u s e d a m u s c l e  has b e e n  comparison pain and  the  shown to  f o u n d t h a t a g r o u p of back  spinal  been  patient  decreased  as a s s e s s e d  of  These  experimental  based on a  ratio  reduced  has  patients than  covert  t h e muscle ischemic  (1980) of  using  induced  found  ratio,  The derived  Pope et a l .  samples  is  Some  Heinrich  shown to be r e l a t e d  Sternbach  a pain  and  pain  and various  treated  patients.  of  variables,  treatment outcome,  pain  LBP populations  (1983)  concerning  have been  non-pain  notion may be a f u n c t i o n  utility  of c o g n i t i v e  in s u c c e s s f u l l y  the  Rollman  in p e r f o r m a n c e on  pain t h r e s h o l d  between  the  hypotheses  Malow a n d Olsen  in  Schandler,  in t h o s e p a t i e n t  pain tolerance trials effects,  pain  'hypervigilance'  have demonstrated  than  as l e s s s e v e r e .  in low b a c k  controls.  involvement  methods  behavioral  Cohen,  predicts  induced experimental  induced  heat t h r e s h o l d s normal  ' a d a p t a t i o n ' model  i t is p e r c e i v e d  Naliboff,  and  an  have higher thresholds  experimentally  radiant  affective  should  discomfort  model.  patients  model,  by the mobility,  decrease pain  muscle straight  muscle balance compared to a  leg pain  tolerant  group.  explored with (1976)  Similarly,  experimentally  found that the  muscle-ischemic Research both  on  pain  task when  Each pain  (Davis,  (Ganchrow,  tolerance. damage, Deems,  Having  may  Timmermans,  Duncan,  to  have been Gregg,  (Fox,  Steger,  variability  reach tolerance  t o l e r a n c e on t h e cold p r e s s o r subcutaneous administration chosen  in t h i s  investigation  has  demonstrated 1979)  1978)  and  on a cold  subjects.  and  limitations  required to in o r d e r  for  ischemic  achieve  to p r e v e n t  differences  tissue  (Sternbach,  subtle variations  in  the  have  been  pain  estimate  1979)  and there  relationship  & Jennisen,  between  1979).  cold-pressor  Therefore,  induced  sensations  ischemic or t e m p e r a t u r e  The  section  of the pain  was  administration,  more akin  pain.  in t h e m e t h o d s  makes  pressure  b e c a u s e of t h e ease of  taken  However,  by thickness  of t e m p e r a t u r e  hand,  mean t i m e  procedures.  can be a f f e c t e d  of  On t h e o t h e r  and the overall  nociception  has been o u t l i n e d  patients.  & Ghia,  and production  procedure  a  substantially  standardization, than  by  shown to alter tolerance  fat and standardization more d i f f i c u l t .  been  Sternbach  one limitation of muscle  Further,  in t o l e r a n c e  is less f o r  pain  non-depressed  to g r o u p  of a lack of a l i n e a r  individual  & Kleiner,  exposure  1977).  has  and  £• B u n n e y ,  has a d v a n t a g e s  sensitivity  & Huey,  Scott,  and elapsed time both  Steiner,  prolonged  reduce the  demonstrations  however,  a c e i l i n g on e x p o s u r e t i m e ,  ischemic muscle task (Moore,  in d e p r e s s e d  Buschbaum,  For example,  has been t h e  Timmermans  subjects,  procedure  in p a i n  o f p a i n as m e a s u r e d  compared to non-pain  induction  states  pain.  intensity  depressed  assessment applications. procedures  induced  r a t i o was g r e a t e r  non-pain  decreased tolerance  role of affect  reported  increased tolerance  pressor  the  to  skeletal  pressure below.  pain  Overt, Nonverbal, Behavioral Aspects of Pain. Pain behavior and expressive displays serve a communicative function (Craig, 1978;  Fordyce, 1978).  Pain and distress behavior  engages health care providers and significant others to help relieve discomfort and distress.  These, therefore, have been identified as  important assessment targets since these behaviors serve to maintain maladaptive chronic pain responses  (Johnson, 1977; Wooley et a l . ,  1978). The subjective experience of pain can be inferred from verbal and non-verbal behavioral indicators of discomfort and distress or avoidance of stimuli which produce those signs (Fordyce, 1978). Fordyce (1976) has argued that verbal reports are subjective, therefore not verifiable, and subject to distortion along the lines previously discussed.  Overt behavior, however, is observable and  publicly  verifiable and therefore constitutes a less distorted index. Non-verbal  behaviors such as paralinguistic vocalizations,  autonomic reflexes, facial expressions, gesticulations, and adjustments  have been used  (Craig &• Prkachin, 1983).  postural  routinely in the clinical assessment of pain Because of distrust of self-report among  clinicians and the general public, non-verbal indicators are more likely to be relied upon in judging the severity of pain. non-verbal indicators was  A preference for  indicated in a study by Johnson (1977)  who  found that nurses reported physiological signs, body movements, and facial expression to be easier indexes to use in pain assessment than verbal communication.  Others have pointed to the necessity of  assessing verbal and non-verbal behaviors simultaneously (Bookwater,  40 Johnson,  & Volkert,  non-verbal  1978).  behaviors  patients than  The discrepancy  in a c u t e p a i n  higher  conditions for  (Teske,  example,  that  Daut  within  t h e same h o u r  in c h r o n i c  pain  than  (Ignelzi,  report  & Cleeland,  chronic  levels of pain to a n e u r o s u r g e o n  to a psychiatrist  verbal  has been o b s e r v e d t o be g r e a t e r  I t has been d e m o n s t r a t e d , report  between  and  pain 1983).  patients  will  to a psychologist  Atkinson,  &  or  Kremer,  1980). Even t h o u g h inferences  drawn  Contextual  or  overt  behaviors  regarding  individual  Prkachin, they al.,  1983).  or  Even t h o u g h  1983).  Also,  Clinicians  may  t h e s e may  observers  (Jacox,  1977) o r a c t u a l l y is a n e e d f o r  covary  and a need f o r  validation  of t h e s e  & Craig,  1983).  Some a t t e m p t s assessment  systems  coding  systems  behaviors  &  observable,  can make e r r o n e o u s j u d g e m e n t s  based  on  Prkachin,  Currie,  & Craig,  s i g n s of d i s c o m f o r t  or  applicable to  the pain  systems  experience.  (Craig  to assess  & Prkachin,  CLBP  a reliable observation  behaviors  (i.e.,  patients.  1983).  and distress  'chronic'  samples of p a t i e n t  developed  guarded  (Craig  are  & Prkachin,  have been made at u s i n g with  pain  or  et  with  "standardized  exaggeration  Turk,  pain  not be s u f f i c i e n t ,  (Craig  problematic.  may a f f e c t  conveying  non-verbal  verifiable,  1983;  1980;  use 'acute'  remain  variables  behaviors  a r e also s u b j e c t to d i s t o r t i o n  pain expression  1983)  these behaviors  difference  a t t e n u a t i o n of expressions  are objective and  pain  This  behavior" pain  is w h y  there  (Fordyce, empirical  Prkachin,  standardized  Keefe and  (Johnson,  and the  1983;  when  Block  Currie,  behavioral (1982)  s y s t e m t o assess t h e o c c u r e n c e of  movement,  bracing,  rubbing,  grimacing,  pain &  sighing)  in a s t a n d a r d  discrete  pain behaviors  independent observer of t h e s e  behaviors  correlated standard CLBP  with  has been  change  with treatment.  Hyde  Facial A c t i o n  for  of pain  Coding  physical  in p a i n  ratings.  behavioral (1986)  System  than  correlate with the pain complaint,  (FACS)  receive  men.  subjective  of  Verbal  Adjective descriptors  Further,  the  and  frequency  treatment Newman  and  patients  (1976)  using  the  found  t h e r e was a  of global  facial  was also f o u n d  pain d e s c r i p t o r s ,  of  undergoing  attenuate expressions,  expressiveness  used  improve  While no e f f e c t was  ratings  is  as a c r i t e r i o n  expression  of  and  w e r e also f o u n d t o  in C L B P  higher  Global  severity  with  patient  measures  examined facial  use of a f f e c t i v e  and  Assessment  assess t h e  position  indicators  to exaggerate or  f o r women to  expressiveness  Seres  r a n g e of motion e x e r c i s e s .  instructions  tendency  intensity.  The frequency  with  shown to decrease with  r a n g e of motion a n d b o d y These  session.  was s h o w n to be c o r r e l a t e d  ratings  behavior.  painful  10 m i n u t e a s s e s s m e n t  duration  to  of  the  disability.  Descriptors.  of t h e pain  experience  e x p e r i e n c e of pain  (Melzack,  have been 1975;  used  1983a).  to  There  appears  to be s u p p o r t  for  distinct  groupings  of v e r b a l  pain  descriptors  roughly  corresponding  to sensory,  affective,  and evaluative  components  of t h e  subjective  of v e r b a l extent,  pain description  different  Experimental reliably  pain experience  pain  pain  components  has been  syndromes  induction  discriminate of t h e i r  (Melzack,  1975).  shown to differentiate,  (Dubuisson  research  Further,  has  & Melzack,  shown that  and  rate differentially  pain  experience  1973).  to  pattern  some  1976).  individuals  the sensory  (Johnson,  the  and  can  affective  Further,  it  has  42 been  shown that  affective  verbal  analgesics rating  can d i f f e r e n t i a l l y  descriptor  scales  affect  (Gracely,  sensory  and  McGrath,  &  Dubner,  1978;1979). As a f f e c t i v e more ' d i f f u s e ' , and  distress  reflecting  less t o t h e s p e c i f i c  1983).  Affectively  emotional or  indicated  verbal  pain descriptors  disturbance  psychological  emphasizing  dimensions  pain description  qualities of pain  (McCreary,  disturbance  affective  (McCreary  (Kremer may  1983).  1983;  becomes suffering,  & Atkinson,  reflect  more  Investigations  patients,  endorsement  and evaluative  & Turner,  related to  in C L B P  b y t h e M M P I , was associated w i t h  descriptors sensory  laden  verbal  a n u m b e r of dimensions sensory  personality  have f o u n d that  increases,  of  pain  dimensions Kremer  as  rather  than  & Atkinson,  1983).  Conclusions. Measurement of pain a minimum chronic  requirement  overt  for  pain experience.  cognitive/affective pain  variables  battery  thoughts,  It was  proposed  during  and verbal  and behaviors  of  experimental  pain  pain,  descriptors  tolerance,  would constitute and adequately  to mediate and maintain  is  'multidimensional'  that measures  t h a t was c o m p r e h e n s i v e  hypothesized  feelings,  a d e q u a t e assessment of t h e  processes  behavior,  assessment  relevant  incongruent  an  sensitive  to  chronic  pain. In c o n t r a s t research addressed  on  CLBP with  below.  investigation, this  chronic  to t h e assessment  Also,  traditional as C L B P  approaches  psychometric patients  outlined  above,  some  instruments  has  were t h e focus of  this  some g e n e r a l  research  and b a c k g r o u n d  pain condition  has b e e n  reviewed  information  in t h e f o l l o w i n g  been  about  section.  43 Chronic  Low Back  Pain  to the  Background  PREVALENCE. physical  limitations  Chronic  & Turk,  adults  in t h e  these,  44% r e p o r t e d t h a t  their  1984).  Nagi,  18% r e p o r t e d  backache  which  impairments  is t h e  (1973)  resulted  individuals  surveyed  persistent  also i n d i c a t e d  Kelsey health  back  pain  & White,  1980),  whose pain  been f o u n d to  Hickman,  w e r e f o u n d to be back  injuries  related  T h e cost of c h r o n i c  (Bonica,  of  with  other  of  from  & Turk, relief  only  1984;  without  1982).  In a d d i t i o n ,  States  Yet,  of  50% h a v e it has  who suffered  permanently  has been  disabled  (Loeser,  back  1980).  disorder  and  1 billion  pounds  s t a t e in  However, payments  including  has b e e n e s t i m a t e d at $ 1 7 . 6 b i l l i o n 1980)  substantial.  in W a s h i n g t o n  a c c o u n t e d f o r 36% o f t h e c o m p e n s a t i o n  care costs  1982).  65,000 were  impact of C L B P  10,000 compensable  injuries  (Flor  6 months,  United  a level  suffer  experience  1981).  Of  been  a  back  (Beals  &  1972).  T h e economic of o v e r  year,  in t h e  life  1976; W a d d e l l ,  (Calliet,  million  in one c a l e n d a r  most will  f o r more than  to w o r k  1.25  in t h e i r  (Nachemson,  persists  return  estimated t h a t of  year.  although  care intervention  patients  injury  a t some p o i n t  1100  backache.  I t has b e e n e s t i m a t e d t h a t 60-80% of p e o p l e w i l l significant  age  impairment  individuals  without  of  backache.  in s i g n i f i c a n t  was t w i c e t h a t of  and of  leading cause  u n d e r 45 y e a r s o f  & Newby  Backache sufferers  care utilization  functional  pain  in p e r s o n s  Riley,  and found  ability to w o r k .  health  low b a c k  and disability  (Flor  U.S.  Problem.  annually  in t h e  study  1 9 7 7 , 25% these  same  m a d e in  work  annually  In a  lost and  in t h e  U.K.  that health  U.S.  (Waddell,  ETIOLOGY.  As with  other  chronic  The  physical  to have multiple etiologies. been elusive f o r physical  cause of C L B P  activity  in n e r v e  vertebrae Turk  (a)  this  physical  degenerative  (b)  structural  (d)  traumatic  proposed to  & Wall,  processes (c)  muscular  and occupational  The  abnormal  in t h e  According  of t h e and  factors,  often  primary  surrounding to  Flor  has been a s s u m e d t o  (primarily  appears  has  result from  1983).  pathogenesis  abnormalities, injury  of s u f f e r e r s .  due to slight changes  (Melzack  CLBP  e t i o l o g y of C L B P  proportion  has been  root fibers  and tissues  (1984),  from  a significant  pain conditions,  and  result  intervertebral  ligamentous and  (e)  discs),  dysfunction,  inflamatory  conditions. It has been e s t i m a t e d , patients who suffer  CLBP  their  1980;  pain  objective  (Loeser,  or  Melzack  to undiagnosed hyperreactivity  Raczynski, backache  1985;  more closely  (Frymoyer  medical  stressful  et a l . ,  pathophysiological  1983).  condition  1985).  of t h e s p i n e  practice  Still,  episodes of a n x i e t y  Thus,  various  other  chronic  back  (a)  Engle,  1959),  (cf.  Gentry  & Bernal,  models  Waring,  (cf.  1977),  1977),  (d)  (c)  respondent  operant  for  (Dolce  &  surveys to  and depression physical  be and  models of  pain 1984):  (Turk  & Flor,  (b)  family  and  models  of  impairments  pain  learning  which  & Milbrandt,  the condition  conditioning  for  been  (Gunn  psychological  have been p r o p o s e d to explain  models  has  epidemiological  have found  basis  Some C L B P ,  is l a c k i n g ,  life events t h a n  1980).  psychodynamic  as 60-78% o f  of t h e m u s c u l a t u r e of t h e back  associated with  more emotionally  & Wall,  abnormalities  F l o r et a l . ,  in g e n e r a l  t h a t as m a n y  h a v e no a p p a r e n t  e v i d e n c e o f an o r g a n i c  attributed 1978)  however,  systems  models  (cf.  (cf.  Fordyce,  45 1979), and  (e)  (f)  social a n d o b s e r v a t i o n a l  cognitive-behavioral  psychological  perspectives  considerable overlap  models  are by  between  not suggest o v e r w h e l m i n g l y psychological  pathogenesis  TREATMENT. had mixed averages  success.  occurs  in  success  of C L B P  Long term  roughly  rates  nerve  mutually  but  reported,  with  operant 1977;  1984)  60% o f c a s e s  such  (Melzack  as s t e r o i d  1984).  Thomas,  Mooney,  relaxation  have demonstrated  also been e q u i v o c a l  and  success  no t r e a t m e n t  and  results  1976),  studies rates of  (Turner,  but  Studies  have  for  reported  CLBP  have  is  been  treated  Hudgens,  &  with  Roberts, studies  EMG b i o f e e d b a c k  and  u p t o 60%, b u t t h e r e  outcome  approaches  1982).  1983)  no c o n t r o l l e d  of  has  injections,  studies  (Turk  have produced  have been f o u n d to be s u p e r i o r  controls  or  with  1977).  successfully  Gullickson,  in c o n t r o l l e d  Promising cognitive-behavioral 2 years  patients  & Pace,  Uncontrolled  results  therapies  While i m p r e s s i v e  undertaken.  lasting for  et a l . ,  & Turk,  Cole,  does  intervention  & Wall,  i n e x c e s s o f 50% ( F l o r  have been  1984).  surgical  therapy,  (Anderson,  research  while success  (Gottlieb,  u p t o 75% o f c h r o n i c  as  1982).  physical  inconclusive.  These  exclusive  and  approaches  Cairns,  1983).  To date,  rates f o r  T h e outcome of p s y c h o l o g i c a l l y - b a s e d promising  1983),  f o r t h e a l l e v i a t i o n of C L B P  & Turk,  blocks,  Craig,  model of p h y s i c a l  (Murray,  success  5 years  (cf.  et a l . ,  any one p a r t i c u l a r  somatic-based treatments,  chemonucleolysis,  Turk  no means  Somatic t r e a t m e n t  m a y b e as l o w as 10% a f t e r with other  (cf.  models  t h e models e x i s t s .  b e t w e e n 30-40% ( F l o r  medication  learning  to  &  have Flor,  effects  relaxation  46 Comprehensive treatment psychologically results  based treatments  but there clearly  changes.  Success  functioning training  packages  at d i s c h a r g e  have been  have produced  are problems  rates of  including  both  t h e most  in s p e c i f y i n g  reported  and  favorable  t h e s o u r c e of  u p t o 79% d e m o n s t r a t i n g  a n d 82% d e m o n s t r a t i n g  somatic  unimpaired  return  at a 6 m o n t h f o l l o w - u p  the  physical  to w o r k  or  (Gottlieb,  et  al.,  1977). Interpretation undertaken  cautiously  been c o n s i d e r a b l e measures subject  used,  The  effects  length  to treatment, (Dolce,  about  management  1984).  of follow  any f o r m of  intervention  alone  since  it has been  (usually  relief from pain  a "placebo"  up,  t y p e of  and  (1984)  works  for  shown that with  1977).  response t h a t can last  such  as  unvalidated  acute  also back  treatment  conservative  as m a n y  as 50% h a v e  Further,  and treatments  has  outcome  have  in d e m o n s t r a t i n g  et a l . ,  There  as w e l l as f l a w s  c o n s i s t i n g of b e d r e s t ) , (Gottlieb,  be  abound.  Flor and T u r k  e s t i m a t e d t h a t 30% o f all p r o c e d u r e s provide  problems  must  inadequate controls,  necessity of adequate controls  is o b v i o u s  reported  in t h e  results  t y p e a n d amount of t r e a t m e n t ,  measures  noted that just  since methodological  variation  self-selection  dependent  pain.  of any t r e a t m e n t outcome  for  it has  been  backache  up to 3 months  (Waddell,  1982). Regardless cannot  of o u t c o m e  research  design  be i n f e r r e d on t h e basis of t r e a t m e n t  some s o m a t i c a l l y psychological problem.  based treatments  support  Conversely,  or  are  may w o r k  interpreted  by  some p s y c h o l o g i c a l l y  problems,  etiology  outcome.  For  because they patients  still  example, provide  as " f i x i n g "  based treatments  may  the work  47 because t h e y  remove  to medical t r e a t m e n t Another most  resistance and enhance cooperation regimens  problem with  relevant to this  'similarities' issue t h a t myth'  with  CLBP  patients  received  & Flor,  1984).  in t h e p a t h o p h y s i o l o g i c a l (Block,  1982;  however, as t h e  Flor  "low-back  the 5"Ds"  loser"  (i.e.,  Drug  in m a n i f e s t a t i o n  Sternbach,  1974).  assessment  research  differences  such  implications  1984).  misuse,  & Chapman,  identification  CLBP of t h i s  for treatment  Flor  Wolf,  of t h e s e  Murphy,  1981).  pain  Back  points  CLBP  is m u l t i p l y next  mechanisms  who present subgroup management  groups  literature,  patients  t o t h e v a l u e of  psychological  differences  with  has  such  1973)  Depression,  to t h e  and  Fordyce,  & Akeson,  Disuse,  One  1983)  psychological  Dysfunction,  patient  emphasize  1984;  different  conceptions  patients  is  'uniformity  t h e r e are clear  Some o f t h e  and patient  to  et a l . ,  & Turk,  underlying  This observation  as t h e  and which  (Turk,  f r o m one individual  addressing  condition.  is t h e a d h e r e n c e t o a  1982;  (Sternbach,  and varies  since  (Block,  homogeneous  (Brena  pain  compliance  as o p p o s e d t o ' d i f f e r e n c e s ' .  in g e n e r a l  mechanisms  Disability)  pain  CLBP  Most i m p o r t a n t l y ,  & Turk,  has f o s t e r e d  with  patients  in p a r t i c u l a r  back  has b e e n t h e t e n d e n c y  little attention  respect to pain  1976; T u r k  alter the  treatment outcome studies,  investigation,  among patients  has  which  and  or  &  determined (cf. psychological  and  subgroup  incongruent  important  (Waddell  et  al.,  1984).  Subgroups  of C L B P  Psychological disabilities  would  undermine  surgical  factors  Patients. in t h e m a i n t e n a n c e of c h r o n i c  appear to be i m p o r t a n t and  rehabilitation  because t h e y  efforts  in C L B P .  pain  may For  serve  to  instance,  a  48 n u m b e r of studies of  have shown  response to surgical  Kuperman, Pondaag, Klonoff,  Golden,  intervention  & Blumer,  1981; Pheasant, & Kokan,  psychometric for  1979;  Gilbert,  1973; Wiltse  Some s t u d i e s inclusion  score  in  have demonstrated  of medical  history  and demographic  tests  response to conservative  results  analgesic medication) (McCreary,  Psychometric patients  test  that cluster  unelevated found  Turner,  clusters  (Bradley,  demonstrated  more contact with  their  p a i n as m o r e i n t e n s e  males  in t h e e l e v a t e d g r o u p s  and  utilized  (Armentrout, and poor  with  Moore,  hospitalization  e l e v a t e d MMPI  1982). the &  psychometric  interventions  (i.e.,  consistent  clinically  subgroups elevated  patients  more  have  and  rates of medication  Other  physical  Hewitt,  Lawlis,  and  & Feltz,  Selby,  (McCreary,  scale c l u s t e r s .  investigations social  1985)  been  rated Further,  consumption have  increased  & McCoy,  associated with  McCreary  and  found  activity  1982),  Mooney,  of  psychopathology  health care professionals  resources.  Parker,  response to t r e a t m e n t  clinically  use of t h e  used to i d e n t i f y  exhibiting  had h i g h e r  restricted  (McGill,  warrant  in b o t h t h e male a n d f e m a l e g r o u p s .  more t r e a t m e n t  similar c l u s t e r s ,  'hit  (Oostdam  not yielded  Using the MMPI,  The group  the  (Murray,  variables  f o r male a n d f o r female C L B P  1983).  Wilfling,  1979).  have been  together.  &  1979;  power with  medical  has  & Dawson,  scores  cases  examining the  however  1951;  However,  predictive  1983).  bedrest,  1975).  individual  Duivenvoorden, to predict  & Herron,  may be t o o low t o  better  Research  (Hanvik,  predictive  Duivenvoorden,  Goldfarb,  & Rocchio,  indicators  scores to be  backache  Oostdam,  rate' o r a c c u r a c y of these p r e d i c t i o n s r e l i a n c e on t e s t  test  (1985)  has  duration  1982), the  and  49 characterized clusters  the  back  as h a v i n g  pain  a "more  patients  intense pain  Some o f t h e e a r l i e s t w o r k examined  differences  radiologic,  and/or  those without  the  organic  signs  signs  indicative of o r g a n i c  Hanvik  p a i n as less i n t e n s e  McNeill,  and to have lower  organic  et a l . ,  1980)  Frymoyer,  and  dimensions:  presence  appropriate  levels of f u n c t i o n a l  significantly correlations  between  status,  patient  observational ratings  s c o r e s on  work  has  Caslyn,  &  CLBP  Garron, scales of  to patients  disability.  organicity  t h a t t h e MMPI but  associated  including  measures  not  and MMPI  found  Loucks,  patients  with  pain and  D'Angelo, recent  without  to  &  life  stress  demonstrable  signs and  status,  problem.  CLBP,  or  with  disability  Swanson  and  diagnosis  Extreme constant  They  over time, and were  pain was  were  scale  independent  and Maruta  vs  significant  d e g r e e of d i s a b i l i t y .  little variability  neurological  scales  there were  are  CLBP  incongruent  While no MMPI  scale scores with  compared two  in a d d i t i o n t o s e l f - r e p o r t .  pain,  related to orthopedic t y p e of pain  (1980)  t h e p r e s e n c e of f u n c t i o n a l  group,  of e x t r e m e  Clements  vs absence of o r g a n i c  associated with  suggesting  organicity pain  pathology  to describe t h e i r  (Leavitt,  in c o m p a r i s o n  orthopedic,  disease. Rosen,  scores,  (Freeman,  adjectives  CLBP  d e v i s e d a scale f r o m t h e  have found that  describe their  (Leavitt,  with  subsequent  discriminator  investigations  patients  (1951)  although  endorse different  1979)  assessment of  neurologic  these groups  Subsequent  self-report  pain  signs.  scale  portrayal".  back  scale to be a u s e f u l  1976).  with  by the elevated  between  such  to differentiate  identified  of  In a m i x e d (1980)  found were not  related to  utilized  high not  related the  to  50 chronicity pain  of t h e d i s a b i l i t y ,  related operations,  and  longer  duration  higher  of p a i n ,  higher  r a t i n g s of facial a n d  number  body  of  pain  behaviour.  Conclusions. along the  While demonstrations  psychological  interpretations  than  not,  that  objective  disease/impairment disability  dimensions  have  and  replicable  and criteria  not been  subjective  (Fordyce  et a l . ,  1978),  Further,  many of these s t u d i e s  psychological exaggerated  Hypotheses  pain  and  Medically signs,  and difficult  incongruent  CLBP  patients  idea t h a t  greater  patient  pain presentation  symptoms,  has  investigations reliability. measures.  and patients  who  dysfunctional  distress,  management.  of p a t i e n t s research  signs to account for  CLBP  based on paradigms  back  patients  independent  were determined pain.  criteria  and exaggerated  identifying  e x p e r i e n c e may be r e l a t i v e l y  previous  often  organicity  interrater  profile clusters, the  More  in  'functional'  solely on s e l f - r e p o r t  support  limitations  Design  a r e p l i c a b l e means of  from  of  in o t h e r  to lack  are associated with  display,  inappropriate  Identification  rely  differences  organic  For t h e most p a r t ,  on t r e a t m e n t o u t c o m e ,  processes  of  estimates w h i c h ,  disease,  are  research.  for the determination  have been f o u n d  lack e v i d e n c e of o r g a n i c  subgroup  there  from this  indicators  specified.  by  research  interesting,  can be d r a w n  been d e t e r m i n e d  Still,  are  of C L B P  (non-organic  pain d r a w i n g s ) whose subjective  pain  of. pathophysiology.  inclusionary  criteria  in w h i c h  'psychologically'  the  was a  a c c o r d i n g t o t h e absence of Thus,  provide  it was assumed  departure involved  organic  here that  the  51 presence of  replicable  incongruent  pain  signs w o u l d be a  i n d i c a t o r of t h e o p e r a t i o n  of d y s f u n c t i o n a l  a lack of p o s i t i v e o r g a n i c  signs.  proposed to differentiate  psychological  A n u m b e r of  the control  better processes  hypotheses  pain from the  than  were  incongruent  pain  groups: 1.  It was h y p o t h e s i z e d pain  signs  processes  that  CLBP  were more likely to engage related to the search,  information  who did  not display these s i g n s , pain  catastrophizing  signs  (pain  less c o p i n g o r  CLBP  were  groups.  accounts induced  error  cognitive  in  more  cognitions) Measures  incongruent  Further,  since d i f f e r e n t  & Turk,  to be  pain and  the  control  methods  1981),  and accounts  both  elicited  were  and  of  of  may be s u b j e c t to d i f f e r e n t  (Genest  patients  displayed  to engage  cognitions.  of  sources  retrospective in  the  used to  assess  activity.  mediate the  cognitive  incongruent  different  the patients subjective  who  or worsening  cognitive assessment trials  If d y s f u n c t i o n a l  that  interpretation  pain were expected  of c o g n i t i v e a c t i v i t y pain  cognitive  When c o m p a r e d to  between  assessing cognitive activity of measurement  and  hypothesized  concerning  incongruent  in d y s f u n c t i o n a l  patients  amplifying  discriminators  patient  pain.  pain ameliorating  cognitive activity primary  concerning  who display  selection,  sensory  incongruent  2.  patients  verbal  processes pain  presentations,  descriptions  who display  these  estimates of pain  concerning  of  signs.  intensity  pain  then  pain would  sensations  it was  be a p p a r e n t  It was e x p e c t e d would  expected  be h i g h e r ,  in  that and  that  52 the patients  with  affectively-laden engage  incongruent  pain  pain d e s c r i p t o r s  in more c a t a s t r o p h i z i n g  r e p o r t of s u f f e r i n g levels of  signs would because t h e y  to be  pain.  reflected  to  Subjective in  greater  depression. behavior  has been d e s c r i b e d  of pain e x p e r i e n c e t h a t  is s e n s i t i v e a n d  than  & Prkachin,  self-report  (Craig  a greater frequency displayed  in C L B P  comparison  the former Since the  of d i s c r e t e  patients  to control  amplification  of pain  behaviors  patients,  sensation  distortion  it was e x p e c t e d  who present with  pain  indicator  less s u b j e c t t o  1983),  pain  as a n  would  be  incongruent  corresponding  and exaggeration  that  to  pain  in  the  of d i s t r e s s  in  group. use of c o p i n g  catastrophizing tolerance with  induced  incongruent  sensory  stimulation  not d i s p l a y  strategies  cognitions  display  since t h e r e  and the  has b e e n  pain  (Turk,  for  a shorter  shown to affect et a l . ,  1983),  interval  signs  differences  in t h e t o l e r a n c e o f p a i n  differences  in e x p r e s s i v e n e s s  with  pain  patients  to tolerate  than  has b e e n e v i d e n c e o f sex  these differences  of  who  noxious  patients who  did  pain.  of these clinical  women who p r e s e n t  presence  p a i n w e r e also e x p e c t e d  incongruent  manifestation  1986),  more  were expected  concerning their  was also e x p e c t e d  Because n o n - v e r b a l  Finally,  use  (Main  differences  & Waddell,  (Weisenberg,  of pain  in C L B P  pain  1977),  patients  criteria.  the  1984b), and  sex sex  (Hyde,  w e r e e x p e c t e d t o be a c c e n t u a t e d incongruent  in  in  53 The dependent presentation  by  sex,  variables design.  were analyzed  Groups  presence o r absence of multiple al.,  1980),  incongruent  exaggerated was,  pain d r a w i n g  in a c t u a l i t y ,  report  scores  status  results  imply a correlation  and  sex  do not  account for  a spurious  potential criteria  confounding  variables  s u c h as c h r o n i c i t y ,  of physical  that  sufferer  (a)  stimulus.  inability  cognitions  cognitions  to persevere,  reflecting and  in his o r  of could rule  out pain  status,  degree  and  (c)  A self-report  her  covert  (i.e.,  reports  those that  assessed  amplify  measure of c o p i n g  C L B P was also i n c l u d e d  (Rosenstiel  standard noxious  o r f o c u s on  strategies  strategies  & Keefe,  of a  including:  helplessness,  the cognitive coping  for  behavior  response to a  a lack of c o n t r o l ,  1978).  functional  were exposed to a standard  and cognitive  (Genest, their  history  does  assumption  incongruent  socio-economic pain  the  assumption  an a t t e m p t w a s m a d e t o with  or  While  determinants  correlated  et  design  obviously,  of t h e c o g n i t i v e / a f f e c t i v e  Patients  and pain tolerance  (b)  This  T h e causal  it was assumed t h a t t h e t y p i c a l  catastrophizing'  pain),  1984a),  n u m b e r of variables  and other  would be reflected  sensory  stimulus,  (Waddell,  1976).  since,  to  characteristics.  assessment model,  noxious  signs  a causal  'prior'  compensation,  Following the assumption  CLBP  et a l . ,  1963).  Since any  impairment/disability,  demographic  were  relationship,  according  not be m a n i p u l a t e d .  & Stanley,  presentation.  pain  & Wadddell,  design,  could  here was t h a t c o g n i t i v e processes pain  (Main  imply causality,  (Campbell  incongruent  physical  (Ransford  a quasi-experimental  pain presentation 'correlational'  were determined  non-organic  symptom  in a 2 X 2 ,  1983).  the  or used  patients An  use  o b s e r v a t i o n a l assessment of pain b e h a v i o r u n d e r s t a n d a r d i z e d c o n d i t i o n s was also u n d e r t a k e n  (Keefe  & B l o c k , 1982), to assess w h e t h e r pain  b e h a v i o r s were associated with t h e p r e s e n c e Patients also completed  of i n c o n g r u e n t  s e l f - r e p o r t measures of d e p r e s s i o n  pain s i g n s . (Beck,  Mendelson, Mock, & E r b a u g h , 1961) a n d v e r b a l pain d e s c r i p t o r s (Melzack,  1975) to assess t h e s e h y p o t h e s i z e d  differences.  Ward,  METHOD  Subjects CLBP  patients  Shaughnessy  were  Hospital  comprehensive practitioners,  admissions following primary  in o r d e r  and provide  criteria: physical (c)  (a)  were chosen f o r  Two  approached  patient  patients  incongruent  pain  in t h e c o n t i n u o u s  T h e mean age o f t h e  patient  were  clinical  Consecutive the  (b)  English  included  to  region complete  formed  of each  in t h e  sex  as  series of  did  the  criteria  below.  criteria  A final for  not  described those  participation  sample was 3 9 . 8 y e a r s  55 -  had a  lumbosacral  displayed  duration  degree  meeting these  presentation  refused  Mean s e l f - r e p o r t e d  -  and  described  w h i l e 20 p a t i e n t s  who satisfied the criteria  range 21-59 y e a r s ) .  groups  20 p a t i e n t s o f e a c h s e x  for  nature  consent to participate,  T h e f i r s t 20, p a t i e n t s  presentation  display the criteria below.  provided  in t h e  and  surgical,  of age,  command of  40 m e n a n d 40 w o m e n ,  Thus,  pain  pain  general  Board,  for  at  B P C is a  who satisfied  20-60 years  (BPC)  from  Compensation  of 1985,  sufficient  each of t h e f o u r  The  referrals  determine the  persistent  study.  t o t a l o f 80 p a t i e n t s ,  incongruent  (d)  Columbia.  patient management.  were between  and  Pain C l i n i c  determine potential  and J u l y  demonstrated  pool f o r t h i s  Workers'  plans f o r  c o m p l a i n t of  the questionnaires,  data analysis.  to:  Back  receives  interventions;  between January  of t h e b a c k ,  subject  specialists,  or other  impairment;  British  assessment centre that  insurance companies  of  from the  in V a n c o u v e r ,  medical  rehabilitation,  recruited  in t h e  study.  (SD=10.5;  of t h e pain  problem,  or  56 chronicity,  was 8 . 8  years  (n=49)  of the  (ri=17)  had one p r e v i o u s  or  sample  more previous  or  or  receiving  litigation,  both  when  disincentive for  index  categories  were  seeking  training  or  average  respect  anglophones.  For  were  On t h e  trades  employment,  high  were able to demonstrate  This  financial  Blishen's  1976).  The  unskilled,  of  occupational  26% ( n = 2 1 )  14% ( n = 11)  as p r o f e s s i o n a l . assessment. 15% ( n = 1 2 )  suggested  overall  intervals  Only  Of the  were  that the  were  were  semi9%  rest,  73%  homemakers  a n d 4% ( n = 3 ) w e r e e n r o l l e d  in  sample  functioning  given  the  pain.  composition,  English  basis of  percentages  level of occupational  back  adjudication  basis of class  level,  classified  programs.  to ethnic 18%,  skilled  patients  h a d some  & McRoberts,  were  disability  assessment.  on t h e  (1976),  employment,  of t h e  two  Compensation  pursuing  of t h e sample  at t h e time of t h e  a relatively  had  or  S i n c e some  and were  determined  33% ( n = 2 6 )  part-time  educational  chronicity  With  was  and McRoberts  competitive  represented  payments  compensation  injury.  at t h e time of t h e  were  17% ( n = 1 4 )  either Workers'  to their  (SD=13.5).  unemployed or  pursuing  related  a n d 9% ( n = 7 )  had full  receiving  was 3 8 . 9  19% ( n = 1 5 )  professional,  not  were  w e r e as f o l l o w s :  semiskilled,  were  (Blishen  Blishen  by  percent  surgeries.  occupations  proposed  (£=58)  and  status  index  (n=7)  surgery,  recovery  mean on t h i s  O v e r 61%  back-related  combined 41% (n=33)  of Canadian  years).  Twenty-one  disability  Socioeconomic  1-30  surgery.  28% ( n = 2 2 )  litigation  range  no p r e v i o u s  w h i l e 25% ( n = 2 0 )  adjudication were  had  back-related  Of the t o t a l , payments  (SD=7.6;  was t h e i r  77% ( n = 6 2 ) second  a command of t h e  were  language,  language  by  Caucasian but  they  completing  a  57 v a l i d MMPI In t o t a l , the  unaided,  57% ( n = 4 6 )  a test which were  in a m a r i t a l  r e m a i n i n g 43% ( n = 3 4 ) Physical  requires  all p a t i e n t s  criteria outlined  below  (Waddell  t h e sample w e r e  18.5% ( S D = 8 . 2 )  This  was  problem back Medication  roughly  pain  the pharmacological C o m p e n d i u m of  being  1984).  f o r men a n d  patients  medication  consumption  analgesics; inflammatory  analgesics;  with  14% ( n = 11) m u s c l e  19% ( n = 15)  reported taking  secondary medical  1 shows  diagnoses  assessment.  diagnostic  Of  assignments  by  primary  contributing  were anatomically  all p a t i e n t s  patients with  sample,  45% ( n = 3 6 )  factors  n o t e is t h a t  Iatrogenic  total  Canadian medications  were coded  breakdown  in  for  18% ( n = 14) 23%  anti-  (n=18)  anxiolytics.  Almost  medication.  interest to  in 32.3% of  they  to  non-narcotic  16% ( n = 13)  behavioral/psychological). and  of  (1984).  by the  the  antidepressants;  the breakdown and/or  action,  content;  for  a sample  S i n c e some  70% ( n = 5 6 )  relaxants;  no  for  for  b a s i s w a s c o d e d as  (1985).  sample,  narcotic  11% ( n = 9 )  sedatives;  Table  patient  w a s as f o l l o w s :  43% a n a l g e s i c s  reported  as d e t e r m i n e d  had more t h a n one t y p e of p h a r m a c o l o g i c a l In t h e  examination  b y Waddell a n d Main  Specialties  widowed.  functional  14.2% ( S D = 6 . 1 )  c o n s u m e d on a r e g u l a r  Pharmaceutical  or  while  Mean p e r c e n t a g e s  t o means  action of t h e d r u g  more t h a n one c a t e g o r y .  divorced,  b a s e d on p h y s i c a l  & Main,  education.  relationship  as t h e p e r c e n t a g e o f  equivalent  referral  reported  separated,  expressed  loss was c a l c u l a t e d f o r  women.  or common-law  were single,  impairment,  a minimum g r a d e 8  were judged  diagnostic  category  as r e p o r t e d  in  the  a l m o s t 24% o f t h e  non-specific  primary  (i.e.,  C L B P was d i a g n o s e d previous  and  i n 1 2 . 8 % of  surgery.  t o h a v e some c o n t r i b u t i n g  Of  the factor  58  r | j  1  Table  1:  Primary  Percentage Sample Diagnostic  Breakdown  Assignments  Mechanical LBP Facet J o i n t Related L B P U n k n o w n o r No Clear Findings Soft Tissue S p r a i n / Injury C h r o n i c Pain S y n d r o m e Discogenic LBP D e g e n e r a t i v e Disc Pain in t h e S e t t i n g of Previous S u r g e r y Fibrocytis Disc P r o t r u s i o n Spinal Stenosis Spondylolithesis Other |  Note:  n=77  (3 m i s s i n g  Diagnoses  in t h e  Patient  | j  Secondary Diagnostic Assignments &/or Contributing Factors  15 0 13 8  Depression 23 8 Physical Deconditioning/ Inactivity 16.3 10 0 Facet J o i n t Related 8 8 Psychological Overlay Drug Abuse/Dependancy 8 8 Pain in t h e S e t t i n g of 7 5 Previous S u r g e r y 3 8 Obesity Soft Tissue S t r a i n / 3 8 Injury Spondylolithesis 3 8 Scoliosis 2 5 C h r o n i c Pain S y n d r o m e 2 5 Leg L e n g t h D i s c r e p a n c y 2 5 Other 7 5  13 8 11 3 6.3 6.3 5 0 5 3 3 2 2 7  of  0 8 8 5 5 5  diagnoses)  |  L  J  t h a t was anatomically  non-specific  sample had a specific  identifiable-anatomical  associated or c o n t r i b u t i n g  in n a t u r e .  Thirty-nine  p e r c e n t of  CLBP condition  behavioral/psychological  the  without  factors.  Equipment Pain b e h a v i o r w a s v i d e o - t a p e d Model  No.  Omnivision preparation  CC077, II V H S  with  video cassette  of c u e i n g  Panasonic AG6300 V C R Verbal  reports  a built-in  standard which  elicited d u r i n g  with  an  microphone, recorder.  RCA and a  Colorvision Panasonic  Audio dubbing,  time sampled  intervals,  was capable of 2 - c h a n n e l the  structured  Camera  interview  for  the  was done w i t h  a  audio  recording.  were  audiotaped  59 with  a Sanyo cassette tape  recorder,  with  a C h r o n u s 3-S  display  apply  pressure  dominant  digital  reported  were added to the  by  No.  stopwatch.  pain to t h e second phalanx  h a n d was c o n s t r u c t e d  specifications  Model  T i m i n g was  The apparatus  of t h e  from acrylic  Forgione and  M1001.  index  plastic  Barber  (1972).  to the  to  Lead  lowered arm to p r o d u c e a p r e s s u r e of  the point where the wedge contacted the  used  f i n g e r of  similar  done  weights  1500 g m s  at  finger.  Procedure The comprehensive practice  standard  assessment  physician,  physiotherapist. the  assessment p r o c e d u r e  orthopedic  and pain  intake  n u m b e r of p r e v i o u s  of C L B P  pending  litigation.  conducting  specialist,  Demographic  duration  their  problem,  assessments,  minutes  Patients A)  how t h e y  as  were given the  and  patient's  intake,  allowance,  an i n t e r v i e w  from  age,  medication  disability  their  (a)  pain,  scheduled  patients  an  information  and  schedule  (b)  a 2-3  in  day  if t h e y w o u l d  procedure for  and consent  and describing  procedures a brief  over  were asked  assessment  research  assessment  requiring  cope w i t h  was  i n an a d d i t i o n a l  describing  of a d d i t i o n a l  was d e s c r i b e d  a general  assessment.  willing to participate  (Appendix  the  followed  a  data were obtained  current  of p a i n ,  The psychologists  Inbetween  purposes.  history  surgeries,  location  included  psychologist,  regarding  T h e e n t i r e team assessment period.  BPC involved  b y one of 3 'teams' which  BPC team p s y c h o l o g i s t ' s  occupation,  at t h e  involved.  questionnaire  research  form  what the The  20  research  asking them  an a s s e s s m e n t o f t h e  be  about  sensations  and  feelings they  would e x p e r i e n c e  p l a c i n g a w e i g h t e d wedge on c o u l d ) ; and  (c) v i d e o - t a p e d  different positions. indicated: for  voluntary  and  (c) t h a t t h e y Permission  The  researchers  also  while a female g r a d u a t e s t u d e n t  below.  b l i n d to pain p r e s e n t a t i o n examination data,  and  files a f t e r completion  a manual and  for  research  assistant assessed  each e x p e r i m e n t e r was Experimental  described  below.  equal  56  (c)  patients  24 p a t i e n t s .  across the  four  a s s e s s m e n t s were c o n d u c t e d  p s y c h o m e t r i c s c o r e s were o b t a i n e d  from p a t i e n t s '  of the teams' a s s e s s m e n t s . served  as c o d e r s .  C o d e r s were  completed t r a i n i n g s e s s i o n s to c r i t e r i o n  Key  the Observational  Details of the data  across  status s i n c e d i a g n o s t i c information,  Procedure; Scoring  Pain; and  and  information, f o r  author assessed  each of the t h r e e s c o r i n g s y s t e m s d e s c r i b e d Scoring  was  (b) c o g n i t i v e \ b e h a v i o r a l t r i a l , and  T h r e e undergraduate students given  time;  a s s e s s m e n t followed the same s e q u e n c e  by  (b)  f o r additional information.  examination  i n t e r v i e w f o r i n a p p r o p r i a t e symptoms. T h e  groups described  researchers;  obtained.  (a) v i d e o o b s e r v a t i o n ,  T o t a l number a s s e s s e d  the  used  pain a s s e s s m e n t p r o c e d u r e s  a d d i t i o n a l medical  experimental  they  a s s e s s m e n t r e s u l t s were to be  c o u l d d e c l i n e to p a r t i c i p a t e at any  p u r p o s e s , was  (i.e.,  c o n s e n t form g i v e n to patients  kept confidential by  could contact the  to access  f i n g e r f o r as long as  and  in t h e experimental  that t h e y  pain e x p e r i e n c e  a s s e s s m e n t of t h e i r a b i l i t y to move in  information  p u r p o s e s and  that p a r t i c i p a t i o n  subjects:  t h e i r index  (a) that t h e experimental  research  research  The  in a s t a n d a r d i z e d  processing  below ( i . e . ,  for the S t r u c t u r e d Scoring  and  r e l i a b i l i t y in  Pain  Interview  S y s t e m f o r Pain  t h e measures used  Drawing Schedule  Behavior).  have been  Self-report Measures. which  included the  Patients  completed a s e l f - r e p o r t  following:  1.  Oswestry  2.  McGill  3.  Beck  4.  Coping  5.  Pain  6.  Inappropriate  7.  Descriptor  Differential  Scales f o r  These self-report  instruments  have been d e s c r i b e d  Low  Pain  Davies,  Pain  Disability  Inventory Questionaire  Drawing  LOW B A C K  Back  S- B r i e n ,  Symptom  Pain  1980)  examples  Scale  PAIN  consists  reflecting  to people s u f f e r i n g 1976).  consumption, walking,  backache  of  personal  sitting,  standing, Scores f o r  percentage disability questionnaire,  Adequate  have been  MCGILL (Melzack,  score.  has b e e n  problem.  consistency  care  degrees  (Waddell  & Main,  1983)  6  of d i s a b i l i t y .  ordered Each  sleeping,  analgesic  & dressing),  sexual  activity,  as m e a s u r e d  shown to decrease with retest  reliability  demonstrated  social  e t al  T h e McGill  c o n s i s t s o f 20 g r o u p s  by  and  &  lifting, activity, a  the  recovery  (r=.99)  (Fairbank,  relevant  medication  t h e scales w e r e summed to p r o v i d e Disability,  scale  1984; W i n g , W i l f l i n g ,  include:  washing  The  Couper,  have been f o u n d to be most  PAIN QUESTIONNAIRE.  1975;  (Fairbank,  10 s c a l e s e a c h c o n t a i n i n g  various  (i.e.,  below:  QUESTIONNAIRE.  Questionnaire  T h e s e areas of d i s a b i l i t y  and t r a v e l l i n g .  back  Pain  DISABILITY  Disability  focuses on t h e p r o b l e m areas t h a t  Kokan,  Questionnaire  Questionnaire  Stategy  Low  behavioral  Back  Depression  OSWESTRY Oswestry  battery  f r o m an  acute  internal 1980).  Pain  of a d j e c t i v e s  Questionnaire used  to  62 s p e c i f y 3 major classes of s u b j e c t i v e affective,  and evaluative.  adjectives  e n d o r s e d on t h e McGill  rating  indexes  which  and evaluative has  scores.  1978;  in b a c k  Leavitt,  Dawson,  (Beck,  pain  dysphoric  feelings  and  COPING Questionnaire  in C L B P  patients  STRATEGY  is a q u e s t i o n n a i r e  c o n s i s t i n g o f 41 i t e m s  (i.e.,  diverting  ignoring  catastrophizing) activity  level)  effectiveness pain).  attention,  The  1961)  by the  Beck  consists  & Craig, Turner,  &  (Lefebvre,  items  of  and energy  Depression  The  by  level.  Inventory of back  Coping  Rosentiel  has  pain  Strategy  and  Keefe  6 scales of c o g n i t i v e pain  sensations,  praying or  control over  Scores on t h e c o g n i t i v e coping  o f 21  1981).  developed  In a d d i t i o n  Inventory  self-reported  cognitive distortion  reinterpreting  (i.e.,  word  Depression  appetite,  a n d one scale of b e h a v i o r a l  ratings  Questionnaire  as w e l l as s y m p t o m s  reflecting  B).  Pain  items sample  of sleep,  pain sensations,  (Appendix  pain  affective,  Prkachin,  Beck  QUESTIONNAIRE.  (1983)  statements,  The  self-evaluations  to be related to g r e a t e r  related events  include 3  1980).  symptoms.  as m e a s u r e d  the  1978; M c C r e a r y ,  & Erbaugh,  as d i s t u r b a n c e s  Level of depression shown  Mock  from  into sensory,  (Crockett,  INVENTORY.  Mendelson,  such  derived  of t h e classes of  & Sheinkop,  & Geisinger,  to depressive  been  populations  Garon, Whisler,  pertaining  depression,  down  sensory,  Factor analysis of t h e McGill  DEPRESSION  Ward,  indices  Pain Q u e s t i o n n a i r e  for the validity  1981; Prieto  BECK  Quantitative  have been b r o k e n  l e n t some s u p p o r t  descriptors  pain experience:  hoping,  coping  there  pain,  coping  self-  &  (i.e.,  increasing  are two pain  & ability  have been  coping  to  shown to  control  decrease be  responsive to cognitive-behavioral 1984).  Principal  component  analyses of t h e  accounting for approximately 1984;  Rosentiel  & Keefe,  be related to d i f f e r e n t component been  reflecting  1983).  PAIN a scoring  system for  depiction their  scoring  were  independently  inter-rater drawing  reliability  reported  by  correlation  (von  Cairns,  shown  to  For example, over  pain  a  has  of a n x i e t y  and Mooney  non-anatomical  of  blind  .89.  (Appendix  rater,  The  (1976)  and  resulting  reliability  Bergstrom,  Brodwin,  graphic  C).  in t h i s  Using sample  in  of t h e  h e r e was c o m p a r a b l e w i t h  Baeyer,  developed  or exaggerated  of t h e pain d r a w i n g s  a second  criteria found  elsewhere  measures  location of t h e pain  80% ( n = 6 0 )  rated  & Rosenberg,  have been  lack of c o n t r o l  self-report  Ransford,  and  and  factors  1983).  quantifying  system,  scoring  with  & Keefe,  of t h e q u a l i t y  (Harrell  of a d j u s t m e n t to C L B P .  catastrophizing  DRAWING.  & Middaugh,  scale h a v e f o u n d 3  These components  patterns  (Rosenstiel  (Kee  70% o f t h e v a r i a n c e  shown to be c o r r e l a t e d  depression  interventions  an pain  reliability  & Brodwin,  1983). INAPPROPRIATE DiPaola,  and Gray  SYMPTOM SCALE.  (1984)  identified  were judged  to be v a g u e ,  progression,  change over  182 b a c k  pain  frequency  in  eliminated. in t h e  patients. normal  A final  low  symptom  to be assessed  in  lacked  scale  routine  was  normal  patterns  low base  interpretation  D).  intake,  rate,  of of  high  were et a l .  Since these a brief  which  in a sample  used b y Waddell  (Appendix history  Morris,  symptoms  anatomy  reliability,  and ambiguous  set of 7 symptoms  inappropriate  designed  subjects,  and  and appropriate  Those with  Main,  a p o o l o f 22 s p e c i f i c  ill-localized, time,  Waddell,  (1984) were  structured  64 interview  covering the  experimental  assessment described  DESCRIPTOR Differential  induced  ratio scales, (15 i t e m s ) .  pain  (Appendix  E).  procedures  Adequate  reliability  r=.89 for  narcotic,  Dubner,  1978;  built  and  scales f o r  Physical  that  deviated from  agreement  between  In a series of b a c k investigators  identified standard  sample,  (Gracely,  (r=.96 for  intensity  intensity,  sensitivity  to  McGrath,  scaling  over  (Chapman,  1983).  sensory  (Gracely,  preferred  intensity  pain  the  cross-modality  psychophysical  SIGNS.  other  et a l . ,  Waddell,  examination anatomical  observers, pain  found  and  patient both  signs  &  properties types  of  1985).  back  high  interrater  and  pain,  retest  high across  report  12% i n a n e w and 2nd  to  percentage assessments. 500  reliability  multiple signs  40 t o 47% i n m u l t i p l e o p e r a t i o n  Kummel,  These were found  involving over  I n c i d e n c e of p a t i e n t s w i t h of b a c k  pain,  reliability  samples,  McCulloch,  based on pain  principles.  in p e o p l e w i t h o u t  0% i n a s a m p l e a s y m p t o m a t i c referral  clinical  using  medication  have been  PHYSICAL  incidence  f r o m 78 t o 86%.  of c u r r e n t  as h a s d i f f e r e n t i a l  Because of t h e  pain  affective  Examination.  (1980)  have a zero  the  intensity),  current  NON-ORGANIC and Venner  ratings  ratio scaling techniques  they  and  verbal  used to rate pain t h r o u g h o u t  and tranquillizing  1979).  Descriptor  (15 i t e m s ) ,  has been d e m o n s t r a t e d  into these scales,  rating  The  scales w e r e d e v e l o p e d  affective  placebo,  and  the  1983) c o n s i s t e d o f t w o  intensity  These were  These  SCALES.  (Gracely,  sensory  procedure,  matching  and  pain  following  below.  DIFFERENTIAL  Scales f o r  descriptor intensity  scale items was c o n d u c t e d  patients, to  range  ranged back-pain referral  from  samples,  t o 100% i n p r o b l e m a d m i s s i o n  T h e r e a p p e a r e d to be s l i g h t display more signs than 1984a).  sex  men  differences  (Lehmann,  (Waddell,  with  et a l . ,  & Waddell,  1980).  1982)  to  report  but only  T h e presence of these  i n d e p e n d e n t of medical  1985;  Main with  w i t h t h e MMPI  non-organic (Waddell,  These deep  the physiotherapist included:  (a)  non-anatomically  simulation rotation,  of axial (e)  distraction,  (f)  disturbance  (i.e.,  overreaction  et a l . ,  impairment physical  and tremor,  SIGNS.  While  (Appendix  A standard limitation  (Brand  organicity  have been  shown  In a t o t a l  sample of 475 p a t i e n t s  (b)  spinal  t h a n 30% u n d e r  on  sensory  leg),  (g)  facial  expression,  Operational  by Waddell,  et a l .  (1980)  G). reliable  indices of  organic  in t h e c o u r s e o f  assessment  & Lehmann,  with  F).  under  simulated  sweating.  set of  to be h i g h l y  (Appendix  nonanatomic  was assessed  r o u t i n e medical  imprecise and unreliable  under  verbalization,  have been detailed  be  based t e n d e r n e s s ,  disturbance  collapsing or  al.,  completed  r e p o r t of pain  regional  anesthesia  (1984b)  and physical  exam.  or  et  1980).  raising greater  disproportionate  and examples  ORGANIC  weakness  stocking  (c)  r e p o r t of pain leg  depression  (Waddell,  assessment  non-anatomically  in s t r a i g h t  regional  a n d Main a n d Waddell  (d)  self-  s i g n s was also f o u n d t o  staff's  based t e n d e r n e s s ,  including  muscle tension definitions  superficial  loading,  increase  or medical  to  £• W a d d e l l ,  and  T h e s e s i g n s w e r e assessed on a c h e c k l i s t t h a t was during  1980).  some  somatic complaints  weakly  diagnosis  et a l . ,  women t e n d i n g  T h e p r e s e n c e of t h e s e s i g n s was c o r r e l a t e d  r e p o r t measures of t e n d e n c y (Main  samples  can  1983),  reliable  sometimes  various  (Waddell  b a c k a c h e a n d 335  the be  indicators  et a l . ,  'normal'  of  1982).  66 subjects,  Waddell  et a l .  (1982)  identified  a low  (less t h a n  8%) o r z e r o i n c i d e n c e  rater  agreement  ( a b o v e 70%), a n d  information.  The final  of o p e r a t i v e  scars,  lumbar flexion (e)  (<5 c m ) ,  (d)  (lumbar  and  tenderness  raising  (<75 d e g r e e s )  irritation,  and  sciatic  (h)  and  developed pattern,  INDEX.  previous leg  physical  percentage  corresponds  (AMA,  1971)  guidelines  RELIABILITY presence/absence assessed  OF  of o r g a n i c  by the staff  means of p e r c e n t a g e between  the  consulted ensure either  PHYSICAL  to American  agreement  on t h e p r o t o c o l  and  observations  in t h e a s s e s s m e n t .  the orthopedic  consultant,  leg  and  (1984)  pattern,  H).  index  have  physical  have time signs,  of  impairment. The  findings  was  Reliability  and  by  correlations BPC staff  of t h e c h e c k l i s t  or  was  to  was c o m p l e t e d  practitioner,  used  Association  FINDINGS.  The checklist  of  These were  This  were calculated.  general  (1982)  of physical  1977)  and the development  flexion,  F).  independently.  (Hartmann,  limited  definitions  Medical  EXAMINATION  non-organic  separately  independent  uniformity  and  from  root compression  index.  for the determination  (c)  dural  a n d Main  (Appendix  impairment  (g)  et a l .  based on pain  raising  t o c a l c u l a t e an o v e r a l l  as  (Appendix  surgery,  presence  straight  Operational  Waddell  Index  recovery  such  in W a d d e l l  Checklist  Impairment  impairment  signs.  (a)  (>1 c m ) ,  restricted  deficits  in d e t a i l  and s t r a i g h t  (f)  inter-  meaningful  included:  on  showed  acceptable  shift)  rhythm  neurologic  IMPAIRMENT  t y p e of f r a c t u r e ,  lateral  buttocks),  Examination  a Physical  lumbar flexion,  (or  root compression  listed on t h e PHYSICAL  list  signs that  clinically  identified  abnormal  these signs were discussed been  in ' n o r m a l s ' ,  provided  set of signs  (b)  examination  by  67 physiotherapist  as p a r t o f t h e p a t i e n t  c h e c k l i s t was completed separate examination reliability  by  a second  f o r 26.2% (n=21)  examination. BPC staff  The  examination  member d u r i n g  o f all p a t i e n t s  and  a  interrater  calculated.  r I I  1  Table 2:  Reliability of the Signs  Non-organic  |  and Organic  Physical  Reliability  Examination  Sign  Non-Organic Signs Superficial Tenderness Deep T e n d e r n e s s Axial Loading Simulated Rotation Straight-leg Raising Under Distraction O v e r - r e a c t i o n to exam Regional D i s t u r b a n c e s Sensory Regional D i s t u r b a n c e s Motor O r g anic Signs Sciatic list Abnormal rhythm from recovery ("catch") Lumbar Flexion Leg Raising Root i r r i t a t i o n s i g n s Root c o m p r e s s i o n s i g n s Tenderness lumbar Tenderness Buttock Operative scars Note:(n=21)  r  | j I  % Agreement  .82 .50 1.00 .68  94 76 100 94  1 .00 .57  100 82  .66  76  1.00  100  .45  82  .55 .35 .79 .86 .54 .23 .31 1.00  82 65 88 94 76 76 82 100  68 Table 2 shows  the  reliability  calculations  signs.  W h i l e t h e r e w a s some v a r i a b i l i t y  signs,  the overall  signs  i d e n t i f i e d was  identified  was  continuous raising higher total  Pearson r=.70.  highly  variables  (degrees), interrater  Physical  correlation Total  left s t r a i g h t reliabilities  Impairment  not demonstrate  found  of  Index  high  patient  variability  reliability  pilot observations were observed reported  giving  elsewhere that  r=.94.  assesments  were  organically  this  reliability  staff  or  relatively  types  (Ignelzi,  reliability  and  r=.57,  reported  indicate that of j u d g e m e n t s  almost  elsewhere  specific criteria, concerning  the  the  et a l . ,  back  et a l . ,  patients'  pain  and  It has  of pain  been  report  Given that present  in  in  these most  high. pain  scale.  to i n t e r r a t e r  not s u r p r i s i n g l y ,  subjects  was a p p a r e n t  1980).  b a s e d on a 7 - p o i n t  (Fordyce,  dichotomous  same t e s t s .  was s u i t a b l y  was  different  across examiners  clinical conditions  identical  signs  scores  n u m b e r of  intensities  the  The  examination  Patient v a r i a b i l i t y  to the  leg  demonstrated  n u m b e r of  small  were followed  under  non-organically  the  as  straight  f o r total  behavior,  also r a t e d t h e e x t e n t t o w h i c h  a g r e e m e n t was organicity  the  signs  respectively.  non-organic  responses  different  undertaken  health care settings, Staff  and  considering  and the  patients  reported to d i f f e r e n t  (degrees)  was  organic  recorded  right  reliability  in e x a m i n a t i o n  different  (cms),  .93,  was c a l c u l a t e d . where  non-organic  and  organic  individual  n u m b e r of  .88,  reliability,  n a t u r e of these v a r i a b l e s , on whom  raising  .83,  to be a c c e p t a b l e e s p e c i a l l y  raters,  are  leg  the  Variables  as l u m b a r f l e x i o n  W h i l e some i n d i v i d u a l did  r=.85.  examination  r e l i a b i l i t y of  between  n u m b e r of  correlated with such  in t h e  for the  problem  Interrater  agreement  1978).  of  T h e data  enhance the  problem.  was  here  reliability  69  Experimental Assessment Procedure. OBSERVATIONAL Keefe and  Block  standing,  reclining,  standardized sitting  reclining  (1982),  both and  a 1-and  (d)  was  each  position  remained constant.  with  t h e p a t i e n t was position  ratings  randomized  prior  (c)  Keefe a n d  rubbing,  The operational other  BEHAVIORS.  I).  Each  (d)  definition  para-linguistic  (a)  standing  walking patients  During  pain  of  tapes  behaviors: and  'sighing'  (a) (e)  such  c o n s i s t i n g of c o n t i n u o u s  OF B E H A V I O R A L  MEASURES.  of p a t i e n t s '  video assessments  were coded  coding  system for  guarded  LBP behavior  in  interaction requests  (see  Scale  below). the  movement,  (Appendix  slightly  to  (b)  J).  include A  each p a t i e n t  using a  c y c l e s o f 20  seconds  10 m i n u t e s  RELIABILITY  the observational  min of  as m o a n s a n d g r o a n s .  were coded for  recording over  1-  Descriptor  sighing  time-sampling  a n d 10 s e c o n d s o f  2-min  The order  were coded f o r  was m o d i f i e d  of pain  two  mainly of  Differential  intervals  (n=28)  (c)  the videotaping,  (1982),  grimacing,  a 1-and  w h i l e t h e amount of time  t o t a l o f 20 o b s e r v a t i o n a l  observation  10-min  both  periods.  Following  sitting,  period,  consisting  provided  Block  indicators  procedure  while  to and after the videotaping  o c c u r r e n c e of t h e f o l l o w i n g bracing,  2-min  across  Patients  pain  Following  (Appendix  kept to a minimum,  changes.  of t h e i r  PAIN  were videotaped  t w o 1-min  the positions  for  OF  c o n s i s t e d of t h e f o l l o w i n g :  (b)  periods,  subjects  and walking  taping  period,  ASSESSMENT  Thirty  (Appendix five  independently (Keefe  &  K).  percent using  Block,  1982).  Reliability  Table 3.  for  each of t h e pain  behaviors  has b e e n  shown  Mean v a l u e s o b s e r v e d w e r e c o m p a r a b l e t o t h o s e  Keefe and  Block  (1982)  n u m b e r of b e h a v i o r s  and  Keefe, Wilkins,  and  Cook  o b s e r v e d was also r e l i a b l e  in  reported  (1984).  by  Total  (r=.82).  1  r |  Table 3:  Means a n d  Reliabilities  of t h e  |  Pain  Behaviors  Reliability  Pain  Behavior  M  Guarded Movement Bracing Rubbing G rimacing Sighing  SD (n=80)  84 2 55 2 20 90 1 77  1 2 2 1 2  (n=28)  97 92 87 90 86  |  % effective agreement  % agreement  86 81 91 68 22  |  1 7 7 2 0  90 84 82 85 81  2 5 0 1 1  L  J  PAIN used,  INDUCTION  PROCEDURE.  as a d a p t e d f r o m  w e d g e of  1500 g m .  weight  finger  of t h e  try  keep t h e w e i g h t  to  Forgione and  non-dominant  w e r e also t o l d t h a t  hand  could  (Appendix finger  could expect to experience.  finger,  a 4 m i n u t e ceiling was  L).  for  imposed.  the experimenter.  with  ratings  were  Spontaneous  noted or  recorded.  phalanx  Patients  a  trials  of t h e  index  were asked could.  They to  sensations  in w h i c h  minutes were  to  Prior  damage to  comments o r  was  plastic  at a n y t i m e .  to p r e v e n t  Thus,  verbal  wherein  were told what  patient tolerated the pressure for the full four by  procedure  as l o n g as t h e y  patients  In o r d e r  pain  (1972),  remove the weight  p l a c i n g t h e w e i g h t on t h e i r f i n g e r , they  Barber  was a p p l i e d t o t h e f i r s t  on t h e i r  they  A pressure  the  the terminated  behaviors,  along  71 The the  pain  Differential  induction  procedure.  on each scale t h a t experienced now?".  Scale  were  ratings  used  throughout  to t h e degree of pain  the experimenter requested  were  Patients were asked to indicate the  best corresponded  whenever  Ratings  intervals  Descriptor  asked  "what  they  is y o u r  by the experimenter  at 30  item  pain--  second  u n t i l t o l e r a n c e was a c h i e v e d o r t h e t r i a l t e r m i n a t e d  by  the  experimenter. COGNITIVE  ASSESSMENT.  patients were assessed (1978)  Structured  (Appendix thoughts  M). they  in a s t r u c t u r e d  Interview  They  Immediately  remembered  thinking  times:  (a)  were t h i n k i n g ,  while they was  gave  removed;  behaviors  ratings  and  during  Genest prompt  subject  (f) the  (1978)  (c)  feeling,  from time to time,  when they  this,  reports.  Pilot t e s t i n g  This  they  (b) and  (e) just  while  were asked  after  at  the  reported  and the  to specific  weight pain;  before the  spontaneous  was  procedure  and  Butler,  and transcribed  sufficient  also e n s u r e d  1979).  verbatim.  r e c o r d of t h e  indicated that  so as t o m i n i m i z e d e m a n d  Meichenbaum  feelings  and experiencing  made s p e c i f i c  used a videotaped  cognitive activity. self-generated  in d e t a i l  (1983)  (d)  weight  comments  or  task.  (a t o f a b o v e )  recorded  After  Genest's  et a l .  saying to themselves  after they felt  s e q u e n c e of e v e n t s  1981;  Pain a n d T u r k ,  b e f o r e t h e w e i g h t was placed d o w n ;  was placed on t h e i r f i n g e r ;  induction,  adapted from  to describe  or  w e d g e was p r e s s i n g on t h e i r f i n g e r . describe what they  interview  Schedule for  were asked f i r s t  after the pain  pain  recalling  t h a t t h e cues  reports  to  the  to elicit descriptions  characteristics Patients'  induction  of  were  (Genest  &  Turk,  were  tape-  72 Transcribed a 5-point  anchored  Structured report (b)  reports scale  Interview  from the cognitive (Appendix  Schedule for  N)  expression  of t h e  (c)  imagery;  undertaken  study  OF T H E  independently  for  percentage  agreement  defined  Genest  frequency  Imagery  (f)  an i n t e r c o d e r  reliability  on the  verbal self;  (e)  (Appendix  coders  of  pain from  distraction;  catastrophizing  N).  All  blind to the estimate.  nature  All  80  coded. COGNITIVE  and are shown sample  MEASURES.  Pearson  Transcripts  correlations  each of t h e c a t e g o r i e s in T a b l e 4 .  Relaxation,  as  Examination  Imagery,  were  and  revealed that fewer than  had a coded o c c u r e n c e of  of  7  or  Non-  distraction.  Because of t h e  low i n c i d e n c e ,  of  distraction,  a n y of t h e s e p r e d e f i n e d  dissociation  as o n e v a r i a b l e ,  Therefore,  and dissociation  new v a r i a b l e was  percentage Activity,  effective  between  and  stategies was called  relaxation,  'Coping  sense of c o n t r o l  and  distraction,  Strategy.  Reliability  agreement=88.3  Correlations  with  Strategy'.  non-imagery  and Catastrophizing  use of a s t r a t e g y  imagery,  was coded along  percentage  agreement=81 .8.  between  relaxation,  w e r e c o d e d as C o p i n g  r=.86 with  Sense of C o n t r o l ,  association  which  a n y of t h e c r i t e r i a f o r  distraction,  p_<.001),  dissociates  non-imagery  all s u b j e c t s .  data f o r the total  individuals  (a)  were calculated for  (1978)  scoring criteria  Pain, f o r t h e p r e s e n c e of  two undergraduate  independently  RELIABILITY  by  by  so as t o d e r i v e  patients were  coded  (d)  of sense of c o n t r o l ;  c o d i n g was  of t h e  following  i n d i c a t i n g a n y of t h e f o l l o w i n g :  relaxation,  assessment were coded  between  revealed a  and catastrophizing and catastrophizing  and  Coping negative (r=-.57, (r=-.39,  73  Table 4:  Reliabilities Categories  and  Frequencies  of t h e  Cognitive  Reliability  Cognitive Activity  Frequency % Agreement  Dissociation Relaxation Imagery Non-Imagery Distraction Sense of C o n t r o l Catastrophizing  %Effective Agreement  36 7 5  .86 .85 .77  89.5 96.5 95.3  84.3 66.0 60.2  6 30 53  .60 .83 .81  96.3 86.0 88.3  60.0 81.7 83.6  n=80  £<.001).  T h e r e was  strategy  and sense of  Determination  no s i g n i f i c a n t  been  Incongruent  proposed that  d e t e r m i n e d on t h e basis of t h e p r e s e n c e o r nonorganic  physical  few patients criterion staff the  would  patients  pain via symptom or  Initial  be i d e n t i f i e d sample),  non-anatomical.  also p r e s e n t e d  and/or  Therefore,  group  the  use  of  Group.  assignment  absence of  assessment  which  difficulties  could  revealed that with this  relatively  as t h e  less t h a n  non-organic  because  it w o u l d  signs  for the  representation purposes  was  of t h i s  sole BPC as  have  pain g r o u p whose expression  visual  be  multiple  was c o n s i d e r a b l y  Using multiple  in t h e a p p r o p r i a t e report  Pain  as i n a p p r o p r i a t e  estimates of 40-60%.  sole c r i t e r i o n  included  findings.  (23.8% of t h i s  original  between  control.  of M e d i c a l l y  It had o r i g i n a l l y  correlation  of  exaggerated  research,  incongruent  pain  presentation  any one of t h e f o l l o w i n g organic  physical  symptoms, patients  signs,  was operationalized  criteria: the  the  were operationalized  who  p r e s e n c e of 2 o r more  p r e s e n c e of 3 o r more  or a score of 5 or g r e a t e r  shows the g r o u p  as p a t i e n t s  non-  inappropriate  on t h e pain d r a w i n g .  Control  b y t h e absence of these c r i t e r i a .  percentages  for  patients  met  satisfying  each of  pai  Table 5  these  criteria.  T a b l e 5:  O c c u r r e n c e of C r i t e r i a Within  Each  Group  Criteria  Group Sex  Non-organic Signs (>1)  Inappropriate Symptoms (>2)  Pain D r a w i n g Score (>4)  Female Male  0 0  0 0  0 0  I ncongruent Pain P a t i e n t s Female Male  65 30  80 55  80 60  Control Patients  (n=80) Note. Percentages  Table 6 shows incongruent  pain  of t h e c r i t e r i a . presentation  calculated  as a p r o p o r t i o n  the percentages  groups  of t h e p a t i e n t s  As Table 6 i n d i c a t e s ,  was more e x t r e m e  basis of one  t h e female and  who satisfied  group.  male  different  female i n c o n g r u e n t  whereas  criterion.  numbers  pain  in t h a t females w e r e more l i k e l y  d i s p l a y 2 o r more of t h e c r i t e r i a , i d e n t i f i e d on t h e  within  o f 20 p e r  to  men w e r e m o r e l i k e l y t o  be  '1  T a b l e 6:  Incongruent  Pain  Patients  by  N u m b e r of  Criteria  N u m b e r of I n c o n g r u e n t Pain C r i t e r i a  Sex  Three  Two  Female  40%  ~50%  Male  15%  15%  n=20 p e r  Correlations organicity  rating.  moderately  One T0%~ 70%  sex.  were calculated These appear  intercorrelated  with  between  the criteria  in T a b l e 7. each o t h e r  scores  All the criteria  and with  the  and  the  were  organicity  rating.  T a b l e 7:  Relationships  Variable  Among  Incongruent  Non-organic Signs  Non-organic  Inappropriate Symptoms  Indicators Pain  Drawing  Score  signs  Inappropriate  Symptoms  .42**  Pain  Score  .53**  .30*  .60**  .33*  Drawing  Organicity  Pain  Rating  .33*  76 Statistical  Analyses.  Categorical data (e.g., employment status, marital status, compensation status) were first analysed using non-parametric statistics to determine if the groups differed on basic descriptive and demographic variables.  Interval patient data (e.g., age, chronicity,  percentage of physical impairment) were analysed in a 2 X 2 (pain group X sex) MANOVA to determine if that combination of variables could account for differences between the four patient groups. Univariate analyses were then examined to identify covariates to be used in subsequent analyses described below.  The purpose of these  analyses was to identify and rule out variables potentially confounding the interpretation of differences between groups on the dependent variables. Dependent variables were divided into 3 a priori conceptual groups:  cognitive variables, behavioral variables, and subjective self-  report variables. To reduce redundancy among the Coping Strategy Questionnaire scales and among the coded pain behaviors, both the scales and behaviors were subjected to principal component analyses and the resulting factor scores used instead of individual scales and specific pain behaviors. Each set of variables was analysed first with a 2 X 2 MANOVA. Univariate analyses were conducted on each of the three variable sets with a Bonferroni stepped down alpha level (i.e. alpha level divided by the number of variables) to provide control over Type I error.  Then,  those variables identified as potential confounding variables were included as covariates in 2 X 2 MANCOVAs for each of the three sets of  77 variables. the  U n i v a r i a t e analyses of covariance w e r e examined again  Bonferroni  analyses f i r s t was  correction with  and then  used to c l a r i f y Following the  vivo cognitions  hypotheses,  and factors  cognitive coping  observers'  without the  interpretation  Questionnaire would  incongruent  applied to alpha  pain g r o u p s ;  and  (b)  pain  b e less i n t h e  would  in t h e  interact  pronounced  incongruent with  incongruent  factor  scores  the  pain  (c)  self-report  intensity  that these of  and  differences  effect  introduction  in  and  pain g r o u p  hypothesized  the  in-  of  pain  while  pain g r o u p s ;  (d)  the coded  over  pain,  It was e x p e c t e d  even with  covariates  less u s e  reflect greater  the above  in f e m a l e p a t i e n t s .  w o u l d e m e r g e as s i g n i f i c a n t  behavior  would  the  Strategy  catastrophizing,  pain g r o u p s ;  sex w i t h  (a)  from the Coping  reflect greater  measures of pain a n d d e p r e s s i o n severity  that:  less s e n s e o f c o n t r o l  r a t i n g of pain w o u l d  tolerance would  of t h e  of  results.  it was e x p e c t e d  reflect greater  Comparison  introduction  of t h e  derived  strategies,  level.  with  more differences the  covariates. Finally, variables  in o r d e r t o assess t h e  in d i s c r i m i n a t i n g  appropriate  incongruent  along with  step-wise  discriminant  variables function  was t o d e t e r m i n e t h e v a r i a b l e s incongruent  from control  pain  that the cognitive  pain  patients,  u s e d as c o v a r i a t e s , analysis. that  variables,  w o u l d e m e r g e as t h e m o s t s i g n i f i c a n t  The  all t h e  these  into a  analysis  discriminate  Following the especially  from  dependent  were entered  p u r p o s e of t h i s  significantly  patients.  of  (male and female c o m b i n e d )  (male and female c o m b i n e d )  variables,  expected  relative contribution  hypotheses,  those assessed  in d i s c r i m i n a t i n g  the  it  was  in-vivo,  groups.  RESULTS Group Differences:  Patient Characteristics  Much of t h e descriptive categorical  in n a t u r e ;  of d e s c r i p t i v e  hence,  variable  patient analysed  No s i g n i f i c a n t  groups  status,  disincentive, second  employment  status,  emerged  in s i g n i f i c a n t l y  Similarly,  groups  taking  (with  with  differences  medication  with  emerged  between  [X. (1 )=12.11,  for  relaxants].  muscle  A  largely  and  properties.  sedative  f o r muscle  p=.0005,  diazepam  of  as a  relaxant  only  A  (with  in t h i s  (Valium)  - 78 -  1 male  but pain  regularly between p=.79,  pain for  significant group  f o r s e d a t i v e s ; "x3(1)=8.53, of t h e data  sedatives  properties.  [ X ( 1 ) = .07,  relaxants]  square  medication  in t h e g r o u p s :  No d i f f e r e n c e  men a n d women  d u e t o t h e f a c t t h a t women prescribed  financial  Chi  2 males w e r e  was a p p a r e n t  Inspection  to have been  with  compared with  muscle  sedative properties.  combined)  was  proportions  A t o t a l o f 10 w o m e n  p=.74,  a  the four  and English  in T a b l e 8. T w o t y p e s  different  sexes combined)  s e d a t i v e s ; "X. (1) = . 1 1 ,  presence of  analysed  a t o t a l o f 16 w o m e n c o m p a r e d w i t h  medication  using  between  ethnic membership,  i n t a k e was also s i m i l a r l y  regularly  emerged  surgeries,  Medication  relaxants.  table  in T a b l e 8.  a n d has been o u t l i n e d  taking  Chi  as s h o w n  analyses  were  contingency  language,  and muscle  and absence  differences  previous  non-continuous  in a 2 X 4 ( p r e s e n c e o r  b y each g r o u p )  square statistics. on marital  data were  p=.0035,  revealed the the effect sample w e r e more  which  has m u s c l e  likely  relaxant  Table 8:  Percentage Breakdown by Group: Categorical Patient Variables Pain Group Control  Variable  Male  Incongruent  Female  Male  Female  5,  X. (3)  £  Financial Disincentive  30  50  30  50  2 63  .45  Had Previous Surgery  40  35  25  55  3 95  .27  Multiple Surgeries  15  15  15  25  1 04  .79  Unemployed  0  5  15  15  4 23  .24  Non-Caucasian  10  15  35  30  4 87  .18  English Second Language  5  15  30  20  4 50  .21  Not Married or Not Common law  45  30  60  35  4 77  .23  Analgesics  70  80  55  75.  3 33  .34  Narcotic Analgesics  35  55  30  50  3 48  .32  Anti-1 nf lamatory Analgesics  5  25  20  20  3 12  .37  AntiDepressants  5  10  10  20  2 38  .50  10  30  0  50  16 92  .0007  5  20  0  30  9 59  .0224  15  15  5  25  3 14  .37  Sedatives Muscle Relaxants Anxiolytic n=20 per group.  Interval  d a t a s u c h as a g e ,  analgesic medication of C L B P Back  problem,  Pain  consumed,  the  Disability  9 contains the  Physical  Table 9:  listed  main e f f e c t s  interaction  were found for  F's w i t h  Physical  Disability  had a g r e a t e r  and a greater  of d a i l y  living.  restricted  et a l .  activity  by  group.  reports  Low  Table  analyses  Demographic  and  4.29 2.21 .81  .001 .044 .584  emerged;  however,  and sex. .0071,  Index  Table  of  have described  revealed  Pain  significant  Inspection  of  the  significant  and the Oswestry  10 b r e a k s  Patients  as i n d i c a t o r s  into a MANOVA.  univariate  in t h e  down the  impairment  physical  of t h e  and  pain  limited in  activities  impairment  'severity'  Low  mean  incongruent  impairment  p e r c e n t a g e of f u n c t i o n a l  (1984)  duration  and the Oswestry  p  down to  Impairment  of  surgeries,  F(7,70)  p e r c e n t a g e of p h y s i c a l  mobility  Waddell  group  Questionnaire.  values of these variables group  both  strength  10.  Table for  effects  alpha stepped  on b o t h t h e  Pain  and the  .70 .82 .93  No s i g n i f i c a n t  Back  were entered  Wilks Lambda (s=1,m=2 1/2,n=34)  Group Sex G r o u p X Sex  Index,  in T a b l e  MANOVA Summary History Variables  Source  effects  Impairment  Questionnaire,  have been  index,  n u m b e r of p r e v i o u s  r e s u l t of t h e M A N O V A  these variables  univariate  socioeconomic  of t h e  and back  Table 10:  Means and U n i v a r i a t e A n a l y s e s : P a t i e n t  Characteristics  P a i n Group  Variable  Age  (years)  Source  Control  Incongruent  Male Female  Male Female  Sex  Group  F(l,76)  £  Sex X Group  :F(1,76) £  £(1,76)  £  M SD  42 13  37 . 11  40 9  41 9  .59  .44  .13  .72  2.OP  .15  SESa  M SD  39 13  40 13  41 15  34 13  1.18  .28  .62  .43  1.41  .24  Surgeries  M SD  .60 .99  .65 .98  .85 .93  .65 1.30  .18  .68  .18  .68  .39  .53  M SD  1.3 1.2  1.4 1.0  1.1 1.1  1.3 .9  .60  .44  .31  .58  .11  .74  M SD  8.7 6.9  8.3 8.9  8.8 7.0  9.3 8.0  .00  .95  .10  .75  .06  .80  M  14.6 6.7  11.7 5.4  22.4 9.7  16.6 8.2  7.02  .01  sn  14.71  .000  .78  .38  M SD  30.1 10.9  32.4 10.0  39.0 15.2  46.6 12.5  3.24  .08  17.51  .000  .90  .35  Analgesic ^ Strength  Chronicity (years)  Physical Impairment  Disability  £ = 2 0 per group. (a) H i g h e r s c o r e s r e f l e c t (b) H i g h e r s c o r e s r e f l e c t  h i g h e r SES. g r e a t e r n a r c o t i c potency  pain  condition.  'severity'  of  In a r e g r e s s i o n  the  back  behavior  indicators.  variation  and  Physical  Impairment  covariates Physical  in  pose  pain  the  of  exception signs,  physical with the  that  pain  restriction.  and  impairment. were  Pain  for  problems,  it w a s  decided  to  A  Questionnaire  correlational  Disability  revealed  Index  11.  physical suggested  However,  were  and  Waddell signs here  the  associated  may by  with  include  be  the  and  as  have  of  of  association report  impairment. pain  with  non-  independent  symptom  the  the  of  (1980)  lack  the  between  number  et a l .  physical  group  inter-correlations  inappropriate  w-ith  analysis  found  illness  measures  Questionnaire,  moderate  also  magnified  account  associated  criteria  with  could  Table  was  investigators  association  Impairment in  those  associated  Disability  the  nonorganic which  be  analyses.  Index,  shown  the  drawing  Inappropriate  Index  Physical  findings,  physical  this  indicators  as  to  interpretive  Impairment  suggested  Since  subsequent  inappropriate  organic  condition  analysis,  related  All  and the  activity  83  r Table  11:  Relationships Between I n c o n g r u e n t Pain  Physical  Physical I ncongruent Pain  Severity  and  Indicators  Physical  Criteria  Impairment  Disability  .16 .33* .37**  Nonorganic Signs Inappropriate Symptoms Pain D r a w i n g S c o r e n=80 * £<.01;  Severity  .48** .49** .36**  ** £ < . 0 0 1 .  J  L  Principal  Component  Coping Prior  Strategy  scales  and  rotated  with  eigenvalues  the  factor  factor  elsewhere may the  (1983) been  for the factor  somewhat  1.  more  accounted  Factor  scores  different 1983).  structure  One  ratio  reason  by  solution  analysis  factors  computed  analyses.  factor  was 9:1  reported  the factor  stable.  from  Strategy  emerged  f o r 69.5% o f  were  data  Coping  component Three  These  to v a r i a b l e  Therefore  rotation.  in s u b s e q u e n t  & Keefe,  the subject  was 6 : 1 .  than  was somewhat  the nine  to a p r i n c i p a l  varimax  and used  Measures  Scales.  with  12.  and Behavioral  differences,  subjected  in T a b l e  (Rosensteil  be that ratio  greater  loadings  structure  of g r o u p  were  orthogonally  as s h o w n  Cognitive  Questionnaire  to a n a l y s e s  Questionnaire  variance  Analyses:  in t h i s  Rosensteil reported  based  The  analyses  for the  the on  resulting  reported  discrepancy sample, and  here  while  Keefe may  have  84  r j  1 Table  12:  |  Principal  Component  Strategy  Questionnaire  Analyses  of  Coping  j j  |  I  the  Factor  Scale  |  1  Ignoring  j  2  3  j  .85  .10  -.13  |  j | | j  C o p i n g Self Statements Reinterpreting Sensations Diverting Attention Increasing Behaviors  .82 .77 .74 .71  .12 -.11 .08 .28  .07 -.07 .35 .11  | j j j  I |  Ability To Decrease C o n t r o l O v e r Pain  .02 .22  .85 .79  .12 -.16  | j  | |  Catastrophizing Praying/Hoping  -.16 .29  -.20 -.20  .84 .78  | j  |  "^=80  | _  L  The  principal  interpretations. deal  with  Factor 3  similar vivo  Factor  reflected  the  Schedule  for  Pain.  the  task.  active  the  u s e of  a pain-related and  perhaps factor  pain  Questionnaire designation ratings,  reflected Interview  in t h e  coping  s e n s e of  structure  factor  strategy  need  coded  for  very in t h e  ameliorating  strategies  Factor  were  which  Structured  loaded  coding for  1 and  on  criteria Pain.  to  self-efficacy.  was  stategies  in t h e  Schedule  following  a perceived  cognitive  Specific  Effectiveness  Structured  the  main  Strategy  thoughts  suggested  resulting  three  Strategy  Coping  resembled in  to t h e  Coping  in t h e  Control  reflected  This  assesment  reflected  closely  2  catastrophizing  conceptually  on  pattern  1 reflected  intervention.  cognitive  loaded  Factor  pain.  miraculous  component  J  also interview  Factor for  in  2,  Sense  of  Catastrophizing  and 3  perceived  also  need  resembled  Structured 13 s h o w ,  the coded  Interview  however,  nonsignificant  Table  f o r miraculous  with  13:  escape  criteria  Schedule  from  the exception  among  these  cognitive  n=80;  in  Table were  of c a t a s t r o p h i z i n g .  Factor 1 Active Coping Strategy  Coping Strategy Sense of C o n t r o l Catastrophizing  Factor  variables  Relationships Between C o p i n g Strategy Q u e s t i o n n a i r e ( C S Q ) F a c t o r s a n d In V i v o  Category  in  on t h e  A s the correlations  CSQ  In-Vivo  reflected  for Catastrophizing  f o r Pain.  the correlations  pain  Factors  Factor 3 Praying/ Catastrophizing  Factor 2 Pain SelfEfficacy  -.13 -.08 .05  Categories  .07 -.01 -.02  -.21 .00 .37**  ** £<.001  Pain Behaviors. Prior to analyses were  subject  using than  to a p r i n c i p a l  varimax  analysis  f o r 65.0% o f t h e v a r i a n c e .  on t h e f a c t o r  analyses.  T h e resulting reported  to overt  loadings  factor  by Turk, pain  emerged  Wack,  with  and used  structure  behaviors orthogonally  eigenvalues Factor  similar  (1985).  greater  scores  in s u b s e q u e n t  was very  and Kerns  behavior:  pain  and rotated  accounted  based  dimensions  component  the five  T w o factors  computed  two  differences,  rotation.  1. T h e s e  distinction  of g r o u p  were  data  to a They  found  ambulation/postural and  86 facial/audible. were  Table  selected  14 r e p o r t s  if t h e y  the loadings  had an e i g e n v a l u e  on the two f a c t o r s .  greater  than  1 f o r both  Factors sets  of  variables.  Table  14:  Principal  Component  Analyses  of t h e Pain  Behaviors  Loading  Behavior  Factor 1  Rubbing Bracing Guarded  Movement  Grimacing Sighing  Factor  .80 .74 .66  .18 .02 .18  .01 .32  .92 .79  2  n=80  Group Differences: Cognitive Measures A  total  of s i x c o g n i t i v e  Questionnaire transcribed sex,  factors  reports)  MANOVA.  problem analyzed  first  Impairment shows,  problem  were  analysed  presentation  without  indices  was a s i g n i f i c a n t both  taken  into  with  coded  between  indicators  categories  from the  pain  presentation  of t h e  variables  and then  physical  main  effect  severity  by  back  were  with  as c o v a r i a t e s .  multivariate  consideration.  Strategy  severity  was f o u n d ,  included  and without  Coping  in a t w o - w a y ,  group  the severity  (the three  main  an association  and Disability  there  presentation  and the three  Since  and pain  measures  Physical  As Table  for  of t h e  pain pain  15  87 r Table  15:  M A N O V A and M A N C O V A Cognitive Measures  Analysis  Summary  Wilks Lambda ( s = l , m = 2 , n = 3 4 1/2)  Source  Table  for  F  E  MANOVA Group Sex Group  X  Sex  .69 .89 .91  5.26 1.44 1.19  .001 .213 .322  Sex  .80 .93 .93  2.85 .86 .92  .015 .531 .483  MANCOVA Group Sex Group  X  N o t e . P h y s i c a l I m p a i r m e n t a n d D i s a b i l i t y s c o r e s u s e d as c o v a r i a t e s . df=(6,71) & (6,69) for M A N O V A & M A N C O V A respectively. J  Univariate determine  which  F's  for  variables,  significantly  different  problem  controlled.  was  presented pain  signs,  in  the  Table patients  individual with  between  16.  groups  Means  and  Relative  with  to  measure  that  characteristic  of  thinking  stepped when  patients pain  catastrophizing, when  they  were  down  the  univariate  incongruent  retrospective  their  alpha  variables  examined to  severity results  without  praying, pain.  of  have  any  presentation  feel  .0083  to  were  the  back  been  incongruent reported  and  hoping  on  the  were  Table  16:  Means  and  Univariate  Analyses:  Cognitive  Analyses: Pain  Group  Variable  Male  Structured  Interview  Coping M SD  Male  Schedule  Strategies 2.5 2.0 1.2 1.0  S e n s e of M SD  Incongruent  Female  Female  for  Pain  2.0 1.1  Control 1.5 .9  1.5 .9  Catastrophizing M 2.1 SD 1.1  2.6 1.4  2.2 1.1  3.6 1.6  Strategy  Coping M SD Pain  Strategies -.08 .24 1.1 1.1  Catastrophizing M -.33 SD .8  -.23.  Factors  .7  .07 1.1  .20 .9  -.31 .8  .03 1.1  -.49 .7  .00 1.0  .82 1.0  n=20 p e r g r o u p . (a) H i g h e r v a l u e s r e f l e c t g r e a t e r ( b ) F a c t o r s c o r e s t r a n s f o r m e d on  £  Covariates  F(1,74)  £  . 00  . 99  5.22  .025  .35  .21  .65  .47  . 49  . 03  . 86  1.62  .21  .80  .37  17.21  .000  (a)  .90  Questionnaire  Self-Efficacy M .10 SD 1.1  F(1,76)  5.86 2.0 1.3  With  Covariates  .03 2.4 1.2  2.3 1.1  Coping  Effect  Group Without  Control  Variables  . 85  .018  (a,b)  7.01  activity. a z-distribution.  .010  Group Differences: Behavioral Measures A  total  factors,  the global  analysed were  of f o u r  behavioral  pain  in a t w o - w a y  analyzed  first  rating,  a n d pain  (the two pain tolerance  duration)  presentation  b y sex M A N O V A .  without  the physical  severity  with  covariates.  As Table  Physical  Impairment  17 s h o w s ,  there  presentation.  However,  of t h e pain  problem  was taken  account,  into  The  scores  was a significant  f o r pain  were  indicators  and Disability  effect  effects  behavior  pain  a MANCOVA  main  measures  when  variables  and then as  multivariate  the physical  no s i g n i f i c a n t  severity  multivariate  appea red.  Table  17:  MANOVA and M A N C O V A Behavioral Measures  Analysis  Summary  Table  for  Wilks Lambda ( s = 1 , m = 2 , n = 3 4 1/2)  Source  MANOVA Group Sex Group  X  Sex  .83 .93 .97  3.79 1.45 .55  .007 .226 .700  Sex  .95 .93 .97  .87 1.30 .58  .484 .277 .678  MANCOVA Group Sex Group  X  N o t e . P h y s i c a l I m p a i r m e n t a n d D i s a b i l i t y s c o r e s u s e d as c o v a r i a t e s . df=(4,73) & (4,71) for M A N O V A & M A N C O V A respectively.  Inspection the  sources  factor  of t h e u n i v a r i a t e  of s i g n i f i c a n t  a n d on t h e global  analyses  difference pain  rating.  were  in T a b l e on t h e  18  in  revealed  that  ambulation/posture  It w a s n o t s u r p r i s i n g  that  when  90 the  physical  severity  reach  significance  1984)  organic  impairment indicated  shown  in  the  s i n c e as  impairment  and  total  however,  Impairment  of  Index,  Table  19.  but  problem  reported  was  pain  that  back  found  ratings.  behaviors moderately  above to b e  was and  elsewhere  correlated  Correlations were  controlled  less  correlated  on  with  the  correlated with  the  these  failed  (Keefe,  et  to al.,  physical  total with  sample the  Disability  Physical score  as  Table  18:  Means  and  Univariate  Analyses:  Behavioral  Variables Analyses: Pain  Group  Group Without  Control  Variable  Pain  Female  Tolerance (sec) M 202 145 SD 69 85  Observer M SD  Pain  Male  Rating 1.4 1.8  Behavior  (a) 1.4 1.5  Factors  Incongruent  Male  Female  153 85  139 97  2.4 2.6  3.1 2.5  With  Covariates  F(1,76)  £  Covariates  F ( 1 , 7 4 ) p_  2 07  .15  .76  .39  8 09  .006  .75  .38  9 75  .003  2.16  .15  2 48  .12  .42  .52  (b):  Ambulation/Posture M -.46 -.20 SD .61 .83  .11 1.1  .55 1.1  Facial/Audible M -.23 SD .61  .•H3 1.2  .16 1.3  -.13 .70  Effect  n=20 p e r g r o u p . ( a ) 10 c m . l i n e w i t h " n o p a i n " t o " p a i n a s b a d as (b) F a c t o r s c o r e s t r a n s f o r m e d to a z - d i s t r i b u t i o n  it c a n  be"  r  i Table  19:  Relationship  Between  Severity  and  Pain  Behaviors  Severity  Physical Pain  Behaviors  Impairment  Disability  Pain B e h a v i o r F a c t o r s : Ambulation/Posture Facial/Audible  .17 .03  .45** .32*  Total  .14  . 54**  .28*  .46**  Pain  Behavior  Observer's  Rating  n=80 * p_<.01;  **  £<.001.  L  J  Group  Differences: A  total  of  Questionnaire present  pain  analysed  in  self-report indicators  severity main  of  effect  self-report  measures  (three  the  intensity, a two-way  then  As  the  became  of  and pain  with  F's the  Differential  the  Beck  analyzed  Table  for  problem  by  first  and  sex  without  Pain  Scale  MANOVA. the  a  presentation.  When  the  into  The  Disability  account,  the  individual  covariates,  all  variables  reached  prior  six  severity  as  significant physical  this  mutivariate  nonsignificant. for  of  were  physical  again  taken  ratings  Inventory)  was  was  there  and  Depression  McGill  Descriptor  Impairment  20,  pain  Pain  Depression  presentation  Physical  in  effect  pain  two  were  shown  main  Univariate introduction  of  scales,  and  multivariate  Measures  six  variables  covariates.  Self-Report  to  significance,  the with  the  93  r Table  20:  MANOVA Report  and  MANCOVA  Summary  Table  for  Self-  Measures  Analysis  Wilks Source  Lambda  (s=1, m=2,n=34  1/2)  F  E  MANOVA Group Sex Group  X  Sex  .69 .91 .93  5.22 1.18 .86  <.001 .327 .525  Sex  .84 .92 .94  2.15 .93 .70  .059 .476 .652  MANCOVA Group Sex Group  X  N o t e . P h y s i c a l I m p a i r m e n t a n d D i s a b i l i t y s c o r e s u s e d as c o v a r i a t e s df=(6,71) & (6,69) for M A N O V A & M A N C O V A respectively. J  L  exception  of  the  Sensory  intensity  stepped  down  only  the  Unpleasantness scale from  to  .0083.  Affective  Therefore,  sensory  pain  and  between  groups.  Therefore patients  level Table  relative  with  to  the  when of  extent  in  somewhat  cautiously  21  McGill  Questionnaire  pain  describing the  Pain  controlling McGill  for  Pain  physical  these  without  any  overall  pain.  Scale  not  was  incongruent used These  MANCOVA  F  into  account,  different  ratios. pain  affective results  main  alpha  achieved  taken  and  the  severity,  significantly  means  and  with  physical  Questionnaire  presentation their  the  severity  were  presents  patients  as  Descriptor  depression  incongruent  a greater  nonsignificant.  After  s c a l e of  significance.  the  Differential  effect  signs, descriptors  must was  be  to  treated  Table  21:  Means and Measures  Univariate  Analyses:  Self-Report  Analyses: Pain  Group  Group Without  Control  Variable  Beck  Male  Female  Incongruent  Male  Depression Inventory M 8.7 7.5 11.4 SD 5.2 4.5 9.0  McGill Pain Sensory M SD  Female  Covariates  Covariates  F(1,76)  £  F(1,74)  £  8.44  .005  2.57  .113  5.14  .026  1.42  .24  18.43  .000  8.24  .005  12.67  .001  4.10  .047  15.19  .000  3.17  .08  .01  .94  Questionnaire 12.9 14.4 5.3 6.5  15.6 6.7  18.2 6.9  1.3 1.9  1.7 1.5  2.7 2.3  4.5 2.8  Evaluative M SD  2.2 1.2  2.3 1.4  2.7 1.3  3.9 1.1  D i f f e r e n t i a l D e s c r i p t o r Scales f o r Pain Sensation M 7.3 7.4 9.5 10.8 SD 3.4 3.0 3.7 2.7 Unpleasantness M 5.1 SD 3.5 per  With  13.8 7.8  Affective M SD  n=20  Effect  group.  2.28 4.9 3.2  5.8 3.8  6.7 4.0  .14  95 Discriminant Since and  Function there  since the  behavioral, function  and  discriminated  pain  was  p_=.0002]  conducted  for  determining  groups.  (Huberty, the  and  was  of  physical The  classified  in  this  discrimant  81.25% o f  pain  were  These  table,  impairment  incongruent  control  index  patients.  used values  function Five  as  of  10 i n c o n g r u e n t  entry  and  were  entered [X. classified  first  has  been  determining been  pain  the  criterion questioned  in  affective  discriminating variables  patients were  function  relative  presented  patients  a  discriminant  measures,  these  analysis  discriminated  as  variables  have  function  order  in  pain  dependent  optimally  the  control  16  correctly  of  on  .optimally  function  were  variables  optimally  based  discriminant  variables  discriminant  3 cognitive  emerged  patients.  while  weight  a  cognitive,  22.  stepwise  importance  the  The  discriminant  Table  variable,  Impairment  all t h e  s e t of  u s e of  in  a  variables  Physical  patients  as  equal,  presentations.  a stepwise  standardized  variables.  shown  the  sex  included  dependent  the  in  what  relative  F-to-remove  groups.  as  the  were  85% o f  shown  with  were  analysis,  which  as  effects  a significant  analysis,  Since  1984),  importance As  this  pain  with  Presentation  women  what  first  to d e t e r m i n e  pain  and  of  in  in  presentation  the  and  In t h e  Pain  measures  along  resulting  Following  men  two t y p e s  entered  simultaneously  as t o  of  of  interaction  to d e t e r m i n e  scores.  (18)=46.784,  no  subjective  the  were  Disability  were  numbers  analysis  variables  Analyses  Table  pain the  23.  rating, pain  correctly  were  misclassifed  classified  as  96  Table  22:  Classification  of  Discriminant  Function  Pain  Group  Membership  Predicted  Actual  Group  Control Pain  Control Pain  with  the  Group  Incongruent Pain  36  4  8  32  I ncongruent Pain  Table  23:  Relative  Ordering  of  Discriminating  Variables  Statistic Variable Standardized Discriminant Function Coefficient  S e n s e of C o n t r o l (in v i v o ) Catastrophizing (CSQ) Physical Impairment A f f e c t i v e Pain R a t i n g (MPQ) C a t a s t r o p h i z i n g (in v i v o )  L  0 0 0 0 0  61 58 55 49 45  F to Remove  10 7 10 6 4  03 69 50 02 40  J  DISCUSSION Cognition  and  Medically  Chronic were or  pain  anatomically  patients  efficacious  symptom  comparison  to  were  CLBP  criteria,  CLBP  criteria  differed  their  deemed patients  kind  of  of  standardized,  noxious  discriminators  between  chronic  maladaptive  or  retrospective factor  escape  Also tendency the  in  for  affective  subjective  pain  as  and  pain  to  with  evaluative  experience  or  was  reflected  pain  in  patients  Coping relative  catastrophizing  back control  tended  a  their  pain.  control  thoughts  in  or  more In  Questionnaire patients wishes  of  pain. patients,  Incongruent scales  to  groups.  Strategy to  of  important  to e n g a g e  concerning  during  exposure  most  control  also a p p e a r e d  pain  presence  during  the  and  pain  occurred the  in  in  incongruent  efficacy  and  to e n g a g e  incongruent  that  report  exaggerated  behavior  variables,  one of  pain  cognitions  their  comparison patients  control  the  events  to o t h e r  and  hypothesized,  display  cognitive  patients  reflecting  from  not  symptom  appeared  whose  As  m o r e of  stimulus  incongruent items  or  incongruent  self-report,  more  miraculous  personal pain  patients  did  Relative  dysfunctional  scores,  endorsed  who  and  localized,  condition,  appropriate.  in t h e  pain.  behavior  poorly  than  one  of  illness  pain  pain  with  indicative  Incongruent  back  with  Pain  vague,  patients  experience  thoughts  to t h e i r  coping  report  whose  inconsistent,  disproportionate  less  Incongruent  of to  Pain  the be  - 97 -  there to  McGill  was  receive Pain  perceived  a  significant  higher  scores  Questionnaire.  and  judged  to  be  on The  98 more  disturbing,  patients with  in  the  distressing,  comparison  notion  incongruent  that  emphasis  incongruent  activity,  and  and  degree the  pain  behaviors, sensory  such  of  condition support  pain  was  idea t h a t  patients.  However,  the  function because  degree of of  in  the the  had  of  and  global  pain,  but  as  consistent  may  were also  underlie  on  the  subjective  pain.  to w h i c h  did  of  incongruent extreme  pain-related  the  control  variables, activity  reach and  pain  as  On  even  Other  display  hand,  the  one  hand,  were  more  and  pain  may  behavior  the  also be  are  the  to t h e  back  these  results  affectively  control  results  to  and  when  due  these  expressed  in  activity  the  due  the  pain  scores,  greater  than  when  hypothesized  significance  patients  and  restriction  depression  emerge to  mobility  more  may  physical  in t h e  ambulatory/postural  ratings,  pain  and  between  consideration.  mobility  other  that  which  limited  Restricted  greater  extent  failed  incongruent  out  cognitive  of  correlates  greater  with  a covariate.  more o v e r t  level  on  the  pain  of  be  pointed  into  physical  introduced  and  has  to  differences  taken  patients,  distressed  that  results  impairment,  important.  is a s s o c i a t e d  ratings  limitation  the  Pain  activity  physical  also  the f r e q u e n c y  observer's  incongruent  incongruent  psychological  found  emerged  was  as  intensity  was  mobility  condition  differences,  was  However,  groups  on  role of  (1974)  disturbance  physical  CLBP  degree  impairment  disability.  of  the  mobility  Sternbach  psychological  incongruent  by  These  cognitive  h e r e was  pain,  limited  group.  physical  patients.  dysfunctional  maintain  pain  to c o n t r o l  debilitating  pain.  While the  functioning  and  pain  suggested more  a  compromised  Patients maladaptive sensation their  and  the  with  to c o n t r o l  'events',  as  concerning of  noxious  Pain  chronic  patients  facilitates  coping  Cognitive number and  of  recognized Wall,  pain  their  pain  cognitive avoid  with more those such  as  a signal  processes  more  greater  activities  and  that  activity.  potential  that  tissue  the  therapeutic than  been  those  with  Negative, if  to  Negative  that  can  pain et  be  and  al., that  those  system'  that  operate  in  First,  the  pain  CLBP may  more  of  and  responses  maladaptive failure  stable factors expectancies  &  evaluate with  likely  to  chores, associated  expectancies or  been  associated  patients be  of,  (Melzack  readily  housework  cognitive  has  distress to  a  avoidance  damage  patients  distress  experiences  to  results  increase  tissue  Those  exercise,  attributed  disability.  pain  damage.  accentuate  and  accentuate  some c h r o n i c  inferences  identify  may  mobility or  argued  1979).  schemas  and  in  Questionnaire  these  a 'cognitive  (Pinsky,  conviction  related  may  pain  to m o d i f i c a t i o n  a physical  develop  the  Leventhal  from  incongruent  endurance.  have  (cf.  amplified  have  which  schemata  report  cognitive  actual  of  bedrest  to  less  (1981)  from  inferred  symptom  have  Strategy  information be  processes  activity,  pain  resistant  as  of  and  demonstrated  distress,  to  Turk  datum  distress  physical  predispose  physical  seek  in,  Cognitive  may  fail  to maintain  a signal  1983).  with  and  as  and  more  Coping  processes  limits  processes  ways  restriction  and  basic  It m a y  who  and  in t h e  the  behavior  presentation  appeared  Genest  sensory  1982).  Incongruent  and  reflected are  pain  anticipated  pain,  cognitive  Pennebaker,  pain  they  pain.  'samples',  processing  1980;  incongruent  in t h a t  associated  In-vivo  drawn  an  coping  ability  cognitive  with  are  difficulties  (Weiner, about  1974)  walking,  in  lifting,  prolonged  activities  (Schmidt,  selectively  the  activity  activity  which  of  (cf.  by  such  avoidance  of  activity  may  Lethem,  be one  greater  in  Second, affect  muscle  are  (Schmidt,  likely  muscle  tension  activity  and  patients  may  (Dolce  be  CLBP  as  this  variable  physical  to  the  mental  behavior  of  bias  pain  activity.  pain,  may  and  A  may  be  lead  to  also  1983;  Slade,  deconditioning.  This  activity  concept  1985)  muscle  differences  in t h e  may  in  underlie  from and  that  was  and  on  "pain-muscle variation  in  of  pain  reactivity  identifiable  CLBP  disease  in  their  back  spasm-pain protective  physical  deconditioning.  musculature  directly  heightened  engage  activity  a 'psychogenic'  not  that  some  with  to a v o i d a n c e  physical  having  processes  stressors  also c o n t r i b u t e  results  fear  mediated  of  1985)  as  physical  mobility  those  group.  impact  results  that  and  & Bentley,  physical  & Birbaumer,  the  perceived  & Raczynski,  cognitive  may  eventually  avoidance  Third,  of  & Raczynski,  idiographic  protective  Turk,  Individual  which  and  of  catastrophizing  processes,  Troup,  supports  to o v e r r e a c t  of  heightened  cognitively  Research  (Flor,  1985).  pain  information  avoidance  Slade,  processes  reinforce  thought  1983)  be  cognitive  may  and  impaired  may  evaluations  (Dolce  this  why  there  cycle"  1985)  (Lethem,  lead to a v o i d a n c e  sensory  reinforce  incongruent  tension  maladaptive  may  may  and  noxious  & Bentley,  physiology.  patients  of  dysfunctional  reason the  Schema  reinforcement  enhanced  Troup,  exercise  Schmidt,  in t u r n  negative  and  1985).  evaluation  causing  cycle  sitting,  These problem  since  and/or processes  1985). investigation  associated  with  seems  to  indicate,  incongruent  pain  an was  important the  lack  of  a  101 s e n s e of  control  during  essential  feature  of  as  pain  which 1983),  also  may  control  over  cognitive  coping  that of  Bandura, s e n s e of  in  being  control  in  is  chronic  activity  effective  levels  an such  pain,  (Skevington,  management  the  of  facilitating The  ineffective may  rigidly,  or  have  may  coping  lack and  threat.  stategies It d i d  of  they  or  and  using  used  at t h e i r  coping coping  have'catastrophized  pain  patients  strategies. skills while  too  may  either case  lack  sensations  a  may  be (cf.  to  a  permanent, have  Incongruent inconsistently,  attempting  the  will  contribute is  no  repertoire  disposal  painful may  on  be t h e  patients  that  these  to  inadequate  control  attribution  their  pain  attenuating  Alternatively, in  an  be  However,  groups  appear  of  would  generated  group.  between  have  perceived  the  pain  not  a function  that  skills  spontaneously  Incongruent  strategies  helplessness  patients  se.  coping  incongruent  emerged. be  pain  specific  cognitive  could  per  of  in t h e  measures  1977).  unchangeable of  u s e of  differences  that  efficacious  reduced  ineffective  frequency  strategies  conviction  of  r e s p o n s e to a s t r e s s o r  helplessness  loss of  that  strategies  in t h e  group  with  a perceived  a lower  cognitive  coping  associated  hypothesized  in  the  Learned  in  Lack  pain.  reflected  differences  experience.  helplessness  1984).  been  reflect  It w a s  of  learned  (Weisenberg,  has  a painful  to  a  history  pain too  implement  coping. These support It is  results  to t h e  suggested  episodes  and  along  emerging here  that  a tendency  with  investigations  cognitive lack to  of  models effective  assume  the  of  reviewed pain  control  worse  and  previously,  (Turk, over  et a l . ,  acute  accentuate  1983).  pain the  add  102 ongoing of  pain  activity,  experience indirectly  may s e r v e to maintain  increase  incongruent  manifestations  speculations  have  direction be  of C L B P .  based  and hypothesized  determined.  maladaptive these  been  Future  cognitive  hypothesized  back  severity,  Still,  research  Thus  the  variables  pain  in  below,  at m a n i p u l a t i n g  in i n c o n g r u e n t  avoidance  and result  data.  of c o g n i t i v e  directed  facilitate  as d i s c u s s e d  on correlational  operation  coping  pain  pain,  causal  has y e t to  and  patients  these  altering  may  elucidate  nature  of t h e  links.  Interpretive Issues One  limitation  By  not h a v i n g  data. results  could  al.,  1980),  potential  strength  of  display  number  that  pain-related  reported pending  litigation  patients) sample  made  status,  that  was  with  other  pain  ethnic  activity invalid'  pain  status,  presence  presentation but their  firm  to c o m p e n s a t i o n  or  are  status.  et a l .  was associated sample The  evidence  litigation.  or It  independent  Lehmann,  conclusions.  a n d d i d not f i n d  consumed,  of c o m p e n s a t i o n  a n d marital  small  of  age,  of m e d i c a t i o n  skill.  (Waddell  was i n d e p e n d e n t  characteristics  or coping  to d r a w larger  type  the  confounding  investigations  membership,  patient  status,  thus  criteria  consumed,  and compensation,  related  factors,  surgeries,  'gross'  it d i f f i c u l t  pain  as s o c i o - e c o n o m i c  medication  was s u b s t a n t i a l l y  presentation  incongruent  cognitive  evidence  for by other  variables  these  is t h e c o r r e l a t i o n a l  the presenting  consistent  of  employment  appears  over  of p r e v i o u s  of a n a l g e s i c  litigation, thus  However,  confounding  chronicity,  research  control  be a c c o u n t e d  interpretation. et  in t h i s  size  (1983) with  (10  present that  This  was  pain  consistent chronic control  with  pain of  concern  patients  financial  characteristics, spuriously The with  the  with  consumption displayed likely  less  the with  in  criteria  by  which  for  on  some d e p e n d e n t  incongruent extreme draw  pain  incongruent  pain  Global of  investigation.  in  about  of  determined  variables. were  treated  differences  and  the  the  and  were  of  have  were  Valium  that  criteria.  women more  This  is  s o m e of  the  more  sociocultural encompassed  In t h i s  study,  attenuated  manifestations  equivalent  the  and  greater  behaviors  Therefore, in  associated  manifestation  1978).  may  be  however  Certainly,  as  be  differences  expression  Extreme  male p a t i e n t s .  sex  the  Craig,  the  history  minimal,  signs  pain-related  (cf.  be  noted  one of  1984).  to  to  Sex  to  pain  found  under  effects  of  to t h e  it  less  is d i f f i c u l t  expression  of  the  to  the  criteria.  indices  organic  were  women  manifestations  conclusions  degree  groups  in  have  found  mobility be  on  as  that  criteria.  appeared  more than  1985)  pain  appear  1984).  incongruent  expression  not  pain  physical  & Waddell,  pain  did  It s h o u l d  which  method sex  of  demographic,  et a l . ,  study  et a l . ,  described  previously  observations  (Main  influence  the  display  women  incongruent  the  to  criteria  by  (Waddell  of  pain  may  variable  patients.  previous  factors  clinical  impairment  each  men  In g e n e r a l ,  present  (Dworkin  inappropriately  these  sex  in t h e  m o r e of  incongruent extreme  was  in w o m e n  than  consistent  with  elsewhere  disincentives  demographic  groups  associated  been  financial  associated  criteria  between  have  incentives.  or  only  expressed  of  non-organic  impairment  Even  with  a  incongruent  in m o b i l i t y  relatively  pain  appeared  small  to  reliability  behavior be  and  reliable  sample,  in  this  patient  variability, of  these  the  u s e of  signs,  determination impairment observed  coefficients  of  was  multiple  or  of  pain  incongruent  research,  keyed  specific  in  this  pain  drawings  5- B l o c k ,  the  were  in  affective,  and  pain  von  back  the  of  the  appropriateness presents of  the  main  or  of  the  back  condition  and  effect  validity  for  of  the  these  impairment the  also  groups  on  that  with  are  not  al.,  1978).  behavior  and  scoring  pain  pain  of  be  condition.  The  elsewhere  of  observations al.,  sensory  on  of  (Keefe  by  way  This  pain  to  cognitive,  for  suggested  intensity than  the  were  by  pain  ratings  more  a of  the  patient  between  Also,  that  a function  CLBP  reflecting  1984).  of  pathophysiological  discrete as  measures  psychological  accounted  relationship  et  including  problem  the  frequency  the  consistent  attributable  imposed  of  (Keefe,  nature  et  research  could  sensory  incongruentness  that  reported  variance  back  situation.  neurological  the  and  a clinical  the  in f u t u r e  CLBP  in  supports and  the  idiosyncratic  (Fordyce, pain  reliability  inadequate  of o r g a n i c i t y  necessity  limitations  depression, severity  CLBP  variables  with  noted  in  1983).  to t h e  Some of  physical  be  of  physical  not o n l y  reliability  et a l . ,  the  pain.  associated  behaviors,  function  of  variability  the  nature  the  The  also  reliable  with  points  behavioral  in  less  that  overall  judgements  measurement  Baeyer,  severity  processes  differences  are  consistent  investigation  physical  processes  behavior  but  It s h o u l d  global  dichotomous  and  reflect  error  the  suggested  signs  may  expression.  investigation,  1982;  This  signs  general  and  consistently.  measurement  previous  Also  reliability  non-organic  individual  standardization  examiners,  of  accomplished  across  to  multiple  the  severity  behaviors more  mechanical  the  lack  after  the  of  a  105 introduction ratings  as  of t h e  specific  Some disability  covariate to t h e  caution  difference  between  about  behavior.  restriction her  and  perceptual was  measures  behavior.  or  not  were  Implications The  painful.  correlated  for  Patient  limitations  treatment  concerning  However,  these  may  explain  why  1985)  or  increased  explanation severe likely  the  physical to  cognitive severity of  of  the  do  outcome  health  impairment  to  explain  the  the  impairment  and  out,  is  behavior  patient's  measures  of  not  tolerance  there  and  activity  report  about  his  flexibility  that  the  or  had  a  maneuver  surprising  (Pope  a  self-report  of  spinal  indicated  it w a s  sensory  stimuli.  pointed  pain  influence  of  potential  pain  et a l . ,  the  that  these  1980).  disability, and  require  between  condition  was  are  et a l . ,  and  therefore, care.  groups  taken  into  due  Another  to  et  One  less  However, when  pain  explanation  al.,  more  were  account,  that  poor  1984). had  even  back  of  Lehmann  patients  more  measured.  predictive 1984;  cautious  mechanisms  these  pain  activity  differences.  variables  (Waddell  be that  imply  theoretical  & Doxey,  utilization  and  designs  indicators  (Dzioba  and  mobility group  correlational  would  distinguished  physical  in  care  findings  back  pain  the  determination  patient  suggest  factors the  the  pain  causal  to t r e a t m e n t  of  on  of  Management  respond  restricted  sufficient  with  incongruent  medical/rehabilitation  the  Therefore,  inherent  results  of  the  has  verifiable  based  Even  in t h a t  physical  (1983)  aspects  were  validity  interpreting  publicly  Most  the  of  in  Fordyce  overt,  component  painful  As  mobility  pain-related  severity  is w a r r a n t e d  indicators.  that  supports  the was  since the degree not  suggested  106 by  these  results  approaches reflected pain  failed  as  sensations. and  to a l t e r  a greater  Mechanic,  The  1976)  Some  pain  than  implications  are  treatment  programs,  less  suggested  effective  strategies  patients,  incongruent strategies  Strategy patients is o n  for  in  be  reducing  heightening  the  more  confidence feelings  Alternatively,  special  assessing  exactly  strategies. process  in of  (Meichenbaum,  skill  cognitive/behavioral  were  in  as  care  the  more utilization  interpret  their  pain  1981;  criteria,  emphasis  or  to  (Turk  pain  the  the  to  incongruent  pain  patients  be  placed  has  considered  been could  pain  to  emphasis  1977).  in  carefully coping  careful  determine  serve  these  and  implement  of  of  1983),  al.,  treatment  would  for  treatment  al.,  et  use  Coping  exacerbations,  (Gottlieb,  pain  in t h e i r  on  et  teaching  control  therapy  that  pain  is o n  no d i f f e r e n t  extent  research  management  incongruent  need  goals  pain  by  may  treatment  over  based  situation  over  helplessness  Future  as  Cognitive-behavioral  the  cognitions  implementation  1985).  pain  et a l . ,  In c o m p a r i s o n  to t h e  In c o g n i t i v e / b e h a v i o r a l of  may  cognitively-based  control  emphasis  how  that  experimental  effective  of  (Leventhal  identifed  patients  Thus,  efficacy  health  components  control.  catastrophizing  counteracting  the  pain  they  results.  extent  pain  Questionnaire. may  these  to t h e  of  styles  patients.  treatment  patients  lack  perception  because  pain  coping  in g r e a t e r  well-being  by  for  cognitive  specific  for  cognitive  and  result  patients  control  medical/rehabilitation  a perceived  may  to t h e i r  programs  be  and  interpretation  pain  threat  conventional  dysfunctional  disturbing  incongruent  may  be that  in c a t a s t r o p h i z i n g  distressing by  would  attention  to  crucial if  achieving  enhance  the  quality  107 of  life o r  enhance  incongruent  responsiveness  pain  referred  available.  pain  and  part  of  the  for  that  on  patients  care  of  part the  more  organic  not  be  associated displays pain  that  with  pain.  patient  It is  prompted  efforts  to  receive  coping  style  referral by  and for  risk  factors may  the  (von  regimens  for  may  Baeyer,  pain  1985).  In  here  not  to  have  patients'  suffering  pain  are  an  assessment  adequate  1983;  of to  what note  be  These important if t h e  in t h i s  et a l . ,  results  regard with  1980)  suggest  assessment referral  of  patient  associated  Waddell,  of  had  that  consultation display.  clinician  inconsistent  necessarily  most  and  anatomically  important  et a l . ,  the  and  determination  It is  for  actuality,  these of  on  pain  the  appeared of  basis  position  to c o n v i n c e  reports  for  no o r g a n i c  exaggerated  of  are  positives  This  'reality'  when  the  be the  psychological  incongruent  The  compensation.  may  is  investigation,  intense,  referral.  more  in o r d e r  especially  requires  there  likelihood  services  false  primary.  (Leavitt,  suggested  a greater  where  being  prompt  problem.  financial skills  are  in t h i s  indicators  of that  patient  dramatic,  referrals  incongruent  prompted  pain  more  psychopathology  pain  patients,  have  consultation  at  problem  acknowledged  of  behavior  of t h e  pain  pain  may  no d o u b t ,  inappropriately  providers  incongruent severe  are  psychological  the  'reality'  patients  psychological  to c o n c l u d e  health  distress  pain  These  clinicians  rehabilitation  patients.  Incongruent being  to  has  or that  target been  in  a  108 Cognitive/Behavioral This  was  the  behavioral  trials  patients.  Reports  experience pain  during  induced  provide  to  an  acute  activity  1983)  in  the  in  actual  al.,  of  using  an  important  and  cognitive  style  and  cognitive-  assessment  of  CLBP  standardized  investigation  coping  of  pain  between  recall  relatively  cognitive-behavioral  Pain  use  immediate  reliably  This  the  discriminators  Further, be  similar  assessment  experimental than  did  of  cognitive  accentuate,  Pain  specific  session  activity  the  correlated.  may  immediately  pain  with  of  supports trials  types  of  cognitions  easily  coded  the  and  potential  (Turk,  discriminate  et a l . ,  produce cued  et  al.,  1983)  subgroups  revealed  self-report,  over  a longer  cognitions  exception  of  of  were  be  roughly  divided  exacerbate,  or  amplify  pain  pain.  Questionnaire, categories, coping  as  Principal well  appeared  strategies,  to  as  different of  results.  cognitive  different  kinds  retrospective  not  made  component  the  suggest  self-efficacy  three  that  and  operations,  of  Interview  main  of  in  cognitive  between was pain  only related  those  those  analyses  Structured  this  events  which  two t y p e s :  sensations  In  measure  correlated  h e r e was into  types  Conceptually  catastrophizing  could  lessen  different  time f r a m e .  assumption  and  1981),  recall  An  activity  attenuate  methods  pain-related  measures,  moderately  (Merluzzi  a structured,  cognitive  kinds  Strategy  suggested  unstructured  reflecting  for  et  data.  previously  cognitive  these  report  Chronic  patients.  study, an  to  most  can  A s s e s s m e n t of  investigation  cognitions  pain  sample  As of  the  in t h e  presentation.  utility  both  CLBP  of  meaningful  clinical  first  (Turk,  were  clinical  Trials  that  that the  Coping  Schedule  categorizations: and  catastrophizing.  109 While f i n e r  theoretical  categorizations The  may  lack  of  between  Sternbach,  1984).  at  not  mean  have  all  no  similar  to t h e  the  during  difference  in  pain  induction  task  behave  experimental has  been  pain  levels  1985).  Perhaps during  pain,  it  than  for  activity  veridical  evaluation.  It w a s differ  in  pain  demonstrating here  may  be  the  also  the  on  more  that  the  that  perseverance.  to t h e  ceiling  or  levels  incongruent The  effect  lack of  are  closer  usual  pain  the  of  may  of  no  of  the  pain  pain  provide  is  how  to intensity. of  It  previous  (Eich  their  CLBP  pain  et  al.,  own a  groups  more  would  patients  a significant  four  of  be  recall  elevated  report  different  was  during  chronic  are  trial  there  kinds  exacerbation's  exaggerate  peoples'  the  different  Strategy  in  which  does  results  sampled  important  is  situations  It w o u l d  acute  pain  This  pain  though  Coping  patients  acute  these  groups.  (cf.  pain.  reported  during  intensity  the  As  on-going,  to t r u s t  with  such  to c o g n i t i o n s  tonic,  pain  of  even  exacerbations,  hypothesized  less  situation the  pain  experimental  cognitive/behavioral  tolerance,  due  is  specific  reflect  experimental  groups  sampled  what  is d i f f i c u l t  cognitive  pain  reported  example,  current  that  may  chronic  situation.  between  acute  and  in t h e  correspond  to t h o s e  measures  manifestation  pain  if c o g n i t i o n s  or  when  Since  acute  closely  shown  argued  back  more  demonstrable.  pain  chronic  tolerance  see  Questionnaire. people  the  pain  more  to the  possible,  in t h e  cognitions  different  cognitions  to  been clinical  that  are  empirically  induced  It h a s  relationship  interesting  be  acute  however,  demonstrate,  back  not  correspondence  differences  not  discriminations  minute  difference  time  limit  no imposed (n=42)  on  exposure  tolerated  difference it m a y  s e n s e of was on  been  that  the  so  pain  showed  presentation.  situationally  four  direction.  may  have  task, that  of  apparatus,  of  Alternatively, as  to  was  Rather  than  actual  more  a high  as  pain  reflected  important.  in  ratings  of  In t h i s  regard  it  less  than  expressed  how  their  pain  tolerance!  behavioral  (cf.  with  1  minute  Perhaps  Wolff,  performance  association  a  tolerance,  tolerated  dimension  preclude  limit t h e r e  the  whom  orthogonal  50%  with  spontaneously had  since over  Even  tolerance,  been  both  they  is a n  specific  pain  minutes.  patients,  tolerance/endurance pain  pressure  perception  that  two  pressure  performance  full  expected  control,  noted the  the  in t h e  have  to t h e  pain  1984)  on  this  to task  is  pain  presentation.  Conclusions CLBP symptom with  patients  report  pain  and  experiencing and  as  pain.  patients  and  displayed  more pain  acitity  and  treatment  by  ability  the  behavior  efficacious  in t h e i r  ability  in  dysfunctional  involvement  incongruent  pain  physical  pain  (surgical  was  pain  these  limitations  the  in  pain  as  variables and  in  cope when  more  mobility. of  the  incongruent  appeared  avoidance  TNS,  to  distressing  While  evidenced  condition.  interventions,  more  criteria.  to  and  catastrophizing  also o b s e r v e d  activity  contribute  back  pain  patients  behavior,  possibly of  illness  to e v a l u a t e  to c o n t r o l  may  incongruent  less  to e n g a g e  a worsening modalities  be  tendency  greater of  to  affective  relative  a function coping  A  more  identified  pain  displayed  appeared  appeared  having  patients  who  depression to  be  Defective  physical  Physically-based physiotherapy)  may  in fail  for  pain as the  incongruent  related  having  cognitive  effective  monitor  pain  in  research  should  facilitate  the  patients  and  being.  patients  activity.  a 'psychological  incongruent  in t h e  pain  pain  a way  whether of  a greater  the  conceptualized and  ability  associated  to  level  of  pain  physical  and  as  alter patients  identified  having  interpret  distress.  management  not  these  patient  cognitive/behavioral  effective  do  conceptualize  perhaps  be  the  interventions  than  strategies  to a t t e n u a t e  development foster  Rather  should  coping  address  these  disturbance'  criteria  u s e of  as  deficits and  Further  interventions skills  by  in  psychological  can  these well-  REFERENCES Ahles,  T.A.,  control  Blanchard,  of  pain:  stimulus. 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C.J.,  Morris,  low-back 9,  64,  back  187.  289,  & Main,  of  Pain,  C.P.  low  D.M.  approach  signs:  Journal,  G.,  Behavioral  conditioning,  nonsurgical  Psychological  22,  Operant  Rehabilitation,  treatment An  to  50,  Psychological  & McCreary,  Hendler,  Bircher,  disorders.  (1984).  N.H.  Medicine,  C ,  of  chronic  Psychology,  therapy.  and  (1982).  (1982).  Symptoms  empirical  Journal  for  behavior  cognitive  Medicine  therapy  II.  response  G.,  An  progressive-relaxation  review.  Predicting  Hospital  group  (1982).  pain:  G.  (1985).  construct.  Clinical  J.,  Diagnosis  Waddell,  and  Robinson,  In  Waddell,  A  and  patients.  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Psychological  of  Annals  Bulletin,  1008-1044.  Weisenberg,  M.  (1980).  Academy  of  Science,  Weisenberg,  M.  (1984).  Melzack  (Eds.),  The  regulation  340,  pain.  of the  New  York  102-114.  Cognitive  Textbook  of  aspects pain.  of  pain.  In  Edinburgh:  P.D.  Wall  &  R.  prediction  of  Churchill  Livingstone. Wilfling,  F.J.,  Klonoff,  demographic, outcome  of  Research, Wilse, as low  L.L.,  spinal 90,  & Kokan,  orthopaedic fusion.  P.  factors  Clinical  (1973).  Psychological,  associated  Orthopaedics  with and  Related  153-160.  & Rocchio,  predictors back  and  H.,  of  P.D.  success  syndrome.  (1975). of  Journal  Preoperative  chemonucleolysis of  Bone  478-483.  -  134  -  and  psychological  in t h e  Joint  treatment  Surgery,  57,  tests of  the  Wing,  P . C ,  analysis  Wilfling, of  disability  Compensation Wolff, In  B.B. P.D.  Wooley,  Wall  S . C ,  model  of  Board,  (1984).  Churchill  F.J.,  & Kokan,  following  & R.  lumbar  Vancouver,  Methods  of  Melzack  P.J.  (1976).  Comprehensive  intervertebral  fusion.  Workers'  B.C.  testing  pain  (Eds.),  mechanisms  Textbook  of  pain.  in  normal  man.  Edinburgh:  Livingstone. Blackwell, chronic  Psychosomatic  B.,  illness  Medicine,  & Winget,  behavior: 40,  135  (1978).  Theory,  379-401.  -  C.  -  A  learning  treatment,  and  theory research.  Appendix A INFORMATION AND CONSENT FORM  We a r e i n t e r e s t e d kinds  of p a i n  are associated  effects  back  Finally  we want  do  to cope  your 1.  pain  pain.  Complete  For this  back  Move from  react  study,  back  disorders  We a r e a l s o  movement  and  interested  a n d on t h o u g h t s to pain  and what  we a r e r e q u e s t i n g  what  in  what  a n d mood. things  they  25 m i n u t e s  of  to s t a n d i n g your  a standard  index  finger  asks  to s i t t i n g  about  how y o u  cope  and describe  be glad  to laying  down  positions  movements;  pairrtask  and feelings  we will  that  pain;  walking  Undertake  Afterwards,  questionnaire  we videotape  thoughts,  that  where  y o u will  the physical  place  a weight  sensations,  occur.  to d i s c u s s  any questions  you have  about  research. Since  disorders, laboratory, from  them.  how p e o p l e  a short  your  your  the  different  time to do t h e f o l l o w i n g :  while 3.  with  has on p h y s i c a l  to s t u d y  with  with 2.  in s t u d y i n g  we w a n t we also  to f i n d  ask for your  a n d medical  the Back  Pain  o u t how pain  is  permission  examination  data  Unit.  -  136 -  related  to o b t a i n  related  to d i f f e r e n t  back  diagnostic,  to y o u r  back  problem  on  137 All used  for  of  information  research  identified  by  voluntary. f r e e to  the  a number. We w o u l d  refuse  is  independent  or  not will  in  or  stop  of t h e no w a y  Thank-you about  this  this  Pain  for  study,  I agree Back  only.  to  Unit  do  in  strict  copy  of t h i s  Signature:  To  to  ensure  appreciate your  Pain  affect  your  will  be  anonymity,  your  in t h e help  participation  Back  Unit,  whether  If y o u  have  not  hesitate  to call  us.  medical  subject  confidence.  study  information  will  Pain  is  time. you  any  Study  choose  strictly  you  this  to  be  are  study  participate  clinic. further  give  questions  permission  condition  that  this  acknowledge  that  I have  Date:  but  Since  for  form.  and  information  solely  to t h e  I also  and  confidential  cooperation  at t h e  time.  in t h i s  Back  at a n y  treatment  kept all  and  your  release and  provide  Participation  participate  investigation  kept  you  the  to  the  purposes  information received  is a  of  Appendix B COPING STRATEGY QUESTIONNAIRE  The seven  scales,  behavioral of  that of  indicated  with 1.  during  activity  (1983)  and 1  consisted  scale  item on a 7 - p o i n t  scale  where:  or behavioral  during activity  pain;  was "always"  T h e seven  items:  activity  scales  "never" indicated  characteristic  indicated  been  t h e '0'  was  that  characteristic  have  consisted  t h e '3' a n c h o r  was "sometimes"  t h e '6' a n c h o r  of  concerning  Each  pain;  activity  pain;  representative Diverting  each  or behavioral  during  and Keefe  of p a i n .  experience  or behavioral  experience  cognitive  the cognitive  of t h e i r  experience  cognitive  Rosenstiel  the experience  rated  that  the cognitive  their  during  Patients  characteristic  by  6 concerning  activity  6 items.  anchor  described  CSQ  listed  the  of  their  below  along  -  attention:  I count  numbers  in m y h e a d  or  run a song  through  my  mind. I think 2.  of p e o p l e  Reinterpreting I don't  I enjoy  the pain  think  of  doing  things  with.  sensations:  it as p a i n  but rather  as a d u l l  or  feeling. I just  think  o f it as some o t h e r  numbness.  -  138 -  sensation,  such  as  warm  139 3.  Catastrophizing: I worry I feel  4.  Ignoring  ali t h e  like  I just Praying  I can't  pay  any  go on  as  or  to G o d  I have faith for Coping  my  it w i l l  end.  on.  attention if  to  nothing  it.  happened.  it w o n ' t  in  last  doctors  long.  that  someday  there  will  be  a  cure  pain.  self-statements:  I tell  myself  No matter 7.  go  whether  hoping:  I pray  6.  about  sensations:  I don't  5.  time  Increased  how  to  be  I can  bad  behavioral  I try I do  that  it g e t s ,  the  I know  pain.  I can  handle  it.  activities:  around  something  overcome  other  I enjoy,  people. such  as  watching  TV  or  listening  to  music. In a d d i t i o n items were had their  concerning also  over  asked their  pain.  to t h e s e the  seven  scales,  effectiveness  of  to  rate,  on  7-point  pain  and  the  extent  the  CSQ  patients' scales,  to w h i c h  the  also contained  efforts  to c o p e .  amount  they  two  were  of  Patients  control  able to  they  decrease  Appendix C PAIN DRAWINGS  Following of  a human  Ransford  form  depicting  Included  at t h e  top  different  types  of  stabbing,  and  outline  the  symbols. 1.  et  of  pain:  aching  location,  Scoring  the  al.  (1976),  both  the  page  were  numbness,  pain.  was  based  Non-anatomical  pain  front  on  and  5 sets  pins  Patients  distribution,  patients  were  and  localization  given  symbols  needles,  of  pain  an  outline  perspectives.  instructed  type  following  back  of  and  were  representing  5  burning, to  illustrate  using  the  on  the  different  criteria:  as  reflected  in  drawings  that  depict: a.  total  b.  lateral was  leg  pain  whole  leg  considered  c.  circumferential  d.  bilateral  (trochanter  anatomically thigh  anterior  considered  area  and  lateral  correct)  pain  tibial  area  pain  (unilateral  was  appropriate)  e.  circumferential  f.  bilateral  9-  use  of  pain  foot  foot  pain  pain  all f o u r  modalities  -  140  -  suggested  in  instructions  thigh  141 2.  Amplification  or  expansion,  of  pain  as  reflected  radiating  to  illiac c r e s t ,  in  drawings  that  depict: a.  back  pain  perineum  (coccygeal  pain  was  not  groin,  or  anterior  considered  exaggerated)  3.  b.  anterior  knee  c.  anterior  ankle  d.  pain  Excessive reflected  4.  in  explanatory  b.  circles  c.  lines  d.  arrows  e.  excessive  Tendency in  included  Details, described  pain outside  that  notes  around  to  and  on  a specific  written  in  painful the  u s e of  the  pain  the t r u n k ,  head,  neck,  or  in  symbols  to  illustrate  areas.  bodily  examples,  descriptions  areas  global  the  as  areas  depict  on  location  areas  painful  highlighting detail  outline  contain:  painful  demarcating  painful  the  or focussing  drawings  a.  areas  been  drawing  emphasis  the  pain  where  upper  additional  extremities  painful are  drawing.  and  Ransford  the et  al.  weighted (1976).  scores  for  these  criteria  have  Appendix D INAPPROPRIATE  Following brief The  Main  structured seven  and  Waddell  interview  symptom  at t h e  for  criteria  1.  Pain  2.  Whole  leg  pain  3.  Whole  leg  numbness  4.  Whole  leg  muscle  5.  Lack  6.  Reaction  7.  Emergency  of  Scoring patient  tip  any  (1984),  the  that  the  patients  presence  comprise  of  were  assessed  inappropriate  scale  have  been  periods  over  previous  in  a  symptoms.  listed  below:  tailbone  weakness  relatively  to o r  was  of  SYMPTOMS  pain-free  intolerance  admission  to  determined  of  treatment  hospital by  for  adding  endorsed.  -  142  -  the  for  back  back  year  pain  pain  number  of  symptoms  the  Appendix  PAIN  DESCRIPTOR  DIFFERENTIAL  SENSATIONS:  PAIN  Extremely Very  E SCALES  UNPLEASANTNESS:  Excruciating  Intense  Unbearable  Intense  Intense  I ntolerable  Strong  Agonizing  Slightly Clear  Horrible  Intense  Dreadful  Cut  Barely  Frightful  Strong  Miserable  Moderate Slightly  Distressing  Moderate  Upsetting  Mild Very  I rritating  Mild  Unpleasant  Weak Very  Uncomfortable  Weak  Annoying  Faint Extremely  Distracting  Weak  - 143 -  Appendix F EXAMINATION CHECKLIST  Please  check  information  POSTURE Sciatic  at each  list  from Lumbar  blank  column  (  (lateral rhythm  f o r each  ) where  & MOVEMENT:  Abnormal  DURAL  the appropriate  sign  and  complete  required.  POSITIVE  NEGATIVE.  shift)  on  recovery  flexion flexion :(  )  IRRITATION:  Bowstring Tripod Femoral  stretch  Straight-leg  raising  with  crossover Straight-leg  _ raising  to  pain:  Right: (  )degrees  Left:  )degrees  (  NONROOT  COMPRESSION:  NORMAL  ABNORMAL  Motor Sensory  '  - 144 -  ANATOMICAL  145 Reflex Root:(  )  PALPATION:  NEGATIVE  Localised tenderness palpation or  over  to  LI  paravertebral  to  over  S1  and/  muscles  Localised tenderness palpation  POSITIVE  to  sciatic  notch Operative  scars  NON-ORGANIC Superficial  SIGNS: tenderness  Non-anatomical underlying  deep  axial  Simulated  rotation  not  anatomically localised  to  loading  in  straight-leg  raising  distraction  Over-reaction  to  examination  (disproportionate tension,  Please  localised  tenderness  improvement  under  not  rate the  tremors,  extent  verbalization, collapsing,  to w h i c h  this  facial  or  expression,  sweating)  back  pain  problem  based: 1 Entirely organic  2  POSITIVE  structures  Simulated  Marked  NEGATIVE  3  4 Mixed  5  6  7 Entirely non-organic  is  organically  Appendix G NON-ORGANIC SIGNS  Detailed  descriptions  (Main  & Waddell,  these  investigators,  1.  of t h e n o n - o r g a n i c  1984; W a d d e l l these  TENDERNESS:  signs  et a l . , 1980).  signs  have  been  Inappropriate  are given  Following  described  tenderness  elsewhere  the work  briefly  of  below:  was c o n s i d e r e d  to b e  one of two t y p e s : a.  SUPERFICIAL: light  pinch  region.  A  posterior nerve b.  localised ramus  irritation  felt  over  identifiable thoracic SIMULATION gave being on  to t h e s k i n  the patient performed  formal  with  these  actually  examination tests  being  conditions  Deep  in t h e  been  These  pelvis  were  in f a c t  that  a n d soft  the movements T h e tests  suggestions -  of pain  146 -  to an  were were  to t h e  'bogus'  pain.  were  that  tissues.  a particular  elict  by  to palpation  it w a s n o t . T h e s e  movements  was that  that  to a  inappropriate.  or extended  essentially  lumbar  caused  was not localised  structure,  to a  conforming  may have  tenderness  area,  sacrum,  performed.  where  area  of t e n d e r n e s s  the impression when  in r e s p o n s e  a n d was not c o n s i d e r e d  anatomical  TESTS:  a wide  distribution  a wide  spine,  reported  over  band  NON-ANATOMICAL: was  2.  Tenderness  tests  that  examination tests  were  The  minimized.  based  difference  'simulated'  conducted  was  without  under  a.  AXIAL to  LOADING:  'loading'  down  on  Report  on  the  of  Report  the  patient's  patient's  neck  of  pain  back  spine.  skull  was  low  to  not  pain  The  in  response  examiner  produce  pressed  a weighted  considered  'load'.  anatomically  deviant. b.  ROTATION: pelvis  were  patient not  was  then  to  to  assess  distracted.  simply  particular  an  physical  a finding  based.  examination  and  a.  straight  on  the  leg  the  the  same  shoulders  plane  together.  the  aspect  of  A  was  while test  behind  in  a  Leg  and  while pain  when  physical  their  the  was  root  that  at o t h e r  manner  and  attention  non-painful,  non-  this  consisted  mobility  was  present  was  present times  that  being  was  on  the  this assessed.  likely  only  was  of  throughout  unaware  condition  was  distraction  patient's  was  consistently  the  routine  the  was  patient  finding  to  be  formal  considered  to  component.  LEG  RAISING:  raising  testing  idea  Primarily,  of  while  a non-anatomical  formal  in t h i s  disappeared  STRAIGHT  when  inappropriate  finding  again  aspect  that  'physically'  have  finding  period,  in  feet  basic  non-surprising.  observing  examination  Thus,  The  a physical  the  pain  present.  Distraction  and  with  anatomically  TESTS:  assess  emotional  was  back  rotated  relaxed  considered  DISTRACTION  of  passively  stood  irritation  test  Report  when  procedure,  on the  Marked  distraction, patient's  suggested  improvement  in  as  with  compared  attention  was  a considerable  focussed  psychological  148 element  limiting  ostensibly position REGIONAL motor body  SLR.  testing  of  the  Distraction  different  patient  DISTURBANCES:  function parts.  involving  The  during  the  Report  of  feature  acomplished  movements  a widespread  essential  was  was  by  SLR  varying  the  test.  altered  region  by  sensory  of  and  neighbouring  divergence  from  accepted  neuroanatomy. a.  SENSORY: in  comparison  typically knee b.  Report  as  WEAKNESS: on  normal  that  with  would  down  could  of  altered  the  involve in  testing  normal, the  by  a  a wide  side.  leg o r t h e  area  This  leg f r o m  weakness  giving  not  be  on  TO  EXAMINATION:  way'  of  was any  a localised  demonstrated muscle  groups  neurological  basis. OVER-REACTION examination facial  that  expression,  sweating.  manifested muscle  as  Over-reaction  disproportionate  tension,  the  pattern.  motor  explained  over  unaffected  entire  a stocking  Abnormal  sensation  tremor,  during  verbalisation,  collapsing,  and/or  Appendix H PHYSICAL IMPAIRMENT INDEX.  Following was  calculated  of  variables  1.  Pain  2.  3.  4.  based  used  a n d Main  on t h e i r  to calculate  pattern:  b.  Back  and referred  c.  Root  pain  pain  a.  Recurring  b.  Chronic  Previous  fracture:  a.  Transverse  b.  Wedge  c.  Fracture  Previous  b. c. Root a.  leg pain  pattern:  process  compression  back  dislocation surgery:  None One More  than one  compression: None  -  149 -  a Physical  weighted  impairment  Low back  Time  (1984),  clinically  a.  a.  5.  Waddell  have  Impairment  chart.  been  Index  T h e breakdown  listed  below:  6.  b.  Doubtful  c.  Definite  Range  of  motion  measures:  a.  Lumbar  b.  Straight  leg  raising  left  c.  Straight  leg  raising  right  Actual  weights  variables  classes  reported  in W a d d e l l  correction  factors  characteristics  in  and  to  flexion  for  the  for  the  and  different range  Main  (1984).  allow f o r  particular  of  the  (checked  (checked  motion These  distraction)  with  manifestations  weights  have  also  between  categories.  distraction)  within  measures  interactions  diagnostic  with  these been  incorporate  various  Appendix VIDEO  1.  Set  up  camera  position 2.  Make the in  3.  the  within  camera  Make  from the  sure  4.  Arrange  5.  Show and on  cue  the  the  and  the  next  Take  cards  bed.  wall  is  patient.  doorway  is o n ,  should  curtains  It is  to t h e  amp  is o n ,  to t h e V i d e o be  are  usually  set f o r  closed  best  to  room.  power  connected  camera  and  in  back  you  should  Walking  the  random  where  Sitting  room f r o m  of  camera  amp  INSTRUCTIONS  in  and  and  indoor  and  that  sit,  stand,  that  Audio  lighting.  the  lights  in  on.  patient  walk.  at t h e  The  shades  room a r e  5 meters  is o n ,  connectors.  the  6.  OBSERVATION  sure V C R  cable  I  order.  want  be on  shotrld  be  them the  Patients  and  repeating  keep  activity.  a pre-video  Standing rating  of  bed.  done  camera.  to  at t h e  should this  should current  Reclining farthest  be told  done  pain  should  be  end  the  to walk  sequence  be  recline,  until  next  intensity  of  to  told  to the using  the to  do  bed. the  DDS  scales. 7.  Start  VCR  and  instruct  patient  is m o v i n g  to  through  look  turn  away  from  from  the  patient one  camera  patient  and  -  to  position  do f i r s t  to a n o t h e r  eyepiece. watch  151  -  activity.  your  Simply  there  Unless is  let c a m e r a  stopwatch.  Do  no  need  roll, not  talk,  smile,  joke,  contact,  or  break  movement  interact eye  you  will  need  to e n s u r e  requesting  position  on  the  activity  Take  a post-video  DDS  scales.  After  session  verbally  the  record  is o v e r , date  is  to o b s e r v e  patient  through  a good  then  of  stop stop  picture  there  the as  rating  makes  patient  changes on  If p a t i e n t  When  that  order  videotape  patient.  contact.  (eyepiece)  Record  with  is  no  is t a k e n . interaction  experimental  these  are  current  tape, the  involved  eye in  viewfinder Other with  assessment  than  patient.  record  and  performed. pain  replace tape.  intensity  lens  cap,  using  and  the  record  Appendix J PAIN BEHAVIORS  Following coded  Keefe  and Block  the  videotapes.  from  Ambulatory/Postural 1.  Guarding: while  Abnormally  recording  The  from  during  using  stationary  the behaviors  described  below  Behaviors  changing  patients  (1982),  canes  or during  rigid  movement  (i.e.,  pacing.  and cannot  sitting,  be hesitant  or  to a n o t h e r  or walkers,  (i.e.,  must  interrupted  one position  a shift)  position  movement  stiff,  standing,  It  when  includes  occur or  during  reclining).  or interrupted,  not  merely  slow. 2.  Bracing:  Position  supports  and maintains  an a b n o r m a l  It c a n n o t  occur  movement  and  be held  must  frequently sitting, walker  not  during  is t h e g r i p p i n g  while  What  wall  the shifting  -  extended  distribution  (i.e.,  pacing,  seconds.  a table,  appears  guarding.  against  fully  of t h e t h e e d g e  be against  standing.  is t e r m e d  leans  simply  an almost  f o r at least t h r e e  b u t can also  movement patient  in w h i c h  of w e i g h t  153 -  weight.  shifting),  It m o s t while  e t c . , or cane  to be b r a c i n g  no o t h e r when  of  of a b e d  It c a n o c c u r  using  limb  with  support,  standing.  or  during  a l e g if b u t is  a  154 3.  Rubbing:  Touching,  which  includes  three  seconds).  behind  the  occur  available, inferred Facial 1.  any  not  must  rub  from  hips,  is  the  or  holding  and  hands  of  patient's  (for  folded or  the  a "sit".  recorded  the  hands  movement  be t o u c h i n g  during  legs  patients'  the  interval  rubbing a  affected  area  a minimum  of  in  pockets  in  lap.  can  non-movement.  affected  If a c l e a r  if t o u c h i n g  It  or  can  area view  be  to is  be not  reasonably  position.  Expressions Grimacing: include: corners  It o f t e n Sighing:  Obvious Furrowed  of  resembles  2.  but  palm(s)  considered  back,  It i n c l u d e s  back,  during  Patients'  low  rubbing,  mouth  brow,  pulled  wincing.  occurs  facial  back,  a  by  shoulders  Cheeks  be  expanded.  other  paralinguistic  of  eyes,  clinched must  pain  be  which  tightened  teeth. alert  to  It  may lips,  often  catch  this.  shift.  exaggerated  accompanied may  narrowed  Observer  during  Obvious  expression  first  exhale  of  rising  and  then  moans  or  Includes  vocalizations.  air,  usually falling. groans  and  Appendix K VIDEO SCORING PREPARATION  1.  Dub over using tape  the first  the V C R  with  "OBSERVE",  then  10 s e c o n d s  always  start  patient  to do t h e f i r s t  the observation  will o c c u r  able  to o b s e r v e  you  should  tape  then  t i m e o u t 20 s e c o n d s you reach  shifting  start  from  comes o n .  Score  tape:  first  observer.  3.  Score  tape:  second  observer.  -  155 -  point  If y o u d o , intervals  one position  d u b b i n g -within  2.  say " R E C O R D Note: that  then  2",  10 t o 90 s e c o n d s  time  y o u told  the  position  y o u will  to another.  say  Do not  most of t h e and  Let  time o u t  t i m e o u t 10 s e c o n d s  then  by  dub.  say " O B S E R V E " ,  at t h e e x a c t  Record  is d o n e  to audio  "RECORD-20".  activity.  during  This  connected  say " R E C O R D - 1 " ,  f o r 10, e t c u n t i l  changes  of t h e t a p e .  microphone  r u n f o r at least  20 s e c o n d s ,  out  10 m i n u t e s  not be  Thus,  of t h e time t h e  Appendix L PRESSURE PAIN PROCEDURE  Instructions finger  to P a t i e n t s :  of y o u r  (dominant)  I will  place the weighted  cause  a sharp  finger of  the pain  lists will  as l o n g  pain  that  best  y o u to place  down  flat  I will  to time  by  a s k y o u to rate  you tried  the thoughts  to keep  index  piece  (point).  which  on the  to t h e w o r d s  the sensations.  about  the  finger  the weight  pointing  describes  plastic  on y o u r  T r y to keep  questions  to y o u while  like  on this  wedge  there.  time  a s k y o u some  occured  hand  as y o u c a n .  from  (point)  I would  will  your intensity on  these  Afterwards, and feelings  the wedge  on y o u r  I that  hand.  Steps: a.  Place  patient's  cushions b.  finger  to e n s u r e  Put the weighted  in t h e p r e s s u r e  a comfortable,  wedge  down  apparatus.  snug  on t h e i r  Adjust  fit. finger.  Start  timing. c.  A s k f o r an immediate thereafter the  d.  on the D D S word  experimental  When and  the patient have  rating  assessment requests  the patient  and then lists.  - 156 -  Record  30  seconds  the ratings  on  sheet.  termination,  immediately  pain.  every  stop  the  watch  rate t h e intensity  of t h e  If t h e  patient  remove At  the  Begin  that tape  not  lifted  the  weight  after 4  minutes,  weight.  termination,  mark  has  will  tell  patients  disappear  recorder  and  in  that a few  SISP.  the  wedge  minutes.  will  leave  a  Appendix M STRUCTURED INTERVIEW SCHEDULE FOR PAIN  The  interview, ONE  adapted  from  OF THE THINGS  STUDY  IS W H A T  ABOUT  WHILE  WE A R E  PEOPLE  TO  THOUGHTS,  FEELINGS  WHILE  I WOULD  ASK A  C A N . OK?  THE  FEW M O M E N T S  TO  YOUR  REMEMBER AT  THAT  RANDOM,  TRY  TIME,  TO  WHAT  EVEN  AND EVEN  IF T H E Y  each  of t h e s u b j e c t ' s  briefly  when  the subject  of  three  items,  the following  subject  reports  pauses.  reflecting  ones, having  at t h e t a p e - r e c o r d e r " ,  items  a n d t h e last done  THAT  -  FINGER DETAIL  BACK WAS  YOU  TO AND  AS  DURING APPLIED  CAN AND  WERE  FEELING  BRIEF  paraphrasing  If t h e s u b j e c t some  item.  ANY  OR  TRIVIAL.  in t u r n ,  away",  158 -  YOUR  THOUGHTS  FINGER.  OCCURRED  THINKING  SEEM  something  "looked  ABOUT  EVERYTHING  the first,  THINKING  T H E WEDGE  YOU WERE  THIS  ON THEIR  YOUSELF  BEFORE ME  IN IN  AND  TO  as f o l l o w s :  IN A S M U C H  IMAGINE  IF Y O U R  Reflect  than  ANYTHiNG  ANSWER  TELL  ABOUT  FEELING  FEW Q U E S T I O N S  JUST  FINGER.  begins  INTERESTED  WAS A P P L I E D  YOU TO  YOU  (1978),  IS P R E S S I N G  OR  PRESSURE  LIKE  ARE  T H E WEDGE  I AM GOING  YOU  Genest  them  has p r o v i d e d  representative  At any point,  non-cognitive "tapped  more  sample  if t h e  ( e g . , "looked  my k n e e " ) ,  respond  159 with,  "WHAT  WERE  tape-recorder",  YOU  THINKING  etc.).  Prompt  if  WHILE  YOU...  necessary.  ( l o o k e d at  See  note  1.  the  Then  ask: IS T H E R E Repeat that  this  question  occurred ONCE  OF  if  until  before  THE  KIND Prompt  ANYTHING  the  the  WEDGE  subject  reports  p r e s s u r e was  WAS  FEELINGS  necessary.  ELSE?  PLACED  AND  Then,  applied.  ON  YOUR  THOUGHTS  repeat  no  until  DID  new  cognitions  Then  proceed:  FINGER, YOU  WHAT  HAVE  no f u r t h e r  THEN?  responses  are  given: AFTER And,  until  THAT,  no f u r t h e r  IS T H E R E When  subject YOU  ON  YOUR  WHAT  WERE  ELSE  JUST  DO  are  can  recall  ask:  no f u r t h e r  THERE,  GIVING  YOU  reported,  ELSE?  SITTING  WITH  REPORTS  RECALL  FEELING,  until  1:  anything  YOU  BEFORE the  IS T H E R E  very  they  REMEMBER?  information:  THE  WEDGE  FROM  TIME  EXPERIENCING,  IMAGE--EVEN  PRESSING TO  TIME,  ANY  FLEETING  OR  RANDOM?  ask:  WHAT  NOTE  DO  YOU  cognitions  FINGER,  THOUGHT,  Again,  CAN  ANYTHING  reports  AS  Finally,  WHAT  briefly  or  THE  subject  WAS  reports  no  subject  a question with  THINKING  WEDGE  ANYTHING  If t h e when  REMEMBER  ABOUT  OR  FEELING  LIFTED? new  cognitions,  repeat:  ELSE?  (1) is  apparent  reports posed,  being or  difficulty  (2) in  u n a b l e to responds either  recall to a  question  formulating  a  160 response or of  the  remembering,  WERE  HOW W E R E  YOU YOU  WAS  THERE  CAN  YOU  If t h e s e  THINKING  with  a question  such  as  one  ANYTHING  TELL  ME  prompts  in  by  If it is  2:  during subject  detail  the  pain  by  of  YOU  PAIN  PRESSURE  be  ON?  THAT? to  elicit  assist  specific  more  by  a statement  a report  of  a cognition  is  simply  task  during  or the  such  interview,  a  minimal  "painting  a  picture"  of  made  the  during  that  something the  situation. the  occurred that  ambiguity  the should  as:  ABOUT  THAT  THEN  TASK)?  clarification  than  aspects  whether  THINKING  additional  then  describing  a question  WERE  Request  insufficient  pressure  is t h i n k i n g  resolved  to  GOING  ABOUT  subject,  unclear  is m e a n t  ELSE  MORE  are  the  more  ABOUT?  FEELING?  response from  interview  be  prompt  following:  WHAT  NOTE  then  if  necessary.  (DURING  THE  Appendix N SISP SCORING KEY  The each had  spontaneously  reported  of the 6 categories the following  cognitions  from  Genest  were  coded  (1978).  on a 5 - p o i n t  T h e 5-point  No o c c u r r e n c e  of t h e thought/feeling  category  2.  Some  of t h e t h o u g h t / f e e l i n g  category  3.  At  4.  Multiple  elements  one clear  5.  occurrance  examples  category  or  that  of t h e t h o u g h t / f e e l i n g  implication  was more than  Implication  rating  for  scale  anchors:  1.  least  scale  that  this  category  thought/feeling  an isolated  cognitive  the thought/feeling  category  event predominated  mental  activity The 1.  categories,  adapted  Dissociates a.  Pain  from From  Statement one  part  statement or  Genest  were  defined  as  follows:  Self  o r implied  meaning  of t h e b o d y that  (1978),  this  with  that  the pain  t h e implication  limitation  made  is l i m i t e d  or  t h e pain  to  explicit less  aversive  bothersome. Examples: that  "My mind  was h u r t i n g " .  comfortable finger  was calm; "I j u s t  thought  I w a s in t h e r e s t  wasn't  going  -  161 -  it w a s j u s t  my  about  how  of my b o d y .  My  to b u g t h e rest  of m e " .  finger  162 b.  Report  of  "Objectively  objectively  observe  some d e t a c h m e n t  was  "I  about  the  An  expression  physical  or  "The  bothersome". something Report  of  on the  the  part  not  the  pain,  fingers".  throbbing and  with  salient).  to feel  in t h e s e  finger  from  is  to  and  feeling  sensations,  to "I  the  it". either  psychological.  Examples:  d.  at my  painful  trying  going  distance  attempting  affect  sensations,  looking of  I was  was  or  in t h e  negative  think  what  feeling  numbness; c.  sensations  (i.e.,  Examples: think  observing"  not  "It  seemed  seemed  irrelevant, thinking  Examples: nothing  pain  was  my  away,  a r m was  thinking  about  not to t h i n k " .  coming,  not  really  experiencing  unimportant".  or  "I t r i e d  far  no  input,  "nothing".  "It f e l t  just  sort  like  of  an  emptiness". 2.  Relaxation Reference state,  to  either  being  physically  Examples: deep  3.  "I f e l t  breath  awhile".  drowsy,  and  relaxed,  or  at  ease,  or  in  a  similar  mentally.  calm,  just  took  felt  the  tension  "I j u s t  tried  to  relax".  image,  either  it e a s y " . drain  away  "I t o o k  a  for  Imagery Report does  of  not  affect.  an  include  pain,  or  from  memory  includes  pain  or  fantasy,  but  without  that negative  163 Examples: finger  and  c a r e of trip 4.  of  any  attempt not  for  a.  of A  thought  to  ignore  the  Control  I had  a hospital "I w a s  bed  smashed  being  planning  my  taken  my  summer  details".  image  "I w a s  going "I  that  sensations  related  attetion  over  to t h e  from  the  pain,  pain,  or  that  above).  my  appointment  my  thoughts  was  tapping  about  if  deliberate the  on  schedule  the  sounds  my  foot".  then  attempt  to  sensations,  to  some  a  is  not  must or  of  or  felt  able  to  control  painfulness.  it w o u l d  be  possible  it s h o u l d n ' t much".  really  "I f e l t  to j u s t  bother  I could  me;  not it  reduce  I tried".  sensations  experience  could,  degree  me as  sensations,  strategy  or  it;  the  pain  patient  "I t h o u g h t  hurt  extensive  "I  not  (see 3  kept  the  wouldn't  the  distract  corridor".  statement  affect  feeling  Expressed  think  in  that  all t h e  an  Examples:  A  on  of  or  or  tomorrow".  physical  b.  imaging  nurses".  thinking  constitute  from Sense  lying  nice  Examples:  5.  was  just  Distraction  Report  does  by  home,  Non-Imagery  an  "I w a s  or  use  or  some  the  attribution  painfulness,  action  of  the  sufficient: be  strategy  explicit  deliberate  use,  or  or or  of  the  patient.  intention implicit  or  to  some  Just  the  affect  of  to  variation  awareness  (e.g.,  statement  technique  of use  of  the  determined intent).  164 Examples: my  "I w a s  finger,  about  just  because  something  it".  "I  to  toes...and  pinch  that  would  help".  that  it  hurt  turned head,  and  can  myself  then  when  my  your  right  I looked  when  was  at  this  that  on  conscious  feelings wiggle  leg.  my  seemed  away  song  it d i d n ' t  in  I thought  it it  I looked  singing  I noticed  you're  on  "When  "I  to c o n c e n t r a t e  increase  distract  more than  away".  not  sometimes  you  started  trying  so I  in  my  bother  me  as  much". BUT "I  NOT:  was  "I  bored  was  and  just  looking  began  around  thinking  the  about  room".  a book  I'm  reading". A his  statement  that  reactions  the  patient  to t h e  sensations  he c o u l d  persevere  aversive  stimulation.  Examples: tolerance could  control  of  of  'You've  got  "I  think  pain? to  to t h e  reactions  Examples:  take  to  was  to  or  felt  able to  could  this.  I've  it's  some  that  take  control is,  tolerate  got  a  a snap".  it w o u l d  I could  use  or  experienced,  pain,  myself--that  attempt  reactions  I can  pain,  a bit  deliberate  affect  for  control  what's A  despite  "Oh  could,  the  good  "I f i g u r e d  be  painful,  it  anyway".  strategy  or  technique  or  the  attribution  some  of  the  patient.  concentrating  keep  it o n ;  on  you've  saying got  to  to keep  I  but  sensations, action  that  to  of  myself, it  on,'  165 and  gritting  pinching stay  6.  my  and  Indication  of  I was  that  being  and  "I  so  kept  my  anything".  by  I could  in  and  was  able  how o t h e r s  to  had  longer",  being  stop  lip  "I  about  me s t a y  control  knew  biting  thinking  made in  Example: I just  teeth,  leg--doing  because  done, e.  my  able to  whenever  terminate. I wanted,  going".  Catastrophizing a.  An or  expression  of  "worrythoughts" Examples: to my an  "I  electric  anxiety,  about  was  finger".  thought,  b.  fear,  was  thinking  that  there  might  or  something  hurt'".  damaged  if  unpleasant patient attend  feelings.  thought to  escape  or  from  thinking  I  else  such  .  or  about "I  to (a)  little o t h e r  events  my  be  "I  pain"  (as  arm  might  or  a be  other  a statement  than  (b)  or  the  pain,  reference or  to  to  that or  the  could  not  pain,  attempts  to  both. the  anything couldn't  hate  pain  feelings,  for  there".  happen  long".  drawn  else;  "I  in  thought  Either:  "Except  pain". "  or  to  unpleasant  Examples:  the  of  anything  discomfort,  "I  I stayed on  outcomes. to  cognition).  focused  affect,  going  reported  Attention  dire  negative  was  will  of  other  what  current This  possible  afraid  "I  or  pain,  else".  I wasn't "All  concentrate  really  I could  on  feel  anything  was  166 Examples: starting from  to  the  you  "It's  really  bug  about  about  i t . . . It w a s at  Termination thought  "I  I'd  myself, taking of to  no  herself  or  was  trying  away  steady,  thinking  I should  not to  think  When I  way  got  mentions  to  a little could  I was  longer'".  I stand  encouraging  I just  it...'I  "It  was wish  to  I could  stay  crossed  didn't. . .  it o f f ' . . . I w a s keep  a  wondering, "I  myself  it o f f " .  but  (as  stay).  through,  to  having  not t e r m i n a t i n g  decision  to t a k e  'You've it o f f  to g e t  me m o r e . . .  patient  to t a k e  it o f f ,  like  in". my  thinking,  saying  to  it o n . . . I f i g u r e d  I'd  be  soon". control  over  sensations,  painfulness,  or  sensations.  Examples:  "It  from  concentrate  it)".  long  wanted  to t a k e  'God,  feel  I stay  it o u t ' . . . k e p t  mind  reactions  The  the  how  really  Indication  "All  should  was  was  hurt".  a resolved  thinking, take  bothering  termination  Examples:  pain  t h i n g s . . . I was  thoughts.  not  Well,  it  "I  n o w . . . It  trying  The  hard".  other  it,  about  conflict,  again...  it w a s  think  looked  me  me t h e r e . . . J u s t  thought  know,  bugging  a lot o f  (the  the on  pain)  it".  pain  patient's  "I  didn't  attempt  to  distract  work.  I  couldn't  wondered  anyway  (despite  whether attempts  I would to  control  


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