MANAGEMENT OF PATIENTS WITH CHRONIC PAIN

MANAGEMENT OF PATIENTS WITH CHRONIC PAIN

MANAGEMENT OF PATIENTS WITH CHRONIC PAIN Edited by STEVEN F. BRENA, M.D. Department of Rehabilitation Medicine and Anesthesiology Director, Pain Control Center STANLEY L. CHAPMAN, Ph.D. Department of Rehabilitation Medicine MTP!:iUMITED Intern.ational Medical Publishers

Published in the UK and Europe by MTP Press Limited Falcon House Lancaster, England Published in the US by SPECfRUM PUBLICATIONS, INC. 175-20 Wexford Terrace Jamaica, NY 11432 Copyright 1983 by Spectrum Publications, Inc. Softcover reprint of the hardcover 1 st edition 1983 All rights reserved. No part of this book may be reproduced in any form, by photostat, microfilm, retrieval system, or any other means without prior written permission of the copyright holder or his licensee. ISBN-13: 978-94-011-6313-2 e-isbn-13: 978-94-011-6311-8 DOl: 10.1007/978-94-011-6311-8

Preface This book has been written for the general health care professional, from every medical and paramedical specialization. Because pain is the most common factor driving patients to seek professional advice, it is likely that every physician, psychologist, and therapist has been clinically exposed to the difficulty and the frequent frustration of dealing with people in pain. All of them may find in this book some explanations for their puzzles and some updated information, which usually are published in specialized journals not ordinarily read by the general practitioner. Actually the book has been addressed to professionals at two different levels of general practice. At one level is the busy practitioner who treats most patients with' 'acute" pain, and who may use this information in daily practice to prevent the onset of chronic pain; a common effort from all professionals currently is needed to curb the "epidemic" of chronic pain in the United States. At another level the book has been addressed to the practitioner who may have a more intense desire to become involved in the actual management of chronic pain patients. The book is roughly divided into three sections: the first six chapters deal with definitions and concepts of pain, and with basic information about the neurophysiology and the psychology of pain. Chapters 7 and 8 describe in some detail certain pain syndromes most commonly seen in general practicce. In these two chapters, the material has not been ordered according to traditional etiologies. but rather according to pain mechanisms; this approach affords a clearer understanding of the physiological factors underlying clinical phenomena. The second section (Chapters 9, 10, and 11) describes the diagnostic process in pain problems; again the material is not presented according to traditional etiological diagnosis, but rather it describes a comprehensive pathological, psychological, and operational process for the evaluation and the classification of chronic pain states. The third section (Chapters 12-21) critically reviews treatment modalities presently available for management of chronic pain. Chapter 22 has been added to provide health practitioners with a brief insight into the process of law for pain-disabled patients, which often becomes intertwined with general practice and affects the behaviors and the health of patients involved. Many data are presented to support the points that have been made; the bulk of evidence from the literature has been "filtered" - so to speak - to extract the v

vi CHRONIC PAIN pertinent facts and some classical "pearls" of medical information, without overloading the text with excessive references. Considerable information also is provided through the clinical and research findings from the Pain Control Center. The core of the message contained in this book in some ways may be shocking to the general practitioner; many cases of chronic pain represent a veritable "sensory" disability, not dissimilar in neurophysiological and psychological mechanisms from the motor disability of patients with central injuries impairing the musculoskeletal system. The editors wish to thank the contributors for their efforts in pouring out into their respective chapters a knowledge distilled from their clinical and academic experience. A circular, comprehensive vision of the complexity of pain could not have been achieved without their valuable cooperation. Grateful thanks are also addressed to the secretaries of the Emory Pain Control Center, Edna Davis and Leigh Tinker, who spent so much overtime in typing and retyping the manuscript; without their faithful cooperation, it would have been hard to meet the challenge of writing a book. Finally, a warm thanks should go to the members of our own families, for their loving patience and understanding during the long evenings and weekend hours spent in the solitude of the office, reading, writing, and editing. Stanley L. Chapman Atlanta, 1982

Table of Contents Preface Contributors Chapter 1 The Mystery of Pain: Is Pain a Sensation? 1 Chapter 2 Pain Control Facilities: Roots, Organization, and Function 11 Chapter 3 The Neurophysiology and Taxonomy of Pain 21 Benjamin L. Crue, Jr. Chapter 4 Endogenous Opioid Peptides and the Control of Pain 33 Kenneth V. Anderson Chapter 5 Pain and Emotions 47 Richard H. Morse Chapter 6 The Role of Learning in Chronic Pain 55 Stanley L. Chapman Chapter 7 Disuse Syndrome: Fibrositic and Degenerative Changes 63 Rene Cailliet Chapter 8 Causalgia and the Deafferentiation Syndromes 73 Benjamin L. Crue, Jr. Chapter 9 Psychological Assessment of Chronic Pain 85 Stephen J. Johnson Chapter 10 The Medical Diagnostic Process 101 Chapter 11 An Algorithm for Decision-Making in Patients with Pain 111, Stanley L. Chapman Chapter 12 Drugs and Pain: Use and Misuse 121 Chapter 13 Milieu Psychotherapy 131 Richard H. Morse v ix vii

viii CHRONIC PAIN Chapter 14 Behavior Modification 145 Stanley L. Chapman Chapter 15 Relaxation, Biofeedback, and Self-Hypnosis 161 Stanley L. Chapman Chapter 16 Acupuncture: Oriental Teaching and Western Findings 173 Chapter 17 Transcutaneous Electrical Stimulation: Use and Misuse 185 Steven L. Wolf, Vaddadi Rao Chapter 18 Nerve Blocks: Chemical and Deep Stimulation Analgesia 195, William D. Hammonds Chapter 19 The Placebo Response 205 James Routon Chapter 20 The Role of the Physical Therapist 211 Bonnie M. Blossom Chapter 21 The Role of the Occupational Therapist 217 Bette A. Groat Chapter 22 Legal Aspects of Pain and Disability 225 Howard I. Grossman Closing Remarks 231, Stanley L. Chapman Index 237

List of Contributors KENNETH V. ANDERSON, Ph.D. Professor of Anatomy Chairman, Department of Anatomy University of Mississippi Jackson, Mississippi BONNIE M. BLOSSOM, R.P.T. Chief Physical Therapist Center for Rehabilitation Medicine STEVEN F. BRENA, M.D. Professor of Rehabilitation Medicine and Anesthesiology Director, Pain Control Center RENE CAILLIET, M.D. Professor and Chairman Rehabilitative Medicine Department University of Southern California School of Medicine Los Angeles, California STANLEY L. CHAPMAN, Ph.D. Senior Associate, Psychology Department of Rehabilitation Medicine BENJAMIN L. CRUE, M.D. Clinical Professor of Neurological Surgery University of Southern California Los Angeles, California Director, New Hope Pain Center Alhambra, California BETTE A. GROAT, M.A., O.T.R. Chief Occupational Therapist Hospital HOWARD I. GROSSMAN, A.B., L.L.B., L.L.M. Administrative Law Judge Decatur, Georgia WILLIAM D. HAMMONDS, M.D. Assistant Professor of Anesthesiology and Rehabilitation Medicine STEPHEN J. JOHNSON, Ph.D. Instructor, Psychology Department of Rehabilitation Medicine RICHARD H. MORSE, M.D., M.P.H. Director, Mercy Hospital Center for Chronic Pain and Disability Rehabilitation Louisiana State University Medical School New Orleans, Louisiana VADDADI RAO, M.D. Assistant Professor of Rehabilitation Medicine Chief of Division, Grady Memorial Hospital ix

" CHRONIC PAIN JAMES ROUTON, M.D. Director, Atlanta Pain Control Center Crawford Long Hospital STEVEN L. WOLF, Ph.D., R.P.T. Associate Professor of Rehabilitation Medicine Atlanta, Georgijl