Over the years, Beyond Pain has compiled an extensive collection of medical research. We have classified each article, and given our own “take” on it, to give you a good understanding of the current research in particular areas. __________________________________________________________________________________________________
Pain & Return To Work
It is natural for some people to become distressed if they stop work because of pain. The consequences of the loss of work can also have major effects on a family’s financial circumstances. Unfortunately, treating health practitioners often fail to realise the importance of returning to work for sufferers of chronic pain. It can be seen as something that is done after the treatments have finished, or when the pain has been ‘cured’. Research shows that the longer a person takes time off work due to pain, the harder it is for them to return. Not just that but the health implications of being off work long term has been compared to the effects of some deadly diseases. Sooner a person gets back to work, better it is for health, wealth and well being.
- Australian and New Zealand Consensus Statement on the Health Benefits of Work Position Statement: Realising the Health Benefits of Work (2011).
Our take: Health practitioner groups are now recognising and supporting the importance of early return to work as part of the rehabilitation process due to the vast health benefits.
- Black C (2008) “Working for a healthier tomorrow: Dame Carol Black’s review of the health of Britain’s working age population,” The Stationery Office, London
Our take: Working is good for us, physically, emotionally, economically and socially. We all need to take a fresh look at the health benefits of work and ensure we all do our part to promote a return to work.
- Bontoux L et al (2009) “Return to work of 87 severely impaired low back pain patients two years after a program of intensive functional restoration,” Annals of Physical and Rehabilitation Medicine 52(1): 17-29.
Our take: A thorough functional restoration program helps to significantly reduce sick leave and increase the number of workers who were at work even 2 years after an intensive program.
- Costa-Black K et al (2009) “Back pain and work,” Best Practice and Research Clinical Rheumatology 24(2): 227-240.
Our take: In general, if safe, return to work is beneficial for recovery and well being. Health care practitioners need to look at this early on following the injury.
Pain, Litigation, Compensation & Return to Work
If you injure yourself at work, you should seek the right advice and be compensated. However, this should not be at the cost of an early return to work which has far more long-term financial and health benefits. The research suggests that Workers’ Compensation claims and litigation that do not encourage an early return to work often results in worsening pain and disability, compared with people with similar injuries/conditions who are not on Workers’ Compensation or have ongoing legal proceedings. The irony of this is that the process that compensates you for your pain can actually end up causing you more pain. Some research also suggests that a promise of a financial windfall could discourage workers from resuming employment after injury. What is most helpful is for an injured worker to utilise the compensation system and focus on getting back to good health and returning to their normal lifestyle irrespective of the level or amount of compensation that they are entitled to.
- Gallagher RM et al (1995) “Workers’ compensation and return-to-work in low back pain,” Pain 61(2): 299-307.
Our take: Although compensation is often awarded on the basis of physical evaluation, the likelihood of receiving compensation is also significantly affected by the level of emotional distress.
- Suter PB (2002) “Employment and litigation: Improved by work, assisted by verdict,” Pain 100(3):249-257.
Our take: Workers who return to work report less pain, less depression, and less disability. Workers who are involved with litigation report more pain, greater depression, and greater disability. Litigation seems to worsen the recovery, employment seems to improve recovery.
- Nicholas MK et al (2003) “Chronic pain, work performance and litigation,” Pain 103(1-2) 41-47.
Our take: Most people with chronic pain are able to work and function normally and therefore complete relief of pain does not necessarily need to be the main goal of treatment. However, litigation (mainly work-related) for chronic pain is strongly associated with higher levels of pain-related disability, even after taking into account may other factors.
- Tait RC et al (1990) “Litigation and employment status: effects on patients with chronic pain,” Pain 43(1): 37-46.
Our take: Working patients report less pain and disability (less down time, less time in bed, less interference of pain with daily activities) than Workers’ Compensation patients. Litigating Non-litigating patients also reported less pain and disability than litigating patients. Litigation and Workers’ Compensation seems to hinder recovery, but it is suggested that litigation may be used as a coping response by patients who are distressed by the adversarial nature of Workers’ Compensation.
Pain & Mood
People may not realise how their thoughts and feelings affect their pain levels. Everything is connected. The mind and the body work together. Research suggests that those who have helpful thoughts end up in a better mindset and actually feel less pain. People in pain who have unhelpful thoughts tend to become angry, frustrated and even depressed experience more pain. It’s not about trying to be positive, but being realistic and having a more helpful outlook.
- Blyth FM et al (2007) “The contribution of psychosocial factors to the development of chronic pain: the key to better outcomes for patients,” Pain 129: 8-11.
Our take: There is growing evidence that psychosocial factors are associated with reporting pain, particularly chronic pain. Moving forward we need have a great understanding of pain, particularly disabling pain, and better interventions, to be used coherently in the workplace or in the community.
- Hummel M et al (2008) “The persistence of a long-term affective state following the induction of either acute or chronic pain,” Pain 140(3): 436-445.
Our take: A negative mindset maintains painful conditions even in the longer term well after the injury or insult has been resolved.
- McCracken LM et al (2005) “A prospective study of acceptance of pain and patient functioning with chronic pain,” Pain 118(1-2): 164-169.
Our take: Willingness to accept you have pain, and to engage in activity despite chronic pain, can lead to healthy functioning, with less medication and better return to work status, for chronic pain sufferers.
- Strand EB et al (2007) “Higher levels of pain readiness to change and more positive affect reduce pain reports – A weekly assessment study on arthritis patients,” Pain 127(3): 204-213.
Our take: 40 subjects were recruited for the study. The results indicate that the subjects with higher levels of readiness to change reported less pain in weeks they also experienced positive effect. The results suggest that a combination of cognitive factors and positive effect is most beneficial in reducing pain levels.
Pain & The Body
Understanding how your body works takes the mystery out of chronic pain. Research shows that there are many chemical changes, biological mechanisms involved in pain, right from the initial injury through to the pain becoming chronic. It is not just a simple pathway from the site of the injury to the brain; we need to consider what happens at the injured area, the spinal cord, and in the brain when we experience pain.
- Ashe M et al (2004) “Tendinopathies in the Upper Extremity: A Paradigm Shift,” J Hand Ther 17: 329-334.
Our take: Traditionally Epicondylitis and de Quervain’s tenosynovitis are common diagnoses made due to the perception that they were due to inflammation. Research now shows that tendons have degenerative areas and a distinct lack of inflammatory cells. Tendinosis and tendonopathies relate to degeneration and therefore therapists should use these more accurate terminologies.
- Banic B et al (2004) “Evidence for spinal cord hypersensitivity in chronic pain after whiplash injury and in fibromyalgia,” Pain 107: 7–15.
Our take: 78 subjects were recruited for the study. Hypersensitivity of the spinal cord can actually cause increased pain in chronic whiplash injury or in people with fibromyalgia. This explains why there is pain in the absence of tissue injury/damage. Abstract
- Bousema EJ et al (2007) “Disuse and physical deconditioning in the first year after the onset of back pain,” Pain 130(3): 279-286.
Our take: A decrease in activity four to seven weeks post injury is not necessarily due to muscle deconditioning, but can be due to a negative attitude and a patient’s perceived physical activity decline. Therefore, we need to address more than just the physical aspects of injury.
- Rodriguez-Raecke R et al (2009) “Brain gray matter decrease in chronic pain is the consequence and the not the cause of pain,” J Neurosci 29(44): 13746-13750.
Our take: 32 patients were recruited for the study. If pain is not control adequately, the brain can shrink (gray matter decreases) as a result of the constant pain messages. However, this does not mean that there is brain damage as this is reversible when pain is treated successfully.
Pain & The Therapist
Treating health practitioners often seek to put labels on what ails their patients and if they can’t, they keep sending patients off to different specialists who may or may not be able to put a label. Sometimes the therapist’s own beliefs cloud their judgement in terms of the most effective treatment. Research suggests that treatment options can vary for the same condition purely because of the doctor’s or therapist’s own fears, assumptions, and their understanding of the condition. One health care practitioner may prescribe rest for back pain because of their own fears and beliefs, and a lack of understanding of pain while another may prescribe gentle regular activity because they have a better understanding. In the end, it is important that the health care professional follows research-backed principles.
- Corbett M et al (2009) “GP attitudes and self-reported behaviour in primary care consultations for low back pain,” Family Practice 26(5):359-364.
Our take: GP’s acknowledge the recommendations to address pain, but differ in the way they treat pain because treatment can be affected by the patient-doctor relationship, which relies on negotiating of mutual perceptions and expectations.
- Coudeyre E et al (2006) “General Practitioners’ fear-avoidance beliefs influence their management of patients with low back pain,” Pain 124(3):330-337.
Our take: GP’s own fears about back pain can affect their ability to follow treatment guidelines, particularly those concerning occupational and physical activities.
- Daykin AR et al (2004) “Physiotherapists’ pain beliefs and their influence on the management of patients with chronic low back pain,” Spine 29(7): 783-795.
Our take: 18 subjects were recruited for the study. Physiotherapists’ own fears and beliefs can influence treatment. Physiotherapists tend to only use their biomedical knowledge to understand pain and give explanations to patients. Pain is much more than this.
- Linton SJ et al (2002) “The back pain beliefs of health care providers: are we fear-avoidant?” J Occup Rehab 12(4): 223-232.
Our take: 60 General Practitioners and 71 Physical Therapists were recruited for the study. The results indicated that there were some therapists with fear avoidant beliefs. Those therapists with fear avoidant beliefs advised patients to avoid harmful movements, believed a reduction in pain was a pre-requisite for return-to-work, and believed that sick leave was a good treatment for pain. Beliefs, clearly contrary to current research.
Pain & Scans
- Boden S et al (1990) “Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation” J of Bone Joint Surg 72: 403-8.
Our take: 67 subjects participated in the study. It’s normal to see bulging discs on spines of people without pain and therefore we must correlate any findings with age and clinical signs and symptoms. We shouldn’t jump to conclusions just on what an MRI scan shows.
- Borenstein DG et al (2001) “The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: a seven-year follow-up study,” J Bone Joint Surg Am 83-A(9): 1306-11.
Our take: 50 subjects participated in the study. Scans cannot predict the development or duration of back pain. Out of 1989 scans, people with the longest duration of back pain didn’t have the worst findings on scans. Therefore there are more than just physical, observable factors to consider.
- Weishaupt D et al (1999) “MR imagining of the lumbar spine: prevelance of intervertebral disc extrusion and sequestration, nerve root compression, end plate abnormalities, and osteoarthritis of the facet joints in asymptomatic volunteers,” Radiology 209(3): 661-666.
Our take: 60 asymptomatic volunteers were recruited for the study. The study found that in people under the age of 50, disc extrusions and sequestration, nerve root compression, end plate abnormalities, osteoarthritis of the facet joints are rare, and therefore may be the cause of pain in symptomatic patients. However, the results are not conclusive.
Pain & Treatment
The research suggests that incorporating education, pacing, exercise and activity, and strategies to change unhelpful thinking patterns are essential components of an effective pain rehabilitation program. The practitioners need to have a thorough understanding of pain and address both psychological and physical factors. The practitioners also need to teach self-management strategies (active therapy) and wean their patients off passive therapy, particularly in the case of chronic pain.
- Arnetz BB et al (2003) “Early workplace intervention for employees with musculoskeletal-related absenteeism: A prospective controlled intervention study,” 45(5): 499-506.
Our take: The management of musculoskeletal injuries should focus on an early return to work and building on functional capacity to yield the best results. Allowing case managers greater access and having meetings with all relevant parties would also benefit.
- Beissner K et al (2009) “Physical therapists’ use of Cognitive Behaviour Therapy for older adults with chronic pain: A nationwide study,” Phys Ther 89(5): 456-469.
Our take: 152 Physical therapists were recruited for the study. Cognitive Behaviour Therapy (CBT) is a proven form of therapy in managing pain, however, few physical therapists incorporate it into their treatment.
- Ferreira ML et al (2007) “Comparison of general exercise, motor control exercise and spinal manipulative therapy from chronic low back pain: A randomised trial,” Pain 131(1-2): 31-37.
Our take: 248 subjects were recruited for the study. The results indicate that motor control exercise and spinal manipulation produced slightly better short-term function and perception of effect than general exercise, but not better medium and long term effects, in patients with chronic non-specific low back pain.
- Lindstrom I et al (1992) “The effect of graded activity on patients with subacute low back pain: a randomised prospective clinical study with an operant-conditioning behavioural approach,” Phys Ther 72(4): 279-290.
Our take: 103 subjects were recruited for the study. The study suggests that a graded activity program could make patients occupationally functional again, when measured by return to work. It can also reduce long-term sick leave.
Pain, Medications & Vitamins
Some people with chronic pain are on a lot of medications. Doctors are often quick to prescribe pain killers or anti-inflammatory pills, and patients take these things simply because their doctor has prescribed them. There are so many families of drugs but none are really effective in the long term. In fact, research does not support long-term use of pain medication in most chronic pain conditions. There are also many vitamins and minerals on the market. The key is to look at these as what they really are – supplements. You need a healthy diet and lifestyle and then take these if there are any shortfalls. Vitamins and minerals are only substitutes for a healthy diet.
- Bilke DD (1994) “Role of Vitamin-D, It’s Metabolites, and Analogs in the Management of Osteoporosis,” Rheumatic Disease Clinics of North America 20: 759-75.
Our take: Osteoporosis is not a disease just due to obvious deficiencies in Vitamin D, calcium, and phosphate. More subtle deficiencies from a lack of dairy products, sunlight, and less intestinal absorption can lead to greater risk of osteoporosis. Having Vitamin D supplements may help in populations where Vitamin D intake is marginal or there is limited exposure to sunlight. Abstract
- Bruehl S et al (2007) “Trait anger expressiveness and pain-induced beta-endorphin release: Support for the opioid dysfunction hypothesis,” Pain 130(3): 208-215.
Our take: Sometimes expressing our anger openly can be due to a dysfunction of how opiod drugs get processed in our body.
- Codd EE et al (2008) “Tramadol and several anticonvulsants synergise in attenuating nerve injury-evoked allodynia,” Pain 134(3): 254-262.
Our take: In some instances, the correct combination of analgesics and anticonvulsants can help manage neuropathic pain.
- Mao J (2008) “Opiod-induced Hyperalgesia: pathophysiology and clinical implications” Pain Clinical Updates 16(2): 1-4.
Our take: Recent research on rats suggests that long term use of Opiods on high doses can actually amplify the pain causing the user to increase the dosage. This is contrary to previous beliefs that the body builds a tolerance that result in an increase in the dose.
Pain, Family, Relationships & Society
Without even realising, people get themselves into patterns where they: focus on their pain, don’t want to talk to their family or friends, don’t want to go to work, and don’t have any quality of life. In short, it becomes all about the pain. Of course this then has implications of family and friends. The research suggests that family and friends respond differently towards a person in pain: they can be solicitous, they may be resentful, or understanding. It is dependent on the attitude of sufferer towards their pain. New research also shows that having chronic pain and being out of work, can actually affect your children in a negative way. For this reason, it is even more important to try and learn ways to manage your pain and move on with your life.
- Blyth FM et al (2001) “Chronic pain in Australia: a prevalence study,” Pain 89(2-3): 127-134.
Our take: 17543 interviews were used in the study. Chronic pain affects a large population in Australia, including the working age, and appears to be strongly associated with markers of social disadvantage.
- Christoffersen, M 1994 “A follow-up study on the long term effects of unemployment on children: loss of self-esteem and self-destructive behaviour among adolescents,” Childhood, vol. 2, no. 4, pp. 212–220.
Our take: Unemployment of parents can have a significant negative effect on children when they grow up to become adults.
- McCracken LM (2005) “Social context and acceptance of chronic pain: the role of solicitous and punishing responses,” Pain 113: 155–159.
Our take: Social influences can play a role in patients’ engagement in activity with pain and their willingness to have pain without trying to control it.
- Reinhardt Pedersen, C & Madsen M 2002, “Parents’ labour market participation as a predictor of children’s health and wellbeing: a comparative study in five Nordic countries,” Journal of Epidemiology and Community Health, vol. 56, no. 11, pp. 861–867.
Our take: If you’re not working for a long time, you can affect your children’s perception of what is normal. This can result in them having a high prevalence of ill health and low wellbeing.
Pain & Sleep
For people in pain, having a good night’s sleep refreshes you, replenishes your energy levels, reduces your pain, improves your mood, and keeps your appetite healthy. Research suggests that poor sleep will increase the pain, and in turn, increased pain levels can result in poor sleep. It can become a vicious cycle.
- Chui YH et al (2005) “Poor sleep and depression are independently associated with a reduced pain threshold. Results of a population based study,” Pain 115(3): 316-321.
Our take: 424 subjects were recruited. Poor sleep and depression is associated with low pain threshold – the more pain you feel, the less sleep and greater depression you have. Even when the pain is managed, poor sleep and depression may persist.
- Edwards RR et al (2008) “Duration of sleep contributes to next-day pain report in the general population,” Pain 137(1): 202-207.
Our take: Sleep can have a significant effect on the pain experience. Poor sleep is associated with increased pain. It is important to consider the effect of sleep when assessing and developing a treatment program.
- Lautenbacher et al (2006) “Sleep deprivation and pain perception,” Sleep Med Rev 10(5): 357-369.
Our take: A lack of sleep may result in a significant worsening of pain levels. A lack of sleep can also hinder the effects of medications, particularly those opioid and serotonin based drugs. This means a lack of sleep amplifies the pain from two fronts.
- Naughton F et al (2007) “Does sleep quality predict pain-related disability in chronic pain patients? The mediating roles of depression and pain severity,” Pain 127(3): 243-252.
Our take: 155 subjects were recruited for the study. Pain severity, depression, and a lack of sleep all have an impact on pain-related disability. Further research is needed in this area as well as whether interventions to improve sleep can help pain severity.
Pain & Education
In order address a problem, you need to know what you are dealing with first. Pain is no exception. One of the biggest issues for sufferers and their practitioners is the lack of understanding of pain. Research suggests that the right education about pain can improve confidence of the sufferer and encourage early return to activity. The research also suggests that the right education can also improve the confidence of the practitioner which can lead to better outcomes. The right education about how pain works is an integral part of effective pain management.
- Indahl A et al (1998) “Five year follow-up study of a controlled clinical trial using light mobilisation and an informative approach to low back pain,” Spine 23(23): 2625-2630.
Our take: 489 subjects were recruited for the study. Sub-chronic low back pain can be managed successfully by undertaking a thorough assessment and then providing the patient with information about their condition, provided in a way that is aimed at resuming fear and encouraging early activity.
- Moseley L et al (2004) “A randomized Controlled Trial of Intensive Neurophysiology Education in Chronic Low Back Pain,” Clin J Pain 20(5): 324-330.
Our take: Education on pain neurophysiology, and not just back school education, needs to be an integral part of treatment.
- Moseley L (2004) “Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain,” Eur J Pain 8(1): 39-45.
Our take: 121 subjects were recruited for the study. Education sessions can change a person’s unhelpful beliefs about pain and disability. By educating people, you can change their beliefs and hence behaviours and help people become more confident in their own ability and become more active.
- Ryan C et al (2010) “The effect of a physiotherapy education compared with a non-healthcare education on the attitudes and beliefs of students towards functioning in individuals with back pain: An observational, cross-sectional study,” Physiotherapy 96(2): 144-150.
Our take: 246 students were recruited for the study. These findings suggest that physiotherapy education brings about positive student attitudes towards functioning in individuals with back pain. This may be partly attributable to receiving a university degree education, but perhaps further enhanced by specifically receiving a physiotherapy degree. This may results in students becoming more evidence-based practitioners following qualification.
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