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Inclex A Acetylcholine, role in pain modulation, 172 Acupuncture, 154 Acute pain contrasted with chronic pain, 140- 141 definition, 18 models for, 124, 212 Administrative law judges (ALJs) appeals of claim denials before, 5, 47, 67 conflicts between disability program administrators and, 74-76, 263 number of, 67 reversal rate by, 75 Age back pain correlated with, 113 characteristic of disabled persons, 94 considerations in disability determi- nations, 46 relation between self-reported pain and, 112 Aid to Families with Dependent Chil- dren, cash disability transfers, 89 Alcoholism among chronic pain patients, 177- 179 disability determinations and, 68 in families of pain patients, 157, 168 Alexithymia, 169 293 Algology/dolorolog~y, 233 Alternative care therapies need for research on, 206 use by chronic pain patients, 153 American Medical Association Commit- tee on the Medical Rating of Physi- cal Impairment, 26 yaminobutyric acid, role in pain modu- lation, 172 Analgesia acupuncture, 154 stimulation-produced (SPA), 134-135, 172 Analgesics for back pain, 203 opioid, 135,172,173, 203 Antidepressants, analgesic erects of, 175-176, 203 Antipsychotic drugs, analgesic effects of, 175 Anxiety relation to chronic pain, 131, 133- 134, 140-142, 166-168 role in maintenance of pain, 3, 140- 141 Anxiolytic drugs electiveness in treating pain, 176 Appeals (SSA) before ALJs, 5, 47, 67 federal district court, 76-78 process for denied claims, 5-6, 46~0, 60

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294 D!~DEX staff and offices involved with, 67 standard of review for, 50 Supreme Court, 50 of termination of benefits, 1, 30, 56- 57 Arthritis classified as disabling by SSA, 41-42, 269 myofascial trigger points related to, 286 outcomes of treatment for, 205 rheumatoid, 42, 80, 114-116, 172 from sustained pain, 137 Articular dysfunction, 197, 200 Aspartic acid, role in pain processes, 131 Az~erbeuf v. Schweiker, pain as legiti- mate disability, 56 B Back pain age, race, and sex correlations with, 113-114 alcoholism correlated with, 177 bed rest and restricted activity for, 202-203 behavior associated with, 218 causes of, 2, 13, 114 - 115, 196-200 clinical manifestations, 115 diagnosis of, 190-195, 204 drug therapy for, 20~203 incidence, 110-111, 113 marital status and recurrence of, 114 measurement of, 129, 179, 218-219, 222, 226 medical care for, 111-112 medical model for, 190-194, 196 nerve damage in, 140 outcomes of treatment, 194, 202-205 pain processes in, 126 physiotherapy for, 112 prevalence of, 104 - 108, 110-111, 113 progression to chrorucity, 109-110 psychosocial factors in, 116 sickness impact of, 221 socioeconomic status and, 115-116 surveys of, 10~108, 110-112 treatment modalities, 111-112, 193- 195, 202-205, 241 work disability from, 109-113, 222- Chronic pain 223, 246 workplace factors in, 116 Baerga v. Richardson, standard for evaluating pain, 56 Barbiturates, treatment of pain with, 176 Behavior modification for treatment of pain, 175, 201-202, 238-239, 243- 244, 250 Beneficiary Rehabilitation Program, 253 Benefits, see Disability benefits; Com- pensation Benzodiazepines, 173, 176, 203 Ber v. Celebrezze, standard for evaluat- ing pain, 55~6 Biofeedback, 238, 240, 243 Bradykinin, release in pain processes, 126 Brief Pain Inventory, 216 Butyrophenones, 176 C Case law on SSA disability determina- tions involving pain Auerbez~f v. Schweiker, pain as legiti- mate disability, 56 Baerga v. Richardson, standard for evaluating pain, 56 Ber v. Celebrezze, standard for evalu- ating pain, 55~6 Werner v. Flemming, consideration of job opportunities in disability de- terminations, 29 Marcus v. Cal~fano, pain as legiti- mate disability, 56 Miranda v. Secretary, standard for evaluating pain, 56 Page v. Celebrate, standard for eval- uating pain, 55, 56 Polasiz v. Heckler, standard for eval- uating pain as a disability, 56~7 CAT scan, for diagnosis of back pain, 192, 204 Causalgia, 139 Central nervous system erects of prolonged pain on, 140 lesions of, 139 monitoring metabolic activity in, 141-142 pain pathways in, 131-133, 141-142 Chiropractic care effectiveness, 154, 206, 237 use by chronic pain patients, 153 age, race, and sex correlated with, 113-114 anxiety and, 131, 133-134, 140-141, 166-168 biopsychosocial model needed for, 27 contrasted with acute pain, 140-141

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INDEX costs associated with, 98 definitions, 18,102, 109 depressive disorders and, 3, 133, 157, 166-168, 172-173 diagnosis of, 195-196, 200-201 epidemiology of, 101-119, 266, 277- 278 experience of, 3, 12, 15, 27, 69, 132- 134, 141, 146, 159 from failure of pain suppression sys- tem, 135 family influences on, 156-158, 168, 172, 178-179, 202 federal court handling of, 7~78 gaps in knowledge on, 7-8, 26~265 genetic predisposition to, 157 kinds of, 109-110 measures of, 10~103, 118-119; see also Measurement of pain models for, 124, 212 neurobiological mechanisms of de- pression and, 171-172 personality factors and, 3, 178-180 physical factors associated with, 11= 115 prevalence, 113-114 progression to, 109-110 psychiatric aspects of, 3, 165-181 psychosocial factors associated with, 116-117, 141, 196, 200-201 research recommendations on, 8-10, 117-119, 139, 180-181, 206-207, 265-266, 281 socioeconomic status and, 115-116 somatization disorder and, 3, 168-169 syndrome, characterization of, 13; see also Myofascial pain syndrome treatment recommendations for, 201- 205, 265 trends over time, 112 Chronic pain patients chiropractic care for, 153 rehabilitation of, 16, 79, 97; see also Rehabilitation substance abuse among, 3, 177-179 treatment of depressive disorders in, 174-177 Claims, see Disability claims Cognitive therapy electiveness, 201, 238, 244 for outpatient treatment of depres- sion,174-175 recommended approach to, 201-202 Compensation effects on outcomes of treatment, 245, 248-252,273-274 295 European programs, 33, 64 neurosis, 249 See also Disability benefits Continuing Disability Investigations, 30,31 Conversion disorder, 169-170 Coping Scale Questionnaire, use in pain measurement, 225-226 Cordotomy, 205 Cornell Medical Index, assessment of chronic pain with, 180 Cultural/ethnic influences on disability, 33 on illness behavior, 158-160 D Dartmouth Pain Questionnaire, 215 Demonstration projects, recommenda- tions for, 9-10, 255-257, 265, 270- 277 Depression (clinical) characteristics, 167 chronic pain and, 3, 133, 157,168, 172~173 in families of pain patients, 157, 168, 172 instruments for measuring, 167 neurobiological mechanisms of pain and, 171-172 prevalence in pain patients, 167 substance abuse associated with, 177 Depressive disorders psychopharmacological treatment, 175-177 psychotherapeutic treatment, 174- 175, 180 Depressive symptoms association between chronic pain and, 167, 168 caused by drug therapy, 173 Diagnosis of pain controversial, 197-198 difficulties in, 13-14, 195-200 expanded model, 19~195 history-taking, 191, 201 laboratory tests, 192 physical examination, 191-192,201 psychosocial factors in, 200-201 recomrr~ended improvements in, 200- 201 special techniques, 192 traditional medical model, 190-194 Dictionary of Occupational Titles, 46 Disability assessment, see Disability determina-

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296 INDEX tions; Measurement of disability as a civil rights issue, 34 compensation programs in Western Europe, 33, 64 cultural components, 33 data collection on, 8, 103-109, 26 267 early identification of, 10, 256, 270- 276 economics of, 87-99 label, damage to patient from, 73 leading causes, 12, 110 measurement of, see Measurement of disability medical model of, 26 mental, 31, 68 pain as basis for establishing, 55~7 prevalence, 94 prevention, funding for, 97-98 rates, 80, 92 severity of impairment, 45,54, 223- 224 SSA debate about, 22-24, 76 unemployment and, 27, 80-81,91-92 work continuation and, 70, 95 workers insured for, 40 Workers' Compensation categories of, 62 Disability benefits appeals of terminations (SSA), 1, 30, 56~7 awards per year (SSA), 30, 38, 40~1, 58, 69, 88-89, 95 cash payments, 38, 50, 88-89 coverage period, 60 eligibility, see Disability determina- tions; Eligibility for benefits expenditures for, 8~98 levels of, 95 negative effects of, controversy, 78- 81, 156, 245, 248-252 payments by SSDI/SSI, 37~8, 40-41, 50, 60, 89, 91-93, 95 private insurance, 60, 63, 89 rehabilitation and, 70-71, 78-81, 255-256, 274 after return to work, 51 simultaneously, SSDI and SSI, 38 termination of, 1, 30, 31, 56~7 types, 60 Veterans Administration, 58-61,89- 90 Workers' Compensation, 59-60,62, 89 See also Compensation Disability Benefits Reform Act of 1984 criteria for determining eligibility, 33-34 scope of, 31 standard for evaluating pain, 1, 21, 51~2, 76 Disability claims annual number filed, 42 application process, 42-46,52-53,60 disposition at all levels, 47-49 economic conditions and, 92,99 evaluation process, 5,42-46, 52, 53- 55, 59 growth of, 30, 69, 81, 91-93 incentives for, 95 most common bases of, 25 pain as a basis for, 55~7 tort settlements, 90 for vertebral disorders, 110 Disability definitions ambiguity in, 68 European, 33 medical condition linked to employ- ability, 68 medical vs. functional concept, 69-70 private sector, 61, 63 restrictiveness of, 70 SSA, 4-5, 14-15, 22, 32-33, 38-42, 61,69-70,256,264,273-274 variation in, 93 Veterans A`lministration, 61 Workers' Compensation, 61 World Health Organization, 17 Disability determinations ability to work considered in, 45, 69- 70 age considerations in, 46 by ALJs, 5, 47,67,74-76,264 appeals of, 5-6, 46~0, 60, 67, 76-78 burden of proof, 57 case law inconsistencies in, 29,55- 57,67,77-78 criteria for, 14, 23, 29~0, 33-34, 57 differential impact of nature of im- pairment, 73 early, 10, 256,270-273 employment opportunities considered in, 2~30,81 evidence required for, 63-64,69,269 face-to-face, 5, 9, 47,64,264,272 federal district court, 7~78 functional approach to, 2,4, 5, 8-9, 45-46,69-70,220,223-224,254, 256,265,268-270,272-273 information gathering for, 8, 5~53, 103-109,265-267 institutional perspectives, 67

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INDEX 297 medical-based, 23-28, 31, 69-70 moral dimension, 67-68 nonmedical factors in, 26, 33, 45-46 pain's role in, 51-57, 59, 61-63 physician concerns about, 2028 physician roles in, 43, 45~6, 71-74 qualifications of evaluators, 43 recommended focus of, 161, 228, 256 SSA sequential evaluation process, 5-6, 43~7, 53~5, 69, 268-269 state-level (DDS), 5, 43, 52 53 subjectivity in, 66-69, 70, 75-76, 82, 264 vocational factors, 45 volume of, 6 Disability expenditures administrative, 96-98 cash transfers, 88-89 direct services, 90-91 medical care, 89-90, 98 trends in, 91-97 Disability insurance legislative background, 21~1 physician objections to, 24 private, 60-64, 89-90 programs, 89; see also Disability benefits; Social Security disability programs (SSDI/SSI) SSA, history of, 22-24 Disabled persons direct services for, 90-91 discrimination against, 34, 81 employment opportunities for, 28~0, 34, 81, 93 labor force participation, 80 medical care payments for, 90 motivation for recovery and rehabili- tation, 10, 25, 78-81, 273 number and characteristics of, 94 work continuation by, 70, 95 Disc herniation education correlated with, 115 pain from, 197 surgery for, 204 work absence from, 112 Discrimination against disabled per- sons, 34, 81 Doctors, see Physicians Dopamine, role in pain modulation, 172, 176-177 Dorsal column stimulation, 205 Drug abuse among chronic pain patients, 156, 173, 177, 179 disability determinations and, 68 Drug therapy antidepressants, 175-176, 203 antipsychotics, 175 for back pain, 202-203 for chronic pain, recommended im- provements in, 203-204 depressive symptoms caused by, 173 opioids, 135,172, 173, 203 in pain management programs, 239, 241 polypharmacy, 156, 173, 227, 241 for somatization disorder, 169 See also Psychopharmacology E Education and training back pain correlated with, 115 considerations in disability determi- nations, 46 disability correlated with, 94 of health care professionals to treat pain, 10-11, 266, 280-283 See also Patient education Electromyography for diagnosis of back pain, 192 Eligibility for benefits criteria for determining, 14, 23, 26, 29~0, 32~4, 69; see also Disabil- ity determinations Medicaid and Medicare, 50 periodic review to confirm, 50 SSDI/SSI, 37~8, 248 Veterans Administration, 58 Workers' Compensation, 61-62 Employment effects on outcomes of treatment, 245-248; see also Return to work; Unemployment; Work disability opportunities for disabled persons, 28-30, 81, 93 substantial gainful activity, 45, 253 End Stage Renal Disease Program, pay- ments for, 90 Endogenous opioid system, 135, 176, 177 Epidemiology of chronic pain, 101-119, 266, 277- 278 of psychiatric disorders, 166-167 Epidural steroid injections for low back pain, 241 Experience of pain description of, 133, 146 individual variables in, 12, 15, 27, 133

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298 SEX threshold, 132,133, 159 tolerance, 3, 69, 133-134, 141 F Factitious disorder, 171 Families of pain patients depression and alcoholism in, 157, 168, 172 influences on illness behavior, 156- 158, 178-179, 238-240 involvement in treatment, 202, 233, 238-240 Federal courts, handling of chronic dis- abling pain by, 76-78 Federal Republic of Germany, disability definition, 33 Fibromyalgia/fibrositis, 197,199-200, 236, 241 Folk healers, 153 Functional impairment assessment of, 2, 4,5,8-9,220,254, 265, 268-270, 27~273 definition, 17 description, 27 imposed by pain, 54 G Glut~mic acid, role in pain processes, 131 H Handicap definition, 34 See also Disability Headaches illness behavior associated with, 134, 218 work days lost because of, 110 Health Belief Model, pain measurement with, 225 Health care services, alternative thera- pies, 153, 206 Heart attack, referred pain during, 129 HHS Co - mission on the Evaluation of Pain, definitions of acute pain, chronic pain, and impairment, 17- 18 recommended rehabilitation demon- stration project, 274 Histamine, release in pain processes, 126 Holistic health care, 153, 206 Hopkins Symptom Checklist-90 (SCL- 90), assessment of chronic pain with, 180, 252 Hyperactivity of sympathetic nervous system, 13~138 Hypnosis, 240 Hypnotic drugs, depressive symptoms from, 173 Hypochondriasis, 3, 170, 171,250 Hysteria, see Somatization disorder I Iatrogenesis, 156,202-205,223,282 mness/pain behavior in absence of diagnosable disease, 152-153 abnormal, 148, 170 avoidance of intimacy, 158 in back pain patients, 218 compensatory mechanisms, 152 conditioning, 157 coping responses, 151-154,156,225- 226,239,243,251 cultural/ethnic influences on, 3, 158- 160 definition, 13 expression/communication of pain, 133,146,151,155-156,159-160, 224-227 factors shaping, 147 family influences on, 15~158,178- 179,238-240 help seeking, 151-154 individual variation in, 147 judgments of, by health care provid- ers, 217 malingering, 15~153 measurement of pain through, 217- 220 modeling, 157 observational data on, 217-219 operant learning, 157, 250 overuse syndromes, 152 pain tolerance factor in, 3, 133-134, 141 personality and, 15~156 processes of, 148-154 psychosocial factors in, 3,112,147, 155, 160 Seclusiveness, 152 reduced physical activity, 152 self-reports of, 219-220 somatization, 155-156,158,168,178

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Index 299 symptom interpretation, 149-151, 224-225 symptom perception, 112, 148-149 Imipramine, 174 Impairments assessment of, 2, 4, 5, 8-9, 220, 264, 265, 268-270, 272-273 concept of, 26-28 definition, 17, 39 differential nature of, 73 duration of, 42 indicators of, 42, 54; see also Disabil- ity determinations mental, 31, 39, 43 musculoskeletal, 41~2 relation to work, 27 severity, 45, 54, 223-224 SSA listing of, 5, 8, 39, 41~2, 45, 54, 69, 265, 267-268 verification of, 28 Veterans Administration ratings of, 58 See also Functional impairment Instruments for measuring disability Northwick Park Activities of Daily Living Index, 220 Sickness Impact Profile (SIP), 221- 222 Instruments for measuring pain Brief Pain Inventory, 216 Coping Scale Questionnaire, 225-226 Cornell Medical Index, 180 Dartmouth Pain Questionnaire, 215 Health Belief Model, 225 Hopkins Symptom Checklist-90, 180, 252 Levine-Pilowsky Depression Ques- tionnaire, 252 McGill Pain Questionnaire (MPQ), 215-216, 251 Minnesota Multiphasic Personality Inventory (MMPI), 179, 180, 221- 222, 250, 251 Multidimensional Health Locus of Control Scale, 224-225 Numerical Rating Scale (NRS), 214 Pain Perception Profile, 216 Purpose in Life Scale, 224 recommendations for, 272-273 Visual Analog Scale (VAS), 21~216, 222, 273 Ways of Coping Checklist, 225 West Haven-Yale Multidimensional Pain Inventory, 215-216 Insurance, see Disability insurance Interpersonal therapy, 174 J Job satisfaction back pain and, 116 disability rates correlated with, 80 Jobs exertional requirements, 46 See also Employment Joint pain, work days lost because of, 110 K Werner v. Flemming, consideration of job opportunities in disability de- terminations, 29 L fedora, analgesic erects of, 177 Labor force participation by disabled persons, 80 employment opportunities as a deter- minnnt of, 81 Legal decisions on disability determinations, incon- sistencies in, 67, 77-78 on pain cases, inconsistency in, 31 See also Appeals; Case law on disabil- ity determinations Leukotrienes, release in pain processes, 126 Levine-Pilowsky Depression Question- naire, 252 Listing of Impairments, SSA, 5, 8, 39, 45, 54, 69, 265, 267-268 Lithium, analgesic effects of, 177 M Malingering, 15~153, 171 Marcus v. Califano, pain as legitimate disability, 56 McGill Pain Questionnaire (MPQ3, 215-216, 251 Measurement of disability instruments for, 220-222 pain relation to functional status, 2, 4, 5, 8-9, 45-46, 69-70, 220, 223- 224, 254, 256, 265, 268-270, 272- 273 rehabilitation-focused tests, 222 sickness impact, 221-222 surveys, 93-94, 103 work performance assessment, 222- 223

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300 INDEX Measurement of pain back pain, 129, 179, 218-219, 222, 226 basic concepts, 212-213 through behavior, 217-220 biases in, 102, 110-111, 181, 224-227 determining chemical substance con- centrations at tissue injury site, 141 difficulties in, 3 - , 129, 253-254 frequency, 104-108 indirect physiological, 142 positron emission tomography, 141- 142 with psychiatric assessment instru- ments, 180-181 recording primary afferent nociceptor activity, 4, 127-129, 141 research recommendations for, 118- 119, 180-181, 281 scaling, see Instruments for measur- }ng pain self-reports, 102-103, 111-112, 213 216, 219-220 subjective states, 213-216 through sympathetic nervous system activity, 142 thermography, 142 Medicaid, disability payments under, 50, 90 Medical care for back pain, 111-112 for chronic pain, costs of, 98 disability program expenditures for, 89-90 See also Rehabilitation; Treatment of pain Medicare coverage after return to work, 51 payments for SSDI beneficiaries, 89- 90 supplemental disability payments un- der, 50 Mental health problems, disability de- terminations and, 31, 68 Methotrimeprazine, 176 Minnesota Multiphasic Personality In- ventory (MIMI), 179, 180, 221- 222, 250, 251 Miranda v. Secretary, standard for eval- uating pain, 56 Modeling/models acute pain, 124, 212 animal, applied to human pain stud- ies, 124, 131, 137 biopsychosocial, for chronic pain, 27 chronic pain, 124, 212 expanded, of low back pain, 194-195 illness/pain behavior, 157 medical contrasted with nonmedical, 212-213 medical, of disability, 26 traditional medical, of low back pain, 190-194, 196 of unemployment-disability relation- ship, 91 Multidimensional Health Locus of Con- trol Scale, pain measurement with, 224-225 Muscle atrophy from sustained pain, 137 Muscle contraction pain-associated, 138 stimulation of primal afferent noci- ceptors, 126 Muscle relaxants for back pain, 203 Myelography for diagnosis of back pain, 192, 204 Myelotomy, 205 Myofascial pain syndrome characteristics of, 286 diagnosis, 288-290 historical background, 286-287 natural history, 287-288 overlap between fibrositis and, 200 perpetuating factors, 138, 290 prevalence of, 240-241, 285-286 psychogenic pain disorder and, 170 treatment, 200, 241, 290-291 Myofascial trigger points in arthritis patients, 286 in back pain, 192, 197, 198-199 characteristics of, 288-290 development of, 198-199 referred pain from, 130, 192, 198- 199, 286-289 N Naltrexone, treatment of pain patients with, 178 National Institute of Mental Health Epidemiological Catchment Area project, 166 Nerve blocks to treat chronic pain, 234, 241, 250 conduction tests for diagnosis of back pain, 192 damage from back pain, 140 Netherlands, disability definition, 33

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SEX 301 Neuralgia, trigeminal and posthe~petic, 140 Neuroleptic drugs, analgesic effects of 175, 176 Nociceptors, see Primary afferent noci- ceptors Norepinephrine, role in depressive ill- ness and pain modulation, 171-172 Northwick Park Activities of Daily Liv- ing Index, 220 Nosophobia, 171 Nuclear magnetic resonance (NMR) im- aging for diagnosis of back pain 192, 204 Numerical Rating Scale (NRS), pain measurement with, 214 Nuprin Pain Report, 103-104, 109-111, 113-115 o Occupational status, back pain and 115-116 Old Age, Survivors, and Disability locust Fund, eligibility for benefits, 37 Opioid analgesics depressive symptoms from, 172-173 long-term pain therapy with, 203 Osteoporosis, 42, 137 Outcomes of treatment adequacy of study designs and meth- odologies, 244 age and educational level as predic- tors of, 251 of arthritis, 205 of back pain, 194, 202-205 behavioral therapy, 243-244, 250 chiropractic care, 154, 206, 237 cognitive therapy, 201, 238, 244 compensation effects on, 245, 248- 252, 273-274 employment effects on, 242, 244-248 multimodal approaches, 24~245 relaxation therapy, 238, 240, 243 p Page v. Celebreze, standard for evalu- ating pain, 55, 56 Pain anatomy and physiology of, 123-142 assessment methods, see Instruments for measuring pain; Measurement of pain causalgia, 139 central nervous system pathways, 131-133 chemicals producing, 126 chronic, see Chronic pain clinically significant vs. experimen- tally induced, 126, 134 cognitive and affective aspects of, 134, 201 common types, 109-110; see also Back pain consideration in disability determina- tions, 51~7, 61-63 of deep somatic and visceral struc- tures, pathways of, 132 definitions, 18, 102, 104-109 description of, 133, 146 diagnosis, see Diagnosis of pain disproportionate to injuries, 136 economics of, 98 effects on central nervous system, 140 enhancement through physiological processes, 136-141. evaluation of, 53~5, 127-129; see also Diagnosis of pain evidence of, 53, 54 experience of, see Experience of pain expression and communication of, 133, 146, 151, 155-156, 159-160, 22~227 functional status and, 2, 4, 5, 8-9, 220, 254, 265, 268-270, 272-273 impaired sensation of, 131, 132 incidence, 110-111 indicators of, 151-152; see also m- nesslpain behavior; Measurement of pain information gathering on, 5243; see also Surveys of pain/disability intensity, 127-128 joint, 110, 136, 218 key court cases, 55~7 from lesions of central nervous sys- tem, 139 management, see Pain management programs/pain clinics meaning attributed to, 149-151, 224- 225 measurement of, see Measurement of pain memory of, 226 muscle contraction associated with, 138 neurological mechanisms and struc- tures, 13, 125, 171-172; see also Pain processes neuropathic, 139-140

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302 INDEX perception, 123-125, 132 from peripheral nerve injury, 139 prevalence of, 104-108,110-111, 113-114 private sector consideration in dis- ability determinations, 61,63-64 psychological factors in maintenance of, 3, 140-141 receptors, see Primary afferent noci- ceptor referred, 129-131,136,192, 19~199, 286-289 religious and moral significance to, 151 response to, see Illness/pain behavior role in disability determinations, 51- 57, 59, 61-63 self-sustaining, 136-140 sensitization, 136 sensory vs. affective aspects, 133-134; see also Experience of pain severity determination, 15, 151, 223- 224 sharp, well-localized, pathway for, 132 sociopolitical issues concerning, 21- 35 SSA standard for evaluating, 21, 51- 52, 55~7 threshold, 132,133, 159 tissue damage and, 14~147 tolerance variation, 3, 69, 133-134. 141 treatment, see Pain management pro- gramslpain clinics; Rehabilitation; Treatment of pain trigger points, see Myofascial trigger points VA consideration in disability assess- ments, 59,61 work disability due to, 103, 109-113, 222-223,246 Workers' Compensation consideration in disability determinations, 61-63 See also Acute pain; Back pain; Chronic pain Pain management programs/pain . . c panics accreditation of, 235 admission criteria, 234,242 behavior modification by, 238-239, 243 cognitive therapy, 238,244 drug therapy in, 239,241 follow-up procedures, 243 goals, 234,245 medical interventions, 240-241 multimodal treatments, 241 245 need for standards, 235-236 outcomes, 242-252 patient education by, 239,248,251 physical treatment modalities, 234, 236-238 psychosocial rehabilitation by, 239- 240 relaxation therapy, 238,240,243 stab qualifications, 235,236 stress management by, 240 studies needed on, 242-245 types of patients, 242 types of treatments, 234,236 variation among, 4,234-235 vocational rehabilitation by, 241-243 Pain Perception Profile, 216 Pain processes convergence-facilitation hypothesis, 130 convergence-projection hypothesis, 130-131 Livingston's vicious circle, 138-140 in low back pain, 126 modulation, 124-125,129,134-135, 172,178 perception, 123-125,132; see also Experience of pain recording activity during, 127 self-sustaining, 13~140 sensory vs. affective, 133-134 transduction, 124-126,141 transmission, 124,126-133 Patient education in treatment ordain, 239,248,251 Peripheral nervous system, pain trans- mission in, 12~133 Personality factors in chronic pain, 3,178-180 illness behavior and, 154 - 166 Phenothiazines, 176 Physician-patient relationship conflicts caused by disability certifi- cation, 25,74,263-264 relevance to treatment of pain, 14 Physicians concerns about medical determina- tions of disability, 24-28 consultative, 7~73 objections to disability insurance, 24 role conflict (gatel~eeping), 71-74 roles in disability determinations, 43, 45-46, 71-74 SSA uses of, 71-74 treating, 71-73

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IDEA 303 Polaski v. Heckler, standard for evalu- ating pain as a disability, 56~7 Positron emission tomography (PET), pain measurement by, 141-142 Potassium release in pain processes, 126 Primary adherent nociceptors activation of, 4, 124-126, 137-139 axons of, 126-127, 131-132 chemical releases by, 131 damage to, 139-140 mechanisms of, 123, 131 monitoring pain intensity through, 127-128, 141 muscle contraction from, 126, 138 peripheral branching of, 130 regeneration of, 139 sensitization through repeated stimu- lation of, 136 Private disability insurance, 60-64, 89-90 Prostagland~ns, release in pain process- es, 126 Psychiatric disorders in chronic pain patients, 166-167, 169; see also De- pression (clinical); Depressive dis- orders Psychogenic pain disorder, 170, 171 Psychological factors in maintenance of pain, 140-141 Psychopharmacology for depressive dis- orders in pain patients, 175-177 Psychosocial factors affecting chronic pain, 116-117, 141, 196, 200-201 in illness behavior, 3, 112, 147, 155, 160 Psychotherapy for pain patients, 169, 174-175, 180, 240 Psychotropic drugs, analgesic effects of, 175-177 Purpose in Life Scale, pain measure- ment with, 224 R Race back pain correlated with, 113-114 relationship between disability and, 94 Recommendations, see Research recom- mendations Recovery, motivation for, 25, 78-81 Referred pain, 130, 192, 198-199, 286- 289 Reflex sympathetic dystrophy, 137-138 Rehabilitation of chronic pain patients, 16, 79, 97; see also Pain management pro- grams/pain clinics costs, 235 disability benefits and, 70-71, 78-81, 255-256, 274 early, 10, 273-276 eligibility for (SSA), 71, 255-256 European encouragement of, 64 exercise program, 237 expenditures for, 90-91, 97-98 financial disincentives to, 25, 79 incentives for, 50-51, 71, 273-274 income support vs., 70-71 issues important to SSA, 252-257 mandatory, 254-255 motivation for, 10, 25, 78-81, 273 private insurance requirements, 61, 63 psychosocial, 239-240 recommended research on, 274-277 VA program, 59, 61 vocational, 90-91, 224, 241-243, 252- 253, 257, 274 weaning pain patients from drugs, 173 Workers' Compensation participation requirements, 61-62 Rehabilitation Act of 1973, section 504, definition of handicapped, 34 Religious healers, 153 Research recommendations case control studies, 118 chronic pain, 8-10, 117-119, 139, 180-181, 205-207, 265-266, 281 clinical studies, 10, 205-207, 245, 278-280 on compensation effects on outcomes, 248-249, 278-279 epidemiological studies of chronic pain, 10, 117-118, 266, 277 - 278, 280 health services utilization, 206, 279 on pain measurement, 118-119, 180- 181, 281 on psychiatric aspects of chronic pain, 180-181 on rehabilitation, 274-277 Residual functional capacity, determi- nation of (SSA), 5, 8-9, 4606, 220, 254, 265, 268-270, 27~273 Return to work disability benefits (SSA) after, 61 factors affecting, 8~81 as a measure of outcome, 248

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304 D!lDEX outcomes of therapies stressing, 242, 244, 246 SSA incentives for, 50 Rhizotomy, 205 S Schedule for Affective Disorders and Schizophrenia, 167 Sciatica, surgery for, 204 Self-care movement, 153 Self-reports in measurement of pain, 102-103, 111-112, 213-216 of illness/pain behavior, 219-220 See also Surveys of pain/disability Self-support program of SSI, 51 Sensitization, 136 Serotonin role in depressive illness and pain modulation, 171-172 role in pain processes, 126, 171-172 Sex, back pain correlated with, 113 Shoulder pain, behavior associated with, 218 Sickness Impact Profile (SIP), 221-222 Social Security Act 1966 amendments, 253 1980 amendments, 30 1984 amendments, see Disability Benefits Refor~n Act of 1984 Listing of Impairments, 5, 8, 39, 41- 42, 45, 54, 69, 265, 267-268 regulations implementing, 39 Social Security Administration (SSA) Appeals Council of Office of Hearings and Appeals, 6, 47, 67 conflicts between Congress and, 68- 69 data collection by, 8, 265-267 history of disability insurance, 22-24 nonacquiescence policy, 77-78 policy implementation role, 68 rehabilitation issues important to, 25~257 Social Security disability programs (SSDI/SSI) amount of monthly payments, 50, 51, 95 appeals process, 5-6, 46-50, 60 application and evaluation process, 5, 42~46, 52~55, 60; see also Disabil- ity determinations benefits paid by, 37~8, 40-41, 50, 60, 89, 91-93, 95; see also Disabil- ity benefits conflicts and contradictions, 6-7, 66- 82, 263-264 contributions during disability, 23 definition of disability, 4 5, 14-15, 22, 32~3, 38-42, 61, 69-70, 256, 264, 273-274 disposition of claimants, 48-49 efficacy, 96-97 eligibility, 37-38, 248 funding reallocation to prevention, 97-98 growth in, 95-96 incentives for rehabilitation and re- turn to work, 50~1 income support vs. rehabilitation, 70- 71 lengths and types of benefits, 60 problem of pain for, 21~5, 37-64, 6~82 purpose, 99 rehabilitation requirements and pro- visions, 61, 70 rules affecting return to work, 80-81 sequential evaluation process, 5-6, 43~7, 53-55, 69, 268-269 stay and offices involved with re- views, 67 state-level (DDS), 5, 43, 52-53 tensions within, 69-76 trends over time, 40-41 workload size, 96 Socioeconomic status, chronic pain and, 115-116 Sociopolitical issues on pain, 21~5 Somatization disorders, 3, 169 tendency to, 155-156, 158 Somatoform disorders features of, 168-171 prevalence, 166 Somatosensory cortex, pain perception in, 123 Somatostatin, role in pain processes, 131 Spinal cord, pain transmission pathway in, 131 Spinal disorders listed by SSA as dis- abling, 41-42 Spinal morphine, focal installation of, 205 Spinal stenosis, surgery for, 204 Spinothalamic tract cells, properties of, 132 Stress management, 240 role in maintenance of pain, 3, 140-

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VEX 305 141, 155 Substance abuse, see Alcoholism; Drug abuse Substance P. role in pain processes, 131, 138, 172 Substantial gainful activity, 45, 253 Suffering association with pain, 150 in absence of diagnosable disease, 153 Surgery, unnecessary, 156 Surveys of pain/disability data collection methods, 8, 52~3, 103-109, 265-267 Nuprin Pain Report, 103-104, 109- 111, 113-115 and related psychiatric disorders, 16~167 See also Self-reports Sympathetic nerves, referred pain caused by, 130 Sympathetic nervous system hyperactivity of, 136-138 measurement of pain through, 142 Symptoms depressive, 167,168, 173 interpretation of, 149-151, 224-225 perception of, 112,148-149 T Thal~Tnus, pain perception in, 123,132 Thermography for diagnosis of back pain, 192 pain measurement through, 142 register of myofascial trigger points on, 289 Training, see Education and training Transcutaneous electrical stimulation (TENS), 234,237 Treatment of pain in alcoholics and drug abusers, 177- 178 bed rest and restricted activity, 202- 203,223 chronic low back, 111-112,193-195, 202-205,241 cognitive-behavioral approach, 175, 201-202,238-239,243-244,250 collaborative approach, 202 compensation status as a factor in, 248-252 difficulties in, 13-14 through distraction and meaningful activity, 149 electrical stimulation of homologous brain regions, 134-135 employment as a factor in, 246-248 expanded model for, 194-195 frontal lobotomies, 134 multimodal approaches, 244-245, 254,255 negative erects of, 156,202-205,223, 282 operant conditioning, 178,238,243, 251 outcomes, see Outcomes of treatments physical modalities, 223-224,237- 238 psychopharmacological, 175-177 psychotherapeutic, 17~175, 240 recommended improvements in, 201- 205,265 relaxation therapy, 238,240,243 stress management, 240 surgery, 20~205 transcutaneous electrical stimulation (TENS), 234, 237 vibration, 237 work simulation techniques, 223 See also Drug therapy Trial work period disability payments during, 10, 51, 257 disincentives to use, 80-81, 274 purpose, 252-253 U Unemployment, disability and, 27,80- 81, 91 V Vertebral disorders claims associated with, 110 classified as disabling by SSA, 42 physiotherapy for, 112 work absence from, 112 Veterans Administration cash disability transfers, 89-90 disability compensation programs, 58-61 Visual Analog Scale (VAS), pain inten- sity measurement with, 21 0 216, 222,273 W Ways of Coping Checklist, use in pain measurement, 225

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306 INDEX West Haven-Yale Multidimensional Pain Inventory, 215-216 Work absenteeism, major causes of, 12 continuation by disabled persons, 70, 95 environment, factors related to back pain, 116 experience, considerations in disabil- ity determinations, 46 performance, assessment of disability through, 222~223 See also Return to work; Trial work period Work disability from arthritis, 115, 205 from back pain, 109-113, 222-223, 246 consideration in disability determina- tions, 69-70 frequency, from pain, 103 from joint pain, 110 relation of impairment to, 27 social predictors of, 80 Workers' Compensation cash disability transfers, 89-90 disability categories, 62 disability compensation programs, 59-63, 89 expenditures for rehabilitation, 97 World Health Organwation, definitions of disability, functional limitation, impairment, 17 X X rays for diagnosis of pain, 192, 201