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- ~ Rehabilitation Approaches and Issues in Chronic Pain As documented throughout this report, the inten- sity and disabling e£ects of chronic pain are highly variable and unpredictable. Among the problems faced by persons with such pain are disruptions in the physical, psychological, social, and economic aspects of their lives. In their search for relief, chronic pain patients often seek care both from several different physicians and also from nontraditional healers; in addition, they may undergo numerous treatments over a period of months or years. At some point in their quest for relief these patients may be referred to specialized pain management programs (or "pain clinics") for re- habilitation. Such programs have proliferated rapidly in the last 20 years. Although they vary greatly in terms of staging, specific treat- ment orientation, and criteria for accepting patients into their pro- grams, these pain clinics are specialized rehabilitation facilities whose approach is consistent with the basic philosophy and approach of rehabilitation medicine. THE REHABILITATION APPROACH Rehabilitation medicine differs from other types of medical practice in a number of ways. A major focus is on preserving residual function and preventing secondary complications (physical, physiological, behavioral, or social) that lead to increased disability. Rehabilitation is geared to the needs of people with multifaceted problems and, therefore, tends to take a multidisciplinary approach to treatment in which experts from a 232
REHABlLITATlON APPROACHES ED ISSUES 233 number of pertinent disciplines work together to design and implement treatment plans. This conscious, focused meshing of the skills and knowledge of professionals from many fields into a multifaceted, tightly coordinated treatment approach sets rehabilitation medicine apart from the other areas of practice that deal with pain patients. In order for a rehabilitation team to function successfully, it is believed that each member must share responsibility for addressing the patient's problems and achieving the goals established. In addi- tion, clinicians generally find that the rehabilitation process is more successful if it includes the active participation of the patient and his or her family and if the goals are set by mutual agreement among the patient, family, and team members. The goals may include a resump- tion of physical and psychological well-being through increased mobil- ity, self-care, communication, emotional and social adjustment, and return to work. Unlike some other areas of medicine that concentrate primarily on the causes and direct consequences of a specific disease or disorder, rehabilitation is directed toward an optimal resumption of performance in all aspects of daily living. This chapter describes pain management programs and the tech- niques they use to rehabilitate chronic pain patients. It reviews the findings from outcome studies on the effectiveness of rehabilitation and on the relation between receipt of compensation and rehabilitation success. In addition, it raises a number of issues about rehabilitation for pain claimants in the context of the Social Security disability system. PAIN MANAGEMENT PROGRAMS: AN OVERVIEW Specialized facilities for the treatment of chronic pain have origi- nated within the past 20 years and are associated with the emergence of a medical specialty known as aIgology or dolorology. This specialty is devoted to the study of pain, and includes a shift in the medical conceptualization of pain as a symptom of disease to chronic pain as an independent clinical entity. It is estimated that there are more than 1,200 organized multidisciplinary pain clinics in existence today (Ho~zman and Turk, 1986), as well as many other small, single- discipline practices calling themselves pain treatment facilities. Chronic pain management programs exist in a variety of organiza- tional settings and facilities. Many programs are university-based, operated by departments of various medical specialties. As such, they are situated in medical centers, community hospitals, rehabilitation hospitals, and the rehabilitation units of hospitals. Some are free-
234 ASSESSED TREATING PINED DYSFUNCTION standing specialized pain centers that focus exclusively or primarily on chronic pain. Programs can be voluntary (nonprofit), government-run (state or federal), or proprietary (either as an individual profit-making entity or as part of a regional or national chain). The philosophy of most pain management programs is to Took at the broad aspects of a patient's life, not just at the medical factors. Treatment is oriented toward the patient and family as a unit and concentrates on restoring functional capacity and limiting disability in all spheres of living; in doing so, this approach Reemphasizes disease processes and diagnostic categories. Although pain reduction is a goal, the total alleviation of pain is less important than enabling the patient to function effectively with whatever residual pain exists. Common criteria for admission to pain management programs include the presence of pain for at least 6 months, that the pain is not due to an active disease process for which other medical or psychiatric treatments are deemed more appropriate, and the patient's agreement to participate actively in the program and to involve his or her family members in the treatment. These programs usually design individualized patient assessments, treatments, and follow-up plans. Medication reduction, psychological treatment (di- rected particularly at depression and anxiety), family counseling, socialization skills, and educational or vocational counseling are emphasized. Physical treatment methods (e.g., transcutaneous electri- cal stimulation [TENS] and nerve blocks) and physical reactivation methods (e.g., exercise, strengthening, conditioning, postural improve- ment, and physical stress-reduction techniques) often are integral components of the treatment plan (Fey and Fordyce, 1983; Roberts and Reinhardt, 19801. Even pain management centers oriented to one primary treatment method tend to use supporting approaches as well. Thus, for example, in a program that espouses a "purely" behavioral approach, one is likely also to find occupational and physical therapy . . . activities. Despite their similar underlying philosophy, chronic pain manage- ment programs or pain clinics vary considerably. They can be roughly classified into three types, each of which may provide inpatient andJor outpatient care. (1) Comprehensive pain centers are multimodal chronic pain management programs with an integrated multidiscipli- nary rehabilitation approach that screen patients prior to admission and routinely include psychological assessment and patient follow-ups; (2) syndrome-oriented pain centers deal with discrete problems (e.g., headache, low back pain, or cancer pain) and may be uni- or multidis- ciplinary; (3) modality-oriented pain centers rely on a particular treatment (e.g., nerve blocks, psychotherapy, transcutaneous stimula-
RENABlLITATION APPROACHES ED ISSUES 235 tion) and tend not to include extensive evaluative procedures (Csordas and Clark, 19861. The Need for Standards Accompanying the rapid increase in the number of chronic pain treatment facilities are several problems for those suffering from pain, for health care providers, and for those who pay for such services. The Commission on Accreditation of Rehabilitation Facilities has begun accrediting chronic pain management programs (there were 50 accred- ited programs by mid-1986) (Whitacre, 1986~. As is true of health care facility accreditation in general, accreditation for rehabilitation facil- ities is based on the availability of particular health care professionals and services, not on the quality of treatment. These standards do require individualized treatment programs, but actual performance criteria are lacking. Performance standards could help to deal with the following three issues. 1. The variation among pain treatment facilities is a substantial problem for the patient who may be inclined to consult the first pain center recommended, assuming that they are all the same. This is especially pertinent because these centers are typically the last resort for sufferers who feel they have tried everything else. The diversity of centers also poses a major challenge for research on the comparative effectiveness of pain treatment facilities. 2. As discussed in Chapter 10, health care professionals tend not to be adequately trained to manage patients with chronic pain. Thus, some pain programs are run by well-intentioned physicians or other health care professionals who nevertheless lack specific training and experience in the management of patients with chronic pain. Further- more, there is concern that some programs are headed by untrained individuals who see the current interest in chronic pain treatment as a way to make money (Bonica, 19811. There is no easy way for either the pain sufferer or the referring physician to differentiate between the good and bad programs. 3. Properly carried out interdisciplinary rehabilitation for chronic pain can be expensive. The cost must be balanced against the patient's needs and resources, the payor of the services, the rehabilitation facility, and the overall system of health care delivery, as well as the potential economic benefit to both the patient and to society of returning an individual to work. Establishing agreed-upon standards could help resolve all three of these issues. Patients and their health care providers must be able
236 ASSESSING ED TREATING PEN ED DYSFUNCTION to decide on the basis of clear, generally accepted criteria which programs are reputable, how the programs differ from one another, and what may be the most appropriate and cost-effective treatment program for a given individual. The committee cautions against the Social Security Administration (SSA) taking any action that could lead to the further proliferation of pain clinics or centers without first setting proper performance standards. REHABILITATION TECHNIQUES FOR PATIENTS WITH CHRONIC PAIN The chronic pain patient of primary concern to the SSA is one in whom no organic or psychological cause has been identified that is sufficient to account for the pain. By the time the patient has been frustrated by the inability of numerous providers to identify the cause of the pain and resolve it, practitioners, employers, family members, and friends may increasingly question the "genuineness" of the pain. Even if the pain initially had a single treatable cause, with time it becomes enmeshed in a complex web of emotional, behavioral, and social interactions that defy simple solutions. The patient suffers not only from the inescapable pain, but also from the uncertainty as to what causes the pain. He or she sees frightful visions of what this unknown threat may portend for the future. The question facing pain centers is how such a patient can be rehabilitated and returned to function despite their pain. Regardless of the specific treatment modalities used, pain centers commonly use two general strategies for rehabilitating chronic pain patients. One approach reassures the patient that the pain will not harm them. Because most practitioners do not truly understand the pain's cause, efforts to convince the patient that the pain is harmless can be difficult and can strain the patient's credulity. The other approach encourages the patient to increase his or her activity and thus discover that this additional activity does not increase their pain. Patients are likely to become more functional as they refocus their attention toward productive and rewarding activities and away from the pain. This strategy mirrors rheumatologists' treatment for pa- tients diagnosed as having fibrositis (Bennett, 1981, 1984) or fibromy- aIgia (Yunus et al., 1982), diagnoses that have no commonly agreed- upon or well-understood etiology (Wolfe and Cathey, 19851. The following sections summarize seven treatment modalities used by rehabilitation programs for patients suffering from chronic pain: physical modalities, behavior modification, patient education, psycho-
REHABILITATION APPROACHES ID ISSUES 23 7 social rehabilitation, stress management, pain control, and vocational rehabilitation. Physical Modalities Nearly all chronic pain treatment programs include some form of physical treatment or an activities program administered by a physi- cal therapist, occupational therapist, activity therapist, or specially trained nursing staff (Tyre and Anderson, 19811. These interventions are designed to alleviate pain and to increase physical functioning. A few reports simply identify physical therapy as one treatment ap- proach without giving further details; others specify the physical modalities used. The 72 responses to a survey of the 263 U.S. centers listed in the 1979 Pain Clinic Directory of the American Society of Anesthesiologists revealed that the treatments most commonly used by physical therapists were (1) an individualized exercise program, (2) instruction in body mechanics, (3) relaxation training, (4) TENS, (~) biofeedback, and (6) group exercise (Doliber, 19841. Nearly every chronic pain rehabilitation program incorporates some form of exercise designed to increase the patient's activity tolerance and range of motion. The exercise program may include stretching, conditioning, strengthening, relaxation, or some combina- tion of these. Many exercises are incorporated into the patient's daily routine in the hope that the patient will continue the exercise at home after completing the program. TENS is used, at least occasionally, in most programs. It is nonin- vasive, relatively inexpensive, harmless, and not likely to interfere with other treatments. Although TENS helps some chronic pain patients, how any individual patient will respond is unpredictable, and its benefit for pain relief is likely to fade with time. Comparing the efficacy of vibration with that of TENS in 267 patients with chronic pain, Lundeberg (1984) concluded that TENS was generally compara- ble with but not quite as effective as vibration. Joint mobilization or manipulation is commonly practiced by phys- ical therapists, chiropractors, some osteopaths, and a few physicians. According to patient reports, chiropractic manipulation alone for chronic back pain rarely provides more than temporary relief. Manip- ulation is more useful as part of a total program than as an isolated treatment approach (Klein and Sobel, 19851. Physical therapists in over half of the 72 chronic pain programs surveyed by Doliber (1984) used hot or cold packs, massage, and/or hydrotherapy in their treatment programs. Other treatment methods
238 ASSESSING kD TREATING PEN ED DYSFUNCTION such as ultrasound, traction, and electrical stimulation were used less frequently. Chronic pain programs usually use the various methods just men- tioned in conjunction with an exercise program. Clinical experience suggests that exercise is a critical element of treatment and that the combination of exercise and other physical modalities is more effective than any single modality. In addition, there is no evidence that any one physical modality alone is totally effective in the treatment of · . c Come pam. Behavior Modification The reconceptualization of chronic pain from a disease model to a behavioral mode] was primarily the work of Fordyce and his colleagues (Fordyce et al., 19681. According to this model, regardless of its source, pain eventually develops a life of its own by interacting with environ- mental factors that reinforce pain behavior. Behavioral treatment methods attempt to improve functioning by helping patients rework and unlearn pain behaviors and by helping family members alter their responses to the patient in order to encourage better functioning. A primary goal of treatment is to demonstrate to patients that they can increase their activity levels and decrease excessive drug use without increased pain (Fordyce et al., 19851. Most pain management programs use at least some behavioral therapy, including operant conditioning, relaxation methods (biofeedback and progressive relaxation), cognitive strategies (including restructuring of thought processes or distraction), or some combination of behavioral strategies, sometimes including physical interventions (Lipton, 19861. One recent study (Heinrich et al., 1985) confirmed experimentally the general impression that pro- grams integrating physical and behavioral rehabilitation are more effective than any one approach alone. Most behavior modification programs for pain include the following seven components, with variable emphasis from program to program. 1. The patient and health care team work together to establish goals and agree on a treatment plan. Baselines of drug usage, function, and reported pain levels are recorded. 2. "Well behaviors" (e.g., recreational exercise, hobbies, social in- teractions, and vocational planning) are reinforced. "Sick behaviors" (e.g., inactivity and pain complaints) are discouraged by disregarding them. Attention is paid primarily to what the patient does rather than to what the patient says.
RENABlLITATION APPROACHES ED ISSUES 239 3. Patients suffering from drug intoxication are gradually with- drawn from nonessential pain medications, including narcotics, non- narcotic analgesics, antidepressants, muscle relaxants, tranquilizers, and sleep medications either through a "pain cocktail" or controlled decreasing dosage. 4. Daily activity quotas are established and graphed so as to increase activity levels gradually. Quotas are revised regularly to encourage progress and avoid failure. Daily graphic feedback of the activity level is considered essential to the behavior modification process. 5. A spouse, family member, roommate, or coworker is taught about pain behavior and the behavior modification approach. This person is also taught how to help replace the pain behavior with well behavior. 6. Patients are taught to generalize their well behavior by transfer- ring it from the therapeutic setting to the patient's home and voca- tional setting. 7. Because of the possibility of having overlooked organic pathology that will be exacerbated by- the exercise and activity program, or of ignoring a new illness, patients and physicians learn to distinguish "new' from "old" symptoms. New symptoms are investigated promptly. The patient is helped to live with old symptoms. Patient Education Patient education takes many forms and is included in some form in most programs. It may include audiovisual presentations, literature, and discussion about such topics as the contribution of psycho- physiological stress to chronic pain, the neurophysiology and anatomy of pain, the role of nutrition and being overweight, the proper use of pain medication, energy conservation, body mechanics, and postural awareness (Gottlieb et al., 1977; Graff-Radford et al., in press). Patient education is as varied as the differences among individual chronic pain patients and the emphasis of individual pain programs. Psychosocial Rehabilitation Some chronic pain programs emphasize psychosocial rehabilitation to help the patient function better despite his or her pain. Such approaches include the following points. · Training in coping skills to teach patients to solve problems and meet responsibilities rather than avoid them.
240 ASSESSING ED TREATING PEN ED DYSFUNCTION · Family retraining to facilitate important interpersonal responses in the modification of pain behavior. A key person is identified through whom the contribution of important others is implemented. · Social rehabilitation to encourage and reinforce increased num- bers of social contacts and activities in the therapeutic milieu and offer the completion of therapy. ~ Psychotherapy is an integral component of most treatment re- gimes. Individual, family, and group psychotherapy may be used. The manner in which this therapy is introduced to patients as well as the patients' perceptions about its potential usefulness are usually critical to its success (Coriey and Zlutnick, 19811. Stress Management Stress management is a common component of chronic pain rehabil- itation programs. It may include relaxation training, biofeedback, and hypnosis. Relaxation training was used in most of the physical therapy programs Doliber (1984) surveyed. Doliber also noted that biofeedback is commonly used by psychologists and physical therapists. Biofeed- back for reduction of muscle tension has been found helpful for upper back, neck, and shoulder pain; for tension headaches; and for jaw pain associated with teeth clenching. It is rarely helpful for low back pain (Fordyce, 19811. Medical Interventions for Pain Control Most of the treatment strategies discussed previously focus primar- ily on the improvement of function. Many medical rehabilitation approaches focus on the alleviation of pain per se. The pain control treatment approaches that may be used in rehabilitation settings include stretch and spray of muscles or injection of trigger points; vibration; nonnarcotic, analgesic, and antidepressant drugs; and pe- ripheral nerve blocks or epidural steroid injections (see Chapters 9 and 10). Attention to Myofascial Trigger Points As discussed in Chapter 10, there is still considerable controversy among physicians about the existence and treatment of myofascial trigger points. Nonetheless, some studies report that trigger points are common in chronic pain patients. Doliber (1984) found that physical therapists in 90 percent of 72 chronic pain treatment programs
REHABlLITATION4PROACHES ED ISSUES 241 reported seeing patients with myofascial syndromes, but that only 56 percent reported seeing them frequently. At the pair treatment center in Miami, 85 percent of a consecutive series of almost 400 patients were found to have myofascial trigger points (Fishbain et al., 19861. There is a growing literature reporting that recognizing and dealing with the factors that perpetuate myofascial trigger points contribute to overall treatment electiveness (Graff-Radford et al., in press). Use of Drugs As discussed ire Chapters 9 and 10, many different kinds of drugs are commonly prescribed for pain patients. Over time, many patients become involved in polypharmacy with multiple providers, which may produce untoward side effects. Most rehabilitation programs for chronic pain emphasize detoxification and withdrawal from non- narcotic and antidepressant drugs; a few programs introduce drugs as a part of their treatment program. The more powerful analgesics and muscle relaxants may interfere so seriously with function that their side effects outweigh their benefits for some patients with Tong-stand- ing chronic pain. Nonsteroidal anti-inflammatory (Irugs are considered useful in patients with primary fibromyalgia (Yunus et al., 1982; Bengtsson, 1986; Bennett, 1984), whereas myofascial pain from trigger points is rarely alleviated by these drugs (Travel! and Simons, 19831. Nerve Blocks and Epidural Steroid Injections Peripheral nerve blocks are commonly used by anesthesiologists diagnostically to localize the source of pain. Occasionally, a temporary diagnostic block proves therapeutic. In a controlled study, epidural steroid injections were found to relieve low back pain in twice as many of the treated patients as in controls, with a statistically significant advantage in the treatment groups at a 3-month follow-up (Dilke et al., 1973~. However, these injections are rarely included as a regular part of chronic pain programs. Vocational Rehabilitation One essential aspect of rehabilitation is vocational rehabilitation Vocational rehabilitation is a specialized practice that focuses on occupational or work function. Generally, vocational retraining starts in the later stages of a rehabilitation program, and builds on the gains in function achieved in the restorative program. The issue of optimum
242 ASSESSING ED TREATING PEN ED DYSFUNCTION timing for vocational counseling and training is raised frequently. It is generally believed that earlier and stronger emphasis on vocational factors, particularly on an early return to work, is likely to result in better outcomes (Goldberg, 1982; Gottlieb et al., 19771. OUTCOMES OF PAIN MANAGEMENT PROGRAMS The general message from the literature on pain management programs is that they almost universally show good effects on the basis of a variety of outcome criteria. Improvement is observed in pain self-reports, measures of physical activity level, employment status, and medication use. There are, however, some important caveats regarding the design and methodology of many of these studies, especially those conducted before about 1982 (see Aronoff et al., 1983; Fey and Fordyce, 1983; Goldberg, 1982; and I~inton, 19821. Some of the specific problems follow: · Admission criteria. Pain management programs usually are quite selective and accept only about one-third of those who are referred for evaluation. Most of the studies do not describe the characteristics of those who were denied admission. Therefore, there is no way of knowing how representative of the entire pain population those persons are who participated. Generally, the patient selection criteria are not well-enough described to enable comparisons among studies. Standardized admission protocols and comparable physical, demo- graphic, laboratory, and psychological data would be useful. · Types of patients. Patients suffering from different types of chronic pain are often reported on within the same study without proper differentiation. It is not clear whether the conclusions drawn for some groups apply to others or whether treatments effective for one type of pain will be as effective for others. This lack of differentiation further impedes comparisons between studies. · Control groups. Many studies lack control groups, and in other studies the groups are not truly comparable. Appropriate patients for such comparison groups are those who are untreated although eligible, or those who are treated only with drugs anchor surgery rather than in a multifaceted rehabilitation program. ~ Treatment ejects. The various components of treatment packages are not well-enough identified to allow an evaluation of their individ- ual components. Thus, it is not known whether the observed outcomes are attributable to particular treatment modalities or to the ~nterac- tive effects of multiple treatments.
REHABlLlTATION APPROACHES ED ISSUES 243 · Follow-up procedures. The length of time between the end of treatment and the follow-up evaluation varies considerably from study to study (and sometimes within a study for different groups of patients). Some follow-ups are conducted too soon after treatment to be informative about the robustness of the reported improvement. In addition, many follow-up evaluations depend on self-report measures alone rather than on more objective, standardized techniques; sometimes retrospective procedures are used, introducing the factor of memory into the ratings (see Chapter 111. Response rates for follow-up also vary considerably and are sometimes too low to generate reliable data. · Outcome measures and criteria for success. Outcome criterion measures are often vague, are not always quantifiable, and lack consistency from study to study. The actual data are sometimes not reported, thus restricting the ability to make judgments about clinical significance. In addition, data on the psychosocial adjustment of patients are often not reported. · Attention to vocational adjustment. There are few studies of the vocational adjustment of persons who have completed pain treatment programs (Goldberg, 19821. Those studies that are available are often too simplified and lack comparative data and control groups. Because, in the context of Social Security disability, vocational adjust- ment might be considered the most important measure of successful rehabilitation, the paucity of well-designed studies in this area is a major problem. Despite these caveats about methodology, some common conclusions emerge from the outcome studies of chronic pain treatment programs (Lipton, 19821. The Operant (or Behavioral Approach. Studies on operant condi- t~oning generally report increased activity levels in patients, reduced medication use, and Towered subjective reports of pain. According to Linton (1986), "The question is no longer 'does it work,' but 'how well does it work, for whom, and why.' " The Relaxation Approach. Relaxation, in the form of biofeedback alone, appears to yield mixed results. However, both progressive relaxation and relaxation as a coping strategy have been found useful in controlling reported pain intensity (Lipton, 19821. It can be tenta- tively concluded that, as a group, patients can benefit from relaxation treatment. An advantage of these techniques is that they are rela- tively inexpensive and easy to administer.
244 ASSESSING ED TREATING PEN ED DYSFUNCTION The Cognitive Approach. Studies using a cognitive-behavioral ap- proach tend to focus on acute (often laboratory-induced) pain, and few use a purely cognitive approach. No strong evidence indicates that cognitive strategies are effective as a treatment of choice for chronic pain (L`inton, 19821. The Multimodal Approach. Studies of multimodal treatment meth- ods generally report considerable improvement at discharge and fol- Tow-up, but they have the same methodological weaknesses as the others. That is, the methods and treatments used varied significantly from study to study, making them difficult to compare. Further, usually the individ- ual components of the treatment techniques are not described. Recent research (roughly post-1982 into the outcome of chronic pain treatment has been much improved (Keefe and Gil, 1985; Linton, 19861. Research design and methodology is better; in addition, important ad- vances in behavioral assessment and treatment methods have been made. A considerable amount of attention has been directed at developing reliable and objective methods for recording behavioral, cognitive, and physiological responses. There is a growing use of standardized question- naires to assess functional status and to measure the severity and quality of pain, and of data analysis using multivariate techniques that pelt simultaneous examination ofthe determinants of treatment response and control for status variables. Other improvements include · increased attention to social and environmental variables that may influence behavioral responses; ~ more standard methods for evaluating antecedents that may elicit maladaptive pain behavior patterns and for evaluating the conse- quences of changing these behaviors; · identification of behavioral and psychological variables that may predict treatment response; and ~ comparison of behavioral approaches to other treatments rou- tinely used in the management of chronic pain. The development of improved outpatient programs for the behav- ioral management of chronic pain has been described as a major advance, as these programs provide for substantial cost savings and less disruption of patients' lives (Keefe and Gil, 19851. An increased emphasis on planning for a patient's return to work, the inclusion of the spouse in the treatment program, and a focus on the collection of long-term, more objective measures of follow-tip data all are important advances in pain treatment programs and research. Yet even with these improvements in treatment and methodology, it
REHABl[ITATlON APPROACHES ED ISSUES 245 is important to recognize that rehabilitating chronic pain patients to their prepain level of functioning is not always possible (Lipton, 19821. Some of the most successful programs evaluated ire well-designed studies report 1-year success rates of about 50 percent (Cinciripini and Floreen, 1982; Gottlieb et al., 19771. Thus, complete rehabilitation of every patient is not currently a realistic goal; treatment, therefore, should be aimed at helping the patient live as normally and produc- tively as possible. Indeed, with this in mind, the appropriate question may not be whether pain management programs are successful, but rather which programs or treatments are most (and least) successful with different types of pain patients (Aronoff et al., 1983~. Research on specific components of successful programs would help to identify their most effective aspects, and comparative studies would further help to refine the programs. In addition, given the limitations of even the most successful treatment programs, the prevention of the development of chronic pain should be an important clinical research priority. In conclusion, it now appears that although the early research efforts investigating the effectiveness of pain management programs were weak, recent work has been more scientifically rigorous. Data from these later studies continue to support the general impression that rehabilitative approaches to chronic pain are elective. However, much more work is required before any particular program or programs can be recommended as the best clinical solutionfs) to the problem, either in general or for specific patients. EMPLOYMENT AND COMPENSATION AS INCENTIVES OR DISINCENTIVES IN OUTCOMES OF PAIN MANAGEMENT PROGRAMS A specific question the Institute of Medicine (IOM) committee was asked to explore was whether receiving disability benefits exerts a negative influence on rehabilitation outcomes, especially on the return to work. This is part of a larger issue about the effects of monetary transfers on work incentives discussed in Chapter 4. Despite the common belief that compensation and litigation are disincentives to the successful rehabilitation of chronic pain patients, the literature increasingly reveals that there is no direct effect. Conversely, of more than passing clinical interest are the results indicating that employ- ment continued or resumed during or immediately after the course of treatment has positive effects on rehabilitation. This information fits well with the view that early rehabilitation and treatment directed toward resumption of a normal life role is desirable.
246 ASSESSING ED TREATING PEN ED DYSFUNCTION Employment as a Factor in Treatment Outcome Results from chronic pain program studies of the relation among compensation benefits, pending litigation, and treatment response are inconsistent. The one consistent finding is that patients who are employed at the outset of treatment appear to have better outcomes. Dworkin et al. (1985) studied the effects of compensation, litigation, arid employment on the treatment responses of chronic pain patients. In a univariate analysis, there were significantly poorer outcome ejects both for those receiving compensation and for those not work- ing. However, when both variables were examined in multiple-regres- sion analyses, only employment had a significant effect on outcomes. Based on these findings and those of other authors (CatchIove and Cohen, 1982; Newman et al., 1978; Seres et al., 1981) indicating that employed patients have better treatment outcomes, Dworkin and his group proposed that the inconsistent results in the literature may be explained by: (1) differences among studies in the proportion of patients who are receiving compensation or have litigation pending and who are also working, (2) variability in compensation laws among states and countries, and (3) differences in the nature of pain treat- ment programs. Several other studies address the issue in various ways. Catchiove and Cohen (1982) conducted a retrospective study of patients who at the outset of treatment were not working and were receiving Workers' Compensation benefits for pain. The patients in the experimental group (~) had been told that returning to work within 1-2 months of beginning treatment was an integral part of the pain treatment program. The control group (~) was made up of patients treated at the center before the requirement to return to work was part of the program. Fifty-nine percent of patients in the experimental group and only 25 percent of those in the control group returned to work during treatment. Ninety percent of the experimental patients who had returned to work on instruction were still working after an average of 9.6 months. Seventy-five percent of control patients who returned to work were still working after 20 months. On follow-up, fewer experi- mental patients were receiving compensation benefits. Of the patients from both groups who were not working, 65 percent continued to receive compensation. Although low back pain was the presenting symptom for 50 percent of patients in both groups, at follow-up it was found that this group was overrepresented among those who had returned to work. However, although this study demonstrates the importance of the expectation that patients will return to work, it
REHABILITATION APPROACHES ID ISSUES 247 should be noted that 40 percent of the experimental patients did not go back to work even when they had been instructed to do so. In another study, Carron and his colleagues (1985) compared chronic low back pain patients at a pain center in the United States with those in a treatment center in New Zealand. They investigated psychosocial and economic factors that may influence disability and recovery in patients from countries with different approaches to the handling of disability compensation. The two groups were demographically simi- lar. However, at initial contact, 49 percent of the U.S. sample were receiving financial compensation as compared with only 17 percent of -the New Zealand sample; in addition, 56 percent of the U.S. patients attributed the pain to a work injury, whereas 37 percent of the New Zealanders did so. Treatment approaches at the two centers were determined to be equivalent; both were outpatient programs following an integrated treatment model based on Fordyce's (1968) behavior modification approach. Patients were assessed by a self-a~ninistered questionnaire pre- and posttreatment. On the pretest, U.S. patients reported significantly greater emotional and behavioral disruption as a result of their pain; they used more medication and were more hampered in personal and vocational functioning. The amount of improvement 1 year after treatment was nearly equal in the two groups; the New Zealand group maintained its initial relative advantage. The anthers attribute these differences in functioning despite the similarity in duration, fre- quency, and intensity of pain to the following aspects of disability management in New Zealand: (1) the availability of Worker's Com- pensation unrelated to on-thejob injury; (2) an absence of adversarial relationships among employer, insurer, and claimant (i.e., no-fault compensation); (3) a required rehabilitation intervention within 30 days of injury; and (4) extensive efforts to place the disabled worker in a job suited to his or her impairment, with substantial penalties for refusing such employment. Seres, Painter, and Newman (1981) studied a patient population in which 40 percent were blue-collar workers in such occupations as construction, logging, and trucking; 84 percent were covered by some form of Workers' Compensation. Results of the study were that full-time employment was associated with maintaining or improving the ability to function; that part-time employment and student status were associated with similar although less striking results; and that not engaging in any such activities resulted in significant regression. Similarly, in an evaluation of Tow back pain patients 80 weeks after rehabilitation treatment, Newman and his colleagues (1978) found
248 ASSESSING ED TREATING PEN ED DYSFUNCTION that full-time workers maintained the greatest gains in physical functioning and in reducing the need for medication. It should be noted that not enough information is available in these studies to allow us to rule out the possibility that those employed, or able to return to work early in treatment, had less severe conditions than other individuals from the outset. It is not clear how these studies apply to Social Security Disability Insurance (SSDI) beneficiaries because in order to be eligible for SSA benefits one cannot be working and must be expected to be disabled for at least 1 year. Taken as a whole, however, the results of these studies seem to indicate that increased attention to vocational rehabilitation for chronic pain pa- tients is warranted. The education of physicians and other treatment providers, the public, and the pain-impaired individual should focus on the possibility, desirability, and encouragement of those with pain returning to work and other activities. Specific instruction about self-regulation of medication and self-management of pain may help reduce illness behaviors that can lead to the inability to work and aid in the adoption of healthful, productive behaviors. Compensation Status as a Factor in Treatment Outcome As mentioned previously, whether the receipt of financial compensa- tion (or the expectation of it from a pending application or legal action) is a disincentive to rehabilitation is a particularly controversial issue. The literature is equivocal on this question and neither dispels nor confirms the common perception that compensation has a negative influence on rehabilitation. Moreover, studies of this issue tend to be flawed in ways that make all conclusions and pronouncements questionable. First, a number of different outcome measures are used. These include improvement in physical functioning, medication reduction, modification of patient attitudes, and a decrease in subjective reports of pain. Return to work is neither the exclusive nor even the major outcome criterion measure of most programs, but it is the outcome of greatest interest to disability insurers. A second major problem with the studies is that not enough detail is given about the patients being studied to know whether their condi- tions were comparable at the outset. Severely disabled people who are receiving compensation may be unsuccessful in their rehabilitation attempts; less severely disabled people who are not receiving benefits may be more successful in their rehabilitation efforts. These differ- ences are to be expected from the relative severity of the patients' conditions and are not, in themselves, proof that receiving compensa-
REHABILITATION APPROACHES ID ISSUES 249 tion is a disincentive to rehabilitation. Not only the diagnosis but also the symptoms, functional capacities, and duration of time with the condition need to be specified and controlled in order to study this question properly. Third, often different kinds of compensation are not distinguished. Because each disability program has different eligibility criteria, it is important to identify particular programs if one wishes to examine the question of incentives. Studies examining the relation between compensation and treat- ment response in patients participating in multidisciplinary pain programs present conflicting evidence. Some studies report differences in outcome, with compensation and disability payment patients exhib- iting less successful results (Block et al., 1980; Brena et al., 1979; Finneson, 1977; Fordyce, 1985; Hammonds et al., 1978; Herman and Baptiste, 1981; Krusen and Ford, 19581. However, other studies have found no significant relation between compensation and treatment outcome (Aronoff and Evans, 1982; Brena et al., 1979; Chapman et al., 1981; Leavitt et al., 1982; MeIzack et al., 1985; Mendelson, 19~34; Painter et al., 1980; Peiz and Merskey, 1982; Rosomoff et al., 1981; Trief and Stein, 19851. "Compensation neurosis"* (sometimes called accident or litigation neurosis) is a frequently mentioned concept in the literature on compen- sation as an influence on recovery. It has been described as a situation in which symptoms occur as a result of an injury or condition for which compensation is being sought, and in which the possibility of financial compensation is thought to be the most significant factor maintaining the symptoms (Weighill, 19831. The theory that such problems are resolved on settlement of a compensation claim is generally not supported (Mendelson, 1984; Tarsh and Royston, 1985~. Furthermore, different outcomes might be expected depending on whether the compensation is in the form of monthly payments or a lump sum award. The literature typically does not differentiate between these possibilities. Studies Suggesting a Negative Effect of Compensation on Outcome Krusen and Ford's 1958 study was one of the first to conclude that patients receiving Workers' Compensation did not benefit from treat- * It should be noted that this is not a psychiatric diagnosis but an informal term adopted by some in an attempt to explain an observed phenomenon.
250 ASSESSING ED TREATING PEN ED DYSFUNCTION ment as much as those not receiving compensation. Major design problems marred this study, primarily in that the two groups were not comparable on sex or initial diagnosis, and improvement was measured only in terms of the discontinuation of pain complaints and the subse- quent resumption of normal activities, including work. In addition, because this study was done wholly through retrospective chart review, data may be tainted by the caregiver's subjective interpretations. Hammonds, Brena, and Unike] (1978) focused on chronic pain patients for whom the primary treatment was the administration of sympathetic nerve blocks as a positive reinforcer for the achievement of particular behavioral goals. Patients receiving compensation were less likely to merit a block than were those not receiving compensa- tion. Further, although not statistically significant, noncompensation patients decreased their semantic index of pain verbalization after they improved functionally, whereas that of compensation patients increased after treatment. The authors concluded that pain behavior is reinforced by conditioning and that financial compensation operates as a reward for the learned pain behavior. Brena, Chapman, Stegall, and Chayette (1979) drew a similar conclusion from a study of 101 patients, all of whom had pending disability cases. (Later studies by this group, however, found no significant relation between compensation and rehabilitation outcomes.) Trief and Stein (1985) evaluated the erects of pending litigation for compensation on treatment outcomes in patients with chronic low back pain who participated in a 6-week behavioral treatment program. The patients were differentiated according to whether they had unsettled legal claims for compensation. Although both groups improved signif- icantly as a result of treatment, there were some differences on specific measures between the two groups. Patients without pending litigation obtained significantly greater reduction on the hypochondriasis and hysteria scales of the Minnesota Multiphasic Personality Inventory (M~D, any achieved "relatively greater," although not significantly different statistically, improvement on two out of three physical mobility behavior measures. Block et al. (1980) reported on a study of patients divided on the basis of referral source. Patients referred from a disability program (Workers' Compensation or other), although significantly improved after a behavioral treatment program, did less well than those referred by physician specialists. In a 1981 article, more valuable for its descrip- tion of on approach to the management of pain than for its research method, Herman and Baptiste found work incentive, employment, and the absence of litigation or Workers' Compensation claims to be signifi-
REHABILITATION APPROACHES ID ISSUES 251 cant in differentiating successes from failures. They concluded that the greatest deterrent to work was the "secondary gain" received or elected from Workers' Compensation and pending litigation. In an exploratory study using discrim~nant analyses, Guck et al. (1986) found that age, compensation status, and education level, taken together, were significant predictors of treatment outcome. In addition, successfully treated patients tended to be younger and less likely to be . . . receiving compensation. Studies Suggesting Little or No Negative Effect of Compensation A number of studies show little difference in outcome between patients who claim compensation and those who do not when their psychological or physical states are assessed. Chapman, Brena, and Bradford (1981) found that pending or current disability claims are "not necessarily" an indication of likely treatment failure. Treatment in this study combined an operant conditioning approach emphasizing patient education and counseling in an attempt to refine internal coping mechanisms and abilities to adopt healthy life behaviors despite pain. Chapman and his colleagues (1981) studied 100 patients, at an average of 21 months posttreatment, divided into three categories of Usability status: currently receiving long-tenn disability payments, baring a pending claim for compensation, and not currently receiving or seeking compensation. They found that changes from pretreatment to foBow-up were not significantly different among the three groups. Commenting that a significantly higher percentage of patients with pending disability claims returned to work compared with those currently receiving disability compensation, the authors suggest that granting open-ended disability be done cau- tiously so as to avoid establishing a permanent sick role. Similar findings are reported by Brena, Chapman, and Decker (19811. Meizack et al. (1985) examined patients suffering from low back pain or other musculoskeletal pain. All were tested on the McGill Pain Assessment Questionnaire (MPQ) and the MMPI. Compensation and noncompensation patients had nearly identical pain scores and pain descriptor patterns. The groups were also similar on the MMPI pain triad (depression, hysteria, and hypochondriasis) and on several other personal variables. Significantly Tower affective or evaluative MPQ scores and fewer visits to health care professionals were made by compensation patients. The authors suggest that the financial security of compensation decreases anxiety, resulting in lower affective ratings but unchanged sensory or total MPQ scores. Rosomoff et al. (1981) looked at low back pain patients who presented
252 ASSESSING ED TREATING PEN ED DYSPUNCTION at a clinic as totally disabled; the majority were in unskilled and semiskilled jobs requiring heavy labor. At the outset, 59 percent were receiving compensation and 41 percent were not. At follow-up (an average of 11 months after the end of treatment), 86 percent of the total group and 88 percent of the compensation patients reported fiall levels of function. Also at follow-up, 70 percent of the entire group and 65 percent of the compensation group were "effectively and appropriately occupied," having returned to work or school or resumed their usual activities. The authors found no difference between groups and concluded that compen- sation status in and of itself does not affect the final outcome of patient functioning. They attribute success to early and aggressive job planning and placement as a central component of treatment. Peiz and Merskey (1982) examined the social adjustment and psy- chological characteristics thought to be representative of a pain clinic population. They examined the effects on personal and social life, spontaneous descriptions of pain, the frequency of depression, and the personal characteristics of chronic pain patients. Interviewers admin- istered the Hopkins Symptom Check List-90 and the Levine-Pilowsky Depression Questionnaire. Patients receiving compensation differed from others only in their higher somatization scores, a difference the authors suggest could have been an artifact of sampling resulting from the unequal sex ratios in the two groups. REHABILITATION ISSUES IMPORTANT TO THE SSA The SSA and Vocational Rehabilitation Administrators of the Social Security disability system historically have relied on the joint federal-state program of vocational rehabili- tation to provide rehabilitation services; this has been an uneasy alliance. One reason for housing the disability determination services at the state level in the first place was to allow the state rehabilitation agencies to screen applicants for vocational rehabilitation services. Another reason was that the arrangement was thought to be cost elective. Between 1954 and 1965, legislative amendments provided both a carrot and a stick to foster rehabilitation. In 1954, when an earnings freeze for disabled workers was passed, the law required the referral of disabled workers to state vocational rehabilitation agencies. When cash benefits were introduced in 1956, a similar referral provi- sion was included with the additional specification that benefits could be withheld or reduced if the disabled beneficiary refused rehabilita- tion services without good cause. The creation of a trial work period
REHABILITATION APPROACHES ID ISSUES 253 was also intended to foster rehabilitation. Despite these measures, the number of beneficiaries who were rehabilitated was small (Treitel, 1979). In an attempt to improve SSA's performance in rehabilitating beneficiaries, Congress established the Beneficiary Rehabilitation Pro- gram (BRP) as part of the 1965 Social Security amendments. Previ- ously, the federal government had provided 80 percent of the voca- tional rehabilitation funds, while the remaining 20 percent came from the states. Under the BRP, the federal government provided 100 percent of the rehabilitation funds; the goal was to stimulate the states to greater rehabilitation activity. Clients had to meet four eligibility requirements, the most important of which was that the predicted period of productive work should be long enough so that the benefits saved would offset the cost of the rehabilitation services. Initially, the maximum amount of SSDI trust funds allocated among the states was fixed at 1 percent of the year's total SSDI payments. In response to the program's encouraging start, the maximum was increased to 1.25 percent in 1973 and 1.5 percent in 1974. The BRP ultimately failed for a number of reasons. Some observers felt that funds had been poured into the state programs faster than they could be wisely spent. The allotment for 1972 was $40.5 million; by 1976 the amount had reached $102.6 million. Questions were raised about the effectiveness of the program, and a number of cost-benefit analyses were conducted, with equivocal results. It was difficult to tell whether all of the clients who had been accepted into the program actually met the eligibility requirements and it was more difficult still to tell whether the recovery of the clients could be attributed to the services received. The program's objective was not to restore the client to maximum effectiveness but to enable him or her to engage in "substantial gainful activity" and hence leave the benefit rolls. In 1981, Congress effectively abandoned the BRP program; since then, state vocational rehabilitation agencies have been reimbursed only for services to federal disability beneficiaries who have been able to return to work for 9 consecutive months (Berkowitz and Fox, 1986~. Less than $1 million per year is currently appropriated to the states for this program. Measurement and Evaluation of Pain The problem for the SSA in determining entitlement for disability benefits or remedial services for chronic pain patients appears to revolve around the difficultyif not impossibilityof objectively mea-
254 ASSESSING ED TREATING PEN ED DYSFUNCTION suring pain (see Chapters 7 and 11~. One solution that has been proposed is to focus on the functional limitation caused by the pain that prevents the person from carrying out a fully active life. Func- tional limitation is more precisely describable than pain, and certain key elements of it can be measured with acceptable validity and reliability. For example, it is possible to verifier alterations in the performance of the activities of daily life. Communication, self-care performance, mobility status, and social activity inside and outside the home or in the workplace could all be used to assess the disabling consequences of chronic pain. Thus, one realistic approach in determining eligibility for the various benefits available is to define that eligibility by a more precise measurement of the components of dysfunction and disability and to use functional assessment as a surrogate for the measurement of pain. Disability level, as demonstrated by properly designed functional tests, may be the most objective and appropriate evidence of the inability to work caused by pain. The Question of Mandatory Rehabilitation There appears to be a trend toward viewing rehabilitation (as defined in this chapter) as the preferred method for the treatment of patients with chronic pain. The Commission on the Evaluation of Pain subscribed to this view, although it stopped short of recommending mandatory rehabilitation for all chronic pain patients. This commit- tee, too, feels that there would be critical problems with such a recommendation. As has been reiterated throughout this report, it is not known how many people have chronic pain or how many of them have conditions that are due to treatable but undiagnosed conditions. Further, not enough is known about existing chronic pain rehabilita- tion facilities in teens of their adequacy, their comparative effective- ness, or their ability to meet either strict standards or a requirement for accreditation. We do know that the number of high-quaTity pro- grams with experienced stab and a focus on the Social Security population is limited and that some of the most successful programs accept only 30 to 40 percent of those referred for pain rehabilitation. We also know that combinations of treatment modalities appear to be elective, but there are insufficient data available to recommend one type of rehabilitative program over another. Quite apart from the practical considerations, there are serious ethical problems in mandating treatment or rehabilitation in order for pain claimants to get benefits. Such a requirement would raise
REHABILITATION APPROACHES ID ISSUES 255 questions of fairness and equity: Would it be fair for pain claimants to have to meet requirements that no other claimants must meet? Conversely, would it be fair for pain claimants to receive a benefit (automatic access to rehabilitation programs) that no other claimant receives? In addition, mandatory treatment would compromise the claimants' autonomy and voluntariness, both of which are key ele- ments in the doctrine of informed consent. Finally, the inception of mandatory rehabilitation would risk promoting a rapid proliferation of pain centers of poor quality because of the sudden availability of funds to pay for such rehabilitation efforts. For all of these reasons, the committee cannot recommend a mandatory rehabilitation require- ment for SSA pain claimants. Research and Demonstration Projects The pain management programs reviewed earlier in this chapter are restorative in their orientation and rehabilitative in their treat- ment approach. Despite methodological shortcomings in study designs, an increasing body of literature supports the view that comprehensive multidisciplinary rehabilitation, provided in special- ized clinics, is useful in reducing the disability and dysfunction associated with chronic pain. Because the programs vary so much in the specific techniques used to rehabilitate pain patients, little is known about which treatment or set of treatments is responsible for the observed improvements. It appears that a multimodality, multidisciplinary approach Is critical, but much more research is needed. Specifically, a major research and demonstration effort is needed to assess the efficacy of comprehensive rehabilitative management services for chronic pain patients. The design should focus on clinical factors and on issues of social and economic policy. The clinical aspect should include research into the process and outcome of rehabilita- tive treatment studied at selected demonstration sites. The study centers should have a comprehensive interdisciplinary approach to chronic pain rehabilitation and a clear definition of the elements of the treatment process. Sites should be chosen that offer differing combinations of treatment approaches to allow a comparison of these various approaches. Common admission and outcome criteria and uniform follow-up evaluation protocols should be used at all sites. The companion policy research effort should include attention to the possibilities that follow.
256 ASSESSING kD TREATING PMN ED DYSFUNCTION 1. Earner Identification and Entry into the System Under SSA rules, a claimant cannot receive benefits until at least 5 months after the onset of a disabling condition. Furthermore, the elapsed time between initial filing and granting of benefits, especially for claimants whose level of dysfunction seems disproportionate to objective medical findings, is often a year or more. Clinicians have observed that the more time that passes, the harder it is to intervene successfully with pain patients. A well-designed, well-evaluated demonstration project to determine the feasibility of early identification and the effects of early rehabili- tation would add significantly to our current knowledge of the predic- tion of long-term disability, the optimal timing and content of reha- bilitation, and the relative costs and benefits of early versus late intervention. In designing such a project, several difficult questions emerge. · How does one identify people earlier? · Who should identify them? · What kinds of people are being sought? Can "high-risk" categories be identified? · Who will be responsible for providing rehabilitation services and for the costs of such services? 2. Expansion of the Initial Assessment of Pain Claimants to Incor- porate a More Functional Approach Medical criteria are used as a basis for presuming or establishing the inability to work. Disability in excess of objective medical evidence, as is often the case with chronic pain claimants, leads to denial of benefits and to possibly unnecessary reviews and appeals. Pain claimants should be able to proceed to the stage of the evaluation process in which the ability to function in working and in performing basic activities is assessed. Such an evaluation is then directly relevant to questions about the possibility of rehabilitation for chronic pain claimants. 3. Disentangling the Current Requirements for Proof of Work Disability and the Requirements for Acceptance into Vocational Rehabilitation The SSA's definition of disability requires the total inability to work. To be eligible for state or federal vocational rehabilitation, however, claimants must be able to demonstrate a future likelihood of employ- ment. This is an inconsistency that must be resolved if claimant rehabilitation is to be achieved.
RENABlLITATION APPROACHES AND ISSUES 257 4. Coordination of Disability Benefits Programs and Rehabilita- tion Services As discussed previously, although state vocational rehabilitation agencies are linked to the SSA, they treat relatively few SSDI or Supplemental Security Income beneficiaries. If rehabilitation is to be an integral part of the federal disability program, the administration and funding of these activities must be better coordinated. 5. Emphasis on Existing Incentives Currently, the Social Security disability programs include provisions designed to encourage people to try to work, such as a trial work period during which disability and medical benefits continue. These features seem to be used very infrequently, at least partly because physicians, lawyers, and beneficiaries are unaware of them. A concerted educational/ information campaign should be undertaken to highlight these provisions and to encourage beneficiaries to take advantage of these opportunities. REFERENCES Aronoff, G.M., and Evans, W.O. The prediction of treatment outcomes at a multidiscipli- nary pain center. Pain 14:67-73, 1982. Aronoff, G.M., Evans, W.O., and Enders, P.L. A review of follow-up studies of multidis- ciplina~r pain units. Pain 16:1-11, 1983. Bengtsson, A.. Primary fibromyalgia: a clinical and laboratory study. Linkoping, Sweden. Linkoping University Medical Dissertations No. 224, 1986. Bennett, R.M. Fibrositis: misnomer for a common rheumatic disorder. Western Journal of Medicine 134:40~13, 1981. Bennett, R.M. Fibrositis: does it exist and can it be treated. Journal of Musculoskeletal Medicine 1(7):57-72, 1984. Berkowitz, E., and Fox, D. The Struggle for Compromise: Social Security Disability Insurance, 193~1986. Background paper prepared for the Institute of Medicine Committee for a Study of Pain, Disability, and Chronic Illness Behavior, 1986. Block, A.R., Kremer, E., and Gaylor, M. Behavioral treatment of chronic pain: variables affecting treatment efficacy. Pain 8:367~75, 1980. Bonica, J.J. Preface. NIDA Research Monograph 36, Rockville, MD, pp. vii-x, 1981. Brena, S.F., Chapman, S.L., and Decker, R. Chronic pain as a learned experience: Emory University Pain Control Center. NIDA Research Monograph 36, Rockville, MD, pp. 7~83, 1981. Brena, S.F., Chapman, S.L., Stegall, P.G., and Chayette, S.B. Chronic pain states: their relationship to impairment and disability. Archives of Physical Medicine and Reha- bilitatzon 60:387~89, 1979. Carron, H., DeGood, D.F., and Tait, R. A comparison of low back pain patients in the United States and New Zealand: psychological and economic factors affecting severity of disability. Pain 21:77-89, 1985. Catchlove, R., and Cohen, K. Effects of a directive return to work approach in the treatment of workmen's compensation patients with chronic pain. Pain 14:181-191, 1982.
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