The Disparagement of Pain: Social Influences on Medical Thinking

Patients with pain often feel that their suffering is taken lightly, dismissed or denied. Before the introduction of anesthesia, pain was regarded as an awful affliction. This view diminished somewhat once anesthesia became available, although it still holds true for some forms of pain, eg, pain associated with terminal cancer. Pain was then treated as less troublesome when it became a reason for disability compensation to be paid. Examples are given of the disparagement of complaints by individuals reporting pain in the past 150 years. Factors that encourage doctors to underestimate patients' pain include the requirement for doctors to control the issue of narcotics; circumstances in which patients may benefit from compensation by claiming that their pain is great; and the development of attitudes that understate the importance of the relief of pain and overstate the importance of activity, exercise and not complaining. Current attitudes in this respect are associated with the insurance industry, but it has been shown that, even patients who do not have a compensable injury or have pain that is not disabling fail to receive the treatment for pain that is appropriate, eg, postoperatively. The present paper reviews and discusses these problems and suggests that disparagement of pain and disability in the medicolegal field also leads to the rejection of pain in other contexts

State-of-the-art clinical assessment of hand function

We have assembled a multi-disciplinary team of engineers, surgeons, clinicians and neuroscientists from Johns Hopkins School of Medicine and Western University to develop a new device for assessing hand function. It will be capable of sensitively measuring fingertip forces across all five fingers and along all movement directions. Then we can use this device to develop and validate a clinical hand assessment for patients with brain injuries.https://ir.lib.uwo.ca/brainscanprojectsummaries/1005/thumbnail.jp

What matters to program partners when implementing a community-based exercise program for people post-stroke? A theory-based qualitative study and cost analysis

BackgroundCommunity-based exercise programs integrating a healthcare-community partnership (CBEP-HCP) can facilitate lifelong exercise participation for people post-stroke. Understanding the process of implementation from multiple perspectives can inform strategies to promote program sustainability.PurposeTo explore stakeholders' experiences with undertaking first-time implementation of a group, task-oriented CBEP-HCP for people post-stroke and describe associated personnel and travel costs.MethodsWe conducted a descriptive qualitative study within a pilot randomized controlled trial. In three cities, trained fitness instructors delivered a 12-week CBEP-HCP targeting balance and mobility limitations to people post-stroke at a recreation centre with support from a healthcare partner. Healthcare and recreation managers and personnel at each site participated in semi-structured interviews or focus groups by telephone post-intervention. Interviews and data analysis were guided by the Consolidated Framework of Implementation Research and Theoretical Domains Framework, for managers and program providers, respectively. We estimated personnel and travel costs associated with implementing the program.ResultsTwenty individuals from three sites (4 recreation and 3 healthcare managers, 7 fitness instructors, 3 healthcare partners, and 3 volunteers) participated. We identified two themes related to the decision to partner and implement the program: (1) Program quality and packaging, and cost-benefit comparisons influenced managers' decisions to partner and implement the CBEP-HCP, and (2) Previous experiences and beliefs about program benefits influenced staff decisions to become instructors. We identified two additional themes related to experiences with training and program delivery: (1) Program staff with previous experience and training faced initial role-based challenges that resolved with program delivery, and (2) Organizational capacity to manage program resource requirements influenced managers' decisions to continue the program. Participants identified recommendations related to partnership formation, staff/volunteer selection, training, and delivery of program activities. Costs (in CAD) for first-time program implementation were: healthcare partner ($680); fitness coordinators and instructors ($3,153); and participant transportation (personal vehicle: $283; public transit:$110).ConclusionDuring first-time implementation of a CBEP-HCP, healthcare and hospital managers focused on cost, resource requirements, and the added-value of the program, while instructors and healthcare partners focused on their preparedness for the role and their ability to manage individuals with balance and mobility limitations. Trial Registration: ClinicalTrials.gov, NCT03122626. Registered April 17, 2017—Retrospectively registered, https://www.clinicaltrials.gov/ct2/show/NCT0312262

Isolated Facet Joint Fracture as a Cause of Chronic Low Back Pain and Sciatica

A case of facet joint fracture following a rear-end motor vehicle accident who presented with chronic low back pain and sciatica is outlined. Diagnosis was made with 99Tc nuclear bone scan and was confirmed on computed tomographic scan after diagnosis with regular radiographs had failed. Facetectomy relieved pain but led to symptoms related to asymmetric load on the opposite facet joint. Symptoms were substantially relieved with a facet joint deinnervation procedure. Facet joint fracture was felt to occur as a consequence of compression forces on the facet joint at the time of impact

Thalamic or Central Pain States Poststroke

Thalamic or central pain states are generally regarded as rare in stroke, occurring in fewer than 2% of patients. However, a recent study suggests that they may be more common, occurring in up to 8% of unselected stroke patients. Cerebrovascular lesions leading to central pain states do not necessarily involve the thalamus, but can occur following lower brainstem and suprathalamic lesions. Damage to the spinothalamocortical tract appears to be a prerequisite to the development of central poststroke pain (CPSP). Development of CPSP is likely related to denervation hyperexcitability of third or fourth order, thalamic or cortical neurons. Central pain is often described as a 'burning' sensation in association with an unpleasant association of tingling, pins and needles, or numbness. Spontaneous or evoked dysesthesia and allodynia/hyperalgesia are common. Central or thalamic pain is generally intractable to most therapeutic interventions. One case is presented to illustrate the typical clinical presentation of thalamic pain states and the difficulties in treating this pain

Chronic Pain Disability in the Workplace

Chronic pain disorders have been associated with increasing disability expenditures in Western industrialized countries. The reason for this increase is unknown. Many chronic pain disorders have been characterized by a lack of readily demonstrable pathology, resistance to treatment and associated psychosocial difficulties. The difficulties inherent in the diagnosis and treatment of chronic pain disorders are compounded by problems in determining disability and entitlement to compensation. Recent attempts to label chronic pain disorders as solely psychosocial issues to the exclusion of biological issues appear to be misguided, particularly in the light of recent evidence supporting an organic etiology in several chronic pain conditions. Such an approach will disproportionately affect those in lower socioeconomic groups in an effort to contain costs. The long term cost to society of targeting a highly vulnerable group with such an approach remains to be determined