Sixty-five studies that evaluated the efficacy of multidisciplinary treatments for chronic back pain were included in a meta-analysis. Within- and between-group effect sizes revealed that multidisciplinary treatments for chronic pain are superior to no treatment, waiting list, as well as single-discipline treatments such as medical treatment or physical therapy. Moreover, the effects appeared to be stable over time. The beneficial effects of multidisciplinary treatment were not limited to improvements in pain, mood and interference but also extended to behavioral variables such as return to work or use of the health care system. These results tend to support the efficacy of multidisciplinary pain treatment; however, these results must be interpreted cautiously as the quality of the study designs and study descriptions is marginal. Suggestions for improvement in research designs as well as appropriate reports of research completed are provided.

Efficacy of multidisciplinary pain treatment centers: a meta-analytic review.

We need a feminist theory of disability, both because 16 percent of women are disabled, and because the oppression of disabled people is closely linked to the cultural oppression of the body. Disability is not a biological given; like gender, it is socially constructed from biological reality. Our culture idealizes the body and demands that we control it. Thus, although most people will be disabled at some time in their lives, the disabled are made “the other,” who symbolize failure of control and the threat of pain, limitation, dependency, and death. If disabled people and their knowledge were fully integrated into society, everyone's relation to her/his real body would be liberated.

Toward a Feminist Theory of Disability

Although published treatment outcome studies for chronic pain have provided favorable support for the efficacy of many pain clinics and the use of specific modalities such as biofeedback and relaxation, there are several factors that mitigate against euphoria. Two related factors that influence interpretation of these reported outcomes are discussed, namely, noncompliance with therapeutic recommendations during treatment and subsequent to treatment termination, and relapse. Conceptual and methodological problems for establishing the prevalence of noncompliance and relapse are reviewed. Several factors that contribute to noncompliance (individual differences, nature of disease or injury, characteristics of the prescribed treatment regimen, health-care provider-patient relationship, and contextual) are discussed. The literature reveals that noncompliance with treatment regimens is quite prevalent across diverse treatment modalities and pain syndromes. The incidence of relapse following initially successful treatment of persistent pain also appears to be high, ranging from 30% to 60%. Studies on arthritis and heterogeneous pain clinic populations suggest that noncompliance and relapse are related; however, this association is less well established for headache patients. Strategies for assessing compliance (i.e., self-report, behavioral, biochemical, and clinical outcome) and the perspectives' of patients and health-care providers on the application of self-care recommendations are discussed. Strategic planning and adherence enhancement tactics to facilitate maintenance of post-treatment gains are described.

Neglected topics in the treatment of chronic pain patients — relapse, noncompliance, and adherence enhancement

Non-surgical treatments of back pain may have prolonged and lasting benefit. Epidural steroid injections is one of the non-operative managements of back pain. These injections are recommended in patients with signs and symptoms of nerve root irritation. Relief of pain is attributed to the anti-inflammatory effect of the steroid. Patients with acute radiculopathy have better response compared to patients with chronic symptoms. Improvement may not be noted until 6 days after the injection. The depression of the hypothalamic-pituitary-adrenal (HPA) axis lasts 3 weeks. While complications have been reported, these are rare. Intrathecal steroid injection is not advisable since polyethylene glycol, the vehicle used in depot steroid preparations, may cause arachnoiditis.

Epidural steroid injections for low back pain and lumbosacral radiculopathy

Based on behavioral theory, it has been hypothesized that spouse solicitous responses to the pain behaviors of chronic pain patients may contribute to the maintenance of pain behaviors and disability. Self-report data support this hypothesis, but direct observational measures have not been used to study this association. In this study, 50 chronic pain patients and their spouses were videotaped while engaging in common household activities, and patient pain behaviors and spouse solicitous behaviors were coded from the tapes. Spouse solicitous responses to non-verbal pain behaviors were significant predictors of physical disability in the more depressed patients, and were significant predictors of rate of non-verbal pain behavior in patients who reported greater pain. Spouse sulicitous responses did not predict psychosocial dysfunction or total self-reported pain behaviors. The results support behavioral theory and indicate the need for further study of the association between spouse solicitousness and patient pain behaviors/disability.

Chronic pain patient-spouse behavioral interactions predict patient disability.

Physical disabilities which produce physical handicaps are increasing in frequency. As many as 10% of the general adult population have a physical handicap (Finley, 1972). Types of handicaps include disabilities which have their onset at birth or in early life, those which have an abrupt onset after puberty, disabilities which have progressive courses and begin before puberty, and progressive disabilities which begin after puberty. Examples include arthritis, amputations, deformities, cerebral vascular disease, coronary heart disease, kidney failure and transplant, blindness, deafness, developmental disabilities, paralysis, and disfigurements. In spite of common belief to the contrary, many disabled people report that their disabilities do not alter their sexuality or libido (Richardson, 1972).

Sexuality and physical disabilities.

A treatment program for chronic pain is reported which focuses on modification of patient pain behavior. After an outpatient pain clinic screening by a multidisciplinary team, the patient with chronic pain (duration of 6 months or longer) is admitted for a 7--8 week inpatient program followed by a 4-week outpatient period. The first week of the inpatient program is used for evaluation of pain behaviors, recording use of pain medications, activity levels, and tolerance for special conditioning exercises. The program is aimed at extinguishing pain behaviors and use of pain medications, increasing activity level, reinforcing well behaviors, and returning patients to full active lives, normal for their sex and age. Of the 34 patients completing the program and returning to full active normal lives, 74% (25) have maintained this attained goal at the time of follow-up from 6 months to 7 years later.

Behavior modification of chronic pain: a treatment program by a multidisciplinary team.

A new programme in sex education and counselling for spinal cord injured adults and health care professionals has been described. The format of the 2-day desensitising-resensitising programme included exposure to a programmed assortment of explicit slides and films of sexual activity. Periodic small group discussions led by trained group leaders constituted the most important part. The results suggest that continued sexual interest, activity and satisfaction can be anticipated for many paraplegics and quadriplegics. An accepting, experimental attitude toward sexual activity promotes satisfaction with an interested and caring partner. However, many health professionals deliver inadequate sexual counselling to patients with spinal cord injury. This may add to the sum of the disabilities carried by the paraplegic and quadriplegic adult.

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A new programme of sex education and counselling for spinal cord injured adults and health care professionals.

Sexual satisfaction and feelings of self-esteem play an important role in the ability to adapt to an acquired physical disability. A framework has been presented to show how sexual function is affected by different types of physical disability, and spinal cord injury has been selected as a specific example. Sexual counseling for the disabled differs little from that for the able-bodied--the same principles apply. It is appropriate to remind not only the counselor but also the disabled that (1) loss of sensation does not mean loss of feelings, (2) loss of potency does not mean loss of ability, (3) loss of urinary continence does not mean loss of penile competence, and (4) loss of genitalia does not mean loss of sexuality.

Sexual conseling of the physically disabled.

The Michigan Rehabilitation Association (M.R.A.) and the Program in Human Sexuality of the University of Minnesota collaborated to produce a 1-day seminar on sexual function in spinal cord injury. Evaluation of the participants and the seminar showed that the program was beneficial for most and harmful for few. Questionnaire responses indicated that few M.R.A. members are currently doing sexual counseling but many see an opportunity to do so. A relationship appeared between those who have received some form of training in sexual counseling and those who are doing counseling with clients. It is postulated that frank and sincere discussion of sexuality may improve rapport between client and counselor. However, before such an interaction can comfortably take place, the counselor may gain from an opportunity to examine his or her own attitudes toward human sexuality and gather more information about the sexuality of physically disabled adults.

Theodore M. Cole

Papers

Sexuality and physical disabilities.

Behavior modification of chronic pain: a treatment program by a multidisciplinary team.

A new programme of sex education and counselling for spinal cord injured adults and health care professionals.

Sexual conseling of the physically disabled.

Rehabilitation professionals and sexual counseling for spinal cord injured adults.