The journal of pain : official journal of the American Pain Society
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Multicenter Study
Engendering pain management practices: the role of physician sex on chronic low-back pain assessment and treatment prescriptions.
The impact of physician sex on dimensions of medical care such as treatment prescriptions and referrals has been underexplored, especially in a pain context. Also, few studies have analyzed whether physician sex moderates the influence of patients' or clinical situations' characteristics on pain management practices or its mediating processes. Therefore, our goal was to explore whether physician sex moderates the effects of patient (distressed) pain behaviors and diagnostic evidence of pathology (EP) on treatment prescriptions and referrals for chronic low-back pain, and to explore the mediating role of pain credibility judgments and psychological attributions on these effects. A total of 310 general practitioners (GPs; 72.6% women) participated in a between-subjects design, 2 (patient pain behaviors) × 2 (EP) × 2 (GP sex) × 2 (patient sex). GPs were presented with vignettes depicting a fe(male) chronic low-back pain patient, with(out) distress and with(out) EP (eg, herniated disc). GPs judged the patient's pain and the probability of treatment prescriptions and referrals. Results showed that EP had a larger effect on male than on female physicians' referrals to psychology/psychiatry. Also, GP sex moderated the pain judgments that accounted for the effect of EP and pain behaviors on prescriptions. These findings suggest framing medical decision-making as a process influenced by gender assumptions. ⋯ This paper shows that physician sex moderates the influence of clinical cues on pain management practices and the mediating role of pain judgments on these effects. It may potentially increase clinicians' awareness of the influence of gender assumptions on pain management practices and contribute to the development of more gender-sensitive services.
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The purpose of this study was to develop and validate a brief, clinically relevant, multidimensional interview to assess pain burden among children and adolescents with sickle cell disease (SCD). The Sickle Cell Disease Pain Burden Interview-Youth (SCPBI-Y) was developed using a panel of experts, patients, and caregivers. Validation was undertaken with children and youth with SCD, ages 7 to 21 years (N = 129), recruited from 4 urban children's hospitals. Participants were recruited from inpatient (n = 62) and outpatient (n = 67) settings. The SCPBI-Y demonstrated strong internal consistency reliability, cross-informant concordance (child-caregiver), and test-retest reliability (outpatient setting). Moderate construct validity was found with validated measures of functional ability, pain, and quality of life. The SCPBI-Y demonstrated construct validity using a contrasted group approach between youth in inpatient versus outpatient settings and by severity of SCD symptoms, suggesting that youth in inpatient settings and with higher disease severity exhibited greater pain burden. Discriminant validity was found between SCPBI-Y and mood. Our preliminary findings suggest that the SCPBI-Y is a valid and reliable multidimensional interview that can be used in different clinical settings to evaluate pain burden among children and adolescents with SCD. ⋯ Multifaceted pain assessments are salient in providing optimal care to children and adolescents with SCD; however, current evaluations are lengthy and cumbersome to administer clinically. The current study introduces and validates a brief, clinically useful multidimensional interview to evaluate pain burden specific to youth with SCD.
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Chronic pain, chronic fatigue, and depressive mood are prevalent conditions in people with spinal cord injury (SCI). The objective of this research was to investigate the relationship between these conditions in adults with SCI. Multivariate analysis of variance, contingency analyses, and hierarchical regression were used to determine the nature of the relationship, as well as the contribution to this relationship of self-efficacy, a potential mediator variable. Seventy participants with SCI living in the community completed an assessment regimen of demographic and psychometric measures, including validated measures of pain, fatigue, depressive mood, and self-efficacy. Results indicated that participants with high levels of chronic pain had clinically elevated depressive mood, confusion, fatigue, anxiety and anger, low vigor, and poor self-efficacy. Participants with high chronic pain had 8 times the odds of having depressive mood and 9 times the odds of having chronic fatigue. Regression analyses revealed that chronic pain contributed significantly to elevated depressive mood and that self-efficacy mediated (cushioned) the impact of chronic pain on mood. Furthermore, both chronic pain and depressive mood were shown to contribute independently to chronic fatigue. Implications of these results for managing chronic pain in adults with SCI are discussed. ⋯ The relationship between pain, negative mood, fatigue, and self-efficacy in adults with SCI was explored. Results support a model that proposes that chronic pain lowers mood, which is mediated (lessened) by self-efficacy, whereas pain and mood independently increase chronic fatigue. Results provide direction for treating chronic pain in SCI.
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We examined changes in intraepidermal nerve fibers (IENFs) to differentiate patients with diabetic neuropathy (DN) and diabetic neuropathic pain (DN-P) from those with DN without pain (DN-NOP). Punch skin biopsies were collected from the proximal thigh (PT) and distal leg (DL) of normal subjects, patients with type 2 diabetes without evidence of DN (DM), or DN-P and DN-NOP patients. Protein gene product 9.5-positive (PGP+) immunohistochemistry was used to quantify total IENF, and growth-associated protein 43 (GAP43) for regenerating IENF. Compared to normal subjects and patients with type 2 diabetes without evidence of DN, both DN-P and DN-NOP have reduced PGP+ IENF densities in DL and PT. Although GAP43+ IENF densities were also reduced in DL for both DN-P and DN-NOP, the GAP43+ IENF densities in PT of DN-P remained at the control levels. Higher GAP43/PGP ratios were detected in DN-P compared to DN-NOP in the DL and PT. In parallel, increased numbers of axonal swellings per PGP+ fiber (axonal swelling/PGP) were detected in DN-P compared to normal subjects, patients with type 2 diabetes without evidence of DN, and DN-NOP in the DL. These axonal swellings were positive for tropomyosin-receptor-kinase A and substance P, suggesting that they are associated with nociception. ⋯ Among patients with DN, the ratios of GAP43/PGP and axonal swelling/PGP are likely to differentiate painful from painless phenotypes.