Medically incongruent chronic back pain: physical limitations, suffering, and ineffective coping (Reesor & Craig, 1988)

Reesor, K. A., & Craig, K. D. (1988). Medically incongruent chronic back pain: physical limitations, suffering, and ineffective coping. Pain, 32(1), 35-45.

Abstract

Chronic low back pain (CLBP) patients with pain and symptomatology incongruent with physical pathology have been found to have a poorer outcome to medical treatment and rehabilitation, and to use health care resources excessively. To examine possible psychological and behavioral bases for this pattern, this investigation contrasted 40 CLBP patients who displayed non-organic physical signs, inappropriate symptoms, and/or anatomically incongruent pain drawings with 40 'control' CLBP patients without incongruent pain criteria. Multivariate analyses revealed that the incongruent CLBP group reported greater pain intensity and depression, received higher observer ratings of pain, displayed more ambulatory/postural pain behavior, and reported more dysfunctional cognitions during pain. Incongruent CLBP patients also were found to have greater physical impairment and disability. When group differences on physical impairment/disability were controlled statistically, all the afore-mentioned differences disappeared, with one exception. Incongruent CLBP patients still displayed more maladaptive and dysfunctional cognitions. These findings indicate that incongruent CLBP patients may be conceptualized as ineffective and overwhelmed in their attempts to cope and as more physically disabled as a result of their pain. The role of cognitive factors, reasons for failure of physically based interventions, and implications for patient management are discussed.

Yesterday we spoke of idiopathic pain… today we encounter a new term… Incongruent pain…

Incongruent pain: the behavioral pattern of the pain sufferers inconsistent with expectations established through findings of medical examinations.

Incongruent pain in CLBP is defined as:

• The observed behaviors during orthopedic examination do not match with the anatomical principle (non-organic sigh)
• Reported symptom severity is exaggerated and does not correspond to either the anatomy or the disease course (non-organic symptoms).
• Exaggerated and non-anatomical drawings patients produce to represent the areas of pain

I especially love the word "exaggeration".... Even if them pains were associated with hallucinations and delusions... Does it mean they don't hurt? 8-O lol sigh

People identified as having incongruent pain seem to be less responsive to treatments.

This study used 40 men and 40 women with the complaints of persistent lower back pain. The patients have been given numerous assessments to evaluate their state of being. Fore information about some of the instruments could be find here.

• The sensory, affective and evaluate pain components of the McGill Pain Questionnaire (MPQ)
• The use of the Descriptor Differential Scales about pain sensation and pain unpleasantness
• Pain drawing was coded using Ransford et al's scoring system to quantify the non-anatomical or exaggeration in patients drawing of pain area.
• The Inappropriate Symptom Scale
• Coping Strategy Questionnaire (CSQ) consisted of 7 scales related to pain coping activity and 2 scale concerning coping effectiveness.
• Beck Depression Inventory (BDI)
• Oswestry Low Back Pain Disability Questionnaire includes 10 scales addressing problems concerning pain-related disability
• Non-organic signs: Signs of pain reports which deviates from anatomical principles.
• Physical impairment contains a set of indices related to organic impairment and physical limitations
• Behavior assessment procedure: Patients were videotaped and pain behaviors are coded.
• Pain induction assessment: Pain was induced using a pressure pain apparatus. Immediate after the pain induction trial, the patients were given a semi-structured interview with responses coded for the following categories of cognitive activities: 1. Use coping strategies such as dissociation, relaxation, imagery and non imagery distraction; 2) expression for sense of control; and, 3) catastrophizing.
• Determination on whether a patients fall into the medically incongruent pain group is based on the following criteria: 1. The presence of 2 or more non-organic physical sighs, 2) the presence of 3 of more inappropriate symptoms; and 3) the presence of 3 or more inappropriate drawing.

Something interesting about the analyses concerning pain and depression measure is that the authors went through great length in describing and interpreting the significance of the results while, in reality, the results of MANOVA did not even reach the significant level or was on "marginally significant."

The following are my favorite paragraphs from the paper…. Apparently, this must have been how the doctors have had in their eyes about me and my condition… Following is my response to the writing by assuming myself as a patient with incongruent pain…

"Chronic pain patients whose illness behavior and symptom report were anatomically inconsistent, vague, poorly localized, and exaggerated or disproportionate to their back pain condition. "—this is why that neurologist thought I might have conversion disorder…

"The absence of cognitions reflecting perceived control or self-efficacy during exposure to a pain stimulus discriminated incongruent pain patient from control patient groups."—Damn… thought I was working hard trying to reflect all that time… How else should I have thought and acted.... 8-O 8-X

"Incongruent chronic pain patients also appeared to engage in more maladaptive, dysfunctional, and anxiety-laden cognitions (i.e., catastrophizing) concerning their pain."--- 8-O It did feel catastrophizing though at times… the pain, the spasm, the inability to recover… shall you be in my shoes please check how well you would fair… 8-O

Sort of like what the authors commented later…

"the degree of subjective and expressed pain may be more a function of the level to which mobility and behavior are compromised because of the pain." Finally something that sounds more like music to my ears... speaking of internal biase.... 8-O lol

"Thus, the subjective pain experience tended to be perceived and judged to be more disturbing, distressing, and debilitating by incongruent pain patients in comparison to control patients." Poor patients with incongruent pain… why can't you simply be like them control group patients?

What do incongruent patients have the tendency to not respond to treatment? One theory the authors came up with was that these patients might have more severe physical impairment and disability; as a result, they need more care than the non-incongruent patients. Another theory is that they need to be taught more adaptive coping cognitive style… (whatever that means.)

Another point I really appreciate from this paper…

"Clinicians may be more likely to conclude incorrectly that these patients have minimal organic basis for pain and that they are malingering. Health care providers may even inadvertently prompt more exaggerated pain and distress on the part of the patient, since a more 'dramatic' presentation may be needed to convince the clinician of the 'reality' of the pain problem. in actuality, incongruent pain patients, in this investigation. appeared to have had a more severe organic pain problem. It is important to note in this regard that incongruent indicators may not necessarily be associated with psychopathology or efforts to receive financial compensation. "

Man, doesn't this paragraph remind me of the time when the doctor I was seeing telling me to talk to my psychiatrist every time I made a complaint or asked the question, "Why am I so in pain?" And, how they refused to believe that I had pain in the neck because the only radiological evidence was the herniation in the lumbar area... because I only had MRI done in the lumbar area... Without the MRI evidence, they wouldn't believe I have problems in the cervical area; at the same time, the doctor refused to prescribe an MRI scan to the cervical spine.... and later, thoracic... And other similar scenarios… again and again… to the extent that I have to wonder to myself... Maybe what they have been insinuating is right.... What it be like if it really is all in my head? And, on a second thought, no wonder the associated experiences are catastrophising since, at some point, it starts to appear to you that, including you yourself, no one really seems to believe in the validity of your condition... 8-O lol sigh

Of course, as the authors have pointed out… never forget that correlations are not causations… All depends on the interpretations…