Eldon Tunks | McMaster University (original) (raw)

Papers by Eldon Tunks

PubMed, Aug 1, 1985

Stabbing paroxysmal pain due to neurological disease can often be controlled by anticonvulsants, ... more Stabbing paroxysmal pain due to neurological disease can often be controlled by anticonvulsants, whereas steady burning pain is often responsive to tricyclic antidepressants, and to neuroleptics. Overuse of opiates may actually aggravate the pain, necessitating detoxification. Transcutaneous electrical nerve stimulation is helpful for conditions in which pain is localized, especially if there is a 'trigger area' or neuroma, or if paresthesias can be stimulated within the painful area. Local anesthetic injection, possibly with corticosteroid, relieves painful scars and neuromas, neuritis, and tender trigger points. Sympathetic blocks are used for post-herpetic neuralgia and sympathetic dystrophies. Relaxation therapy is a very useful psychological treatment.

Japanese journal of psychosomatic medicine, 1984

Journal of the Canadian Chiropractic Association, Dec 1, 1999

ABSTRACT The understanding and treatment of chronic pain is a challenge not easily met. By the ti... more ABSTRACT The understanding and treatment of chronic pain is a challenge not easily met. By the time the patients arrive at a clinic, they have usually lived in that condition for a substantial length of time. The etiological factors are buried under a variety of radiographic, neurological, orthopaedic and psychological investigation. The patients tend to believe that they have a serious physical infirmity. . . . Unfortunately, some patients will not prove to have a disease to be removed, or pain that can be cured. The end results of prolonged disability associated with chronic pain are psychological, social, economic, and familial. Removal of pain is often an unattainable goal. The rationale for intervention with chronic pain patients must be sought in terms of enabling them to develop more effective ways of coping, and in the restoration of roles and functions, which tend to be eroded as the patient assumes his semi-invalid role. Here we see the polarity between the medical model and the rehabilitative viewpoint. The former aims to eradicate the disease that causes the complaint, whereas the latter takes the pain-disability problem as the focus of concern. Chronic pain is an inherently complex human experience, and by necessity, requires the use of diverse and sophisticated conceptual models to account for all its facets. The current literature reflects this complexity, with an ever-expanding body of basic theory and techniques; workers from many different medical and nonmedical disciplines have been applying their own language and theoretical frameworks. There is a growing awareness of the need for systems to conceptually link these varied approaches for the purposes of integrating and using the unique contributions of these coexisting methods of analysis. This attitude that strives for integration provides the "glue" that allows for ecological validity, and provision of a more comprehensive understanding, in our approach to chronic pain disability. It is important to realize that not all "pain treatments" are equally efficacious, and that questions must be asked regarding specificity—"which therapies, for which patients, and for what purposes?" With further refinements in thinking about pain, there has been development and perfection of research methodologies and measurement techniques, which are critical in evaluation of interventions for pain. In the succeeding chapters, the psychosocial factors relevant to the rehabilitation of the chronic pain patient are dealt with from various viewpoints. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Journal of Pain and Symptom Management, 1992

Pain Research & Management, 1997

P ersistent (or chronic) pain occurs with a prevalence of about 10% in the adult population, and ... more P ersistent (or chronic) pain occurs with a prevalence of about 10% in the adult population, and chronic soft tissue pain is especially problematic. Criteria for diagnosis of soft tissue pain disorders suffer from specificity problems, even though they appear to be sensitive in distinguishing between normal and soft tissue pain sufferers. THE PROBLEM OF DIAGNOSIS IN CHRONIC SOFT TISSUE PAIN We are contending with an increasing number of terms or labels for poorly understood chronic conditions such as chronic fibromyalgia, fibrositis, myofascial pain, chronic pain syndrome, chronic fatigue syndrome, myalgic encephalomyelitis, nonarticular rheuma-This paper is based on a presentation at a workshop on consciousness, pain and behaviour at the annual meeting of the

PubMed, Feb 19, 2002

Background: The effect of low-intensity ultrasonography on fracture healing is controversial, and... more Background: The effect of low-intensity ultrasonography on fracture healing is controversial, and current management of fractures does not generally involve the use of ultrasound therapy. We describe a systematic review and meta-analysis of randomized controlled trials of low-intensity pulsed ultrasound therapy for healing of fractures. Methods: We searched 5 electronic databases (MEDLINE, EMBASE, Cochrane Database of Randomised Clinical Trials, HealthSTAR and CINAHL) for trials of ultrasonography and fracture healing, in any language, published from 1966 to December 2000. In addition, selected journals published from 1996 to December 2000 were searched by hand for relevant articles, and attempts were made to contact content experts in the area of ultrasound therapy and fracture healing as well as primary authors of reviewed trials. Trials selected for review met the following criteria: random allocation of treatments; inclusion of skeletally mature patients of either sex with 1 or more fractures; blinding of both the patient and the assessor(s) as to fracture healing; administration of low-intensity pulsed ultrasound treatments to at least 1 of the treatment groups; and assessment of time to fracture healing, as determined radiographically by bridging of 3 or 4 cortices. Two reviewers independently applied selection criteria to blinded articles, and selected articles were scored for methodologic quality. The internal validity of each trial was assessed with the use of a 5-point scale that evaluates the quality of trial method on the basis of description and appropriateness of randomization and double-blinding, and assessment of study withdrawals and likelihood of bias. Results: We identified 138 potentially eligible studies, of which 6 met our inclusion criteria. Agreement beyond chance of quality assessments of the 6 trials was good (intraclass correlation coefficient 0.77, p = 0.03). One trial was a repeat analysis of previously reported data, and 2 trials appeared to report on a shared group of subjects. Three trials, representing 158 fractures, were of sufficient homogeneity for pooling. The pooled results showed that time to fracture healing was significantly shorter in the groups receiving low-intensity ultrasound therapy than in the control groups. The weighted average effect size was 6.41 (95% confidence interval 1.01-11.81), which converts to a mean difference in healing time of 64 days between the treatment and control groups. Interpretation: There is evidence from randomized trials that low-intensity pulsed ultrasound treatment may significantly reduce the time to fracture healing for fractures treated nonoperatively. There does not appear to be any additional benefit to ultrasound treatment following intramedullary nailing with prior reaming. Larger trials are needed to resolve this issue.

The Canadian Journal of Psychiatry, Apr 1, 2008

Background: Chronic pain is a prevalent and costly problem that eludes adequate treatment. Persis... more Background: Chronic pain is a prevalent and costly problem that eludes adequate treatment. Persistent pain affects all domains of people's lives and in the absence of cure, success will greatly depend on adaptation to symptoms and self-management. Method: We reviewed the psychological models that have been used to conceptualize chronic pain-psychodynamic, behavioural (respondent and operant), and cognitive-behavioural. Treatments based on these models, including insight, external reinforcement, motivational interviewing, relaxation, meditation, biofeedback, guided imagery, and hypnosis are described. Results: The cognitive-behavioural perspective has the greatest amount of research supports the effectiveness of this approach with chronic pain patients. Importantly, we differentiate the cognitive-behavioural perspective from cognitive and behavioural techniques and suggest that the perspective on the role of patients' beliefs, attitudes, and expectations in the maintenance and exacerbation of symptoms are more important than the specific techniques. The techniques are all geared to fostering self-control and self-management that will encourage a patient to replace their feelings of passivity, dependence, and hopelessness with activity, independence, and resourcefulness. Conclusions: Psychosocial and behavioural factors play a significant role in the experience, maintenance, and exacerbation of pain. Self-management is an important complement to biomedical approaches. Cognitive-behavioural therapy alone or within the context of an interdisciplinary pain rehabilitation program has the greatest empirical evidence for success. As none of the most commonly prescribed treatment regimens are sufficient to eliminate pain, a more realistic approach will likely combine pharmacological, physical, and psychological components tailored to each patient's needs.

Health care and disease management, Aug 20, 2008

Pain, Aug 1, 1988

Coping' as a concept has achieved wide modem usage both in common parlance and also in the psycho... more Coping' as a concept has achieved wide modem usage both in common parlance and also in the psychological literature. To those of us in clinical practice, there is something very attractive about using the idea of 'coping' in formulation and in treatment. It provides a psychological construct that includes behavioral and cognitive events, permits a prescription for learning by the patient, and helps to distinguish successful from unsuccessful patients. For example, much of the 'coping' literature notes that subjects and patients have poor tolerance to pain if they are 'catastrophizers' (i.e., individuals who seem to exaggerate the significance of a 'stressor' for themselves). Yet, the concept of 'coping' still needs some fundamental clarification. Close to 3 decades of research has led to little unanimity regarding what constitutes 'coping,' how to identify or measure it. The form of the measures and research methodologies have not changed greatly since 'coping' research began, and major advances have been few, raising the possibility that the concept may have reached its heuristic limit. We appeal to the concept of 'coping' in our clinical experience in which we encounter individuals who transform calamities into opportunities for growth, while we encounter others who transform everyday 'hassles' into overwhelming adversities. However, it is impossible to consistently demonstrate differences in 'coping strategies' that would characterize both

Clinical Rheumatology, Dec 1, 1989

Pain threshold was measured using a pressure algometer in 126 subjects, of whom 54 were females a... more Pain threshold was measured using a pressure algometer in 126 subjects, of whom 54 were females and 72 males. These subjects included 18 males and 18 females with rheumatoid arthritis, 18 males and 18females with osteoarthritis, 18 males with ankylosing spondylitis, and 18 male and 18 female healthy control volunteers. Six points were studied on each side of the body : 2 cm above the eyebrow on the forehead, lateral aspect of the arm at the insertion of the deltoid muscle, midpoint of the ulna, hypothenar eminence in the palm, midpoint of the quadriceps muscle, and midpoint of the antero-medial aspect of the tibia. None of these points corresponded to the "'trigger"points in fibromyalgia. The pain threshold was statistically significantly higher in patients with ankylosing spondylitis than in patients with osteoarthritis, and these in turn were statistically higher than in the normal subjects. Patients with rheumatoid arthritis had significantly lower pain thresholds than the normal subjects. No laterality in pain threshold was identified, but females had in general a lower pain threshold.

Canadian Medical Association Journal, May 23, 2006

C hronic non-cancer-related pain (CNCP) includes chronic pain of a nociceptive or neuropathic nat... more C hronic non-cancer-related pain (CNCP) includes chronic pain of a nociceptive or neuropathic nature with variable influence by psychological and socioenvironmental factors. Opioids are the most potent analgesics available and are well established for the treatment of severe acute, 1 surgical 2 and cancer pain. 3 However, their use to ameliorate CNCP is still controversial because of the side effects of opioids, the physical tolerance they build up (with the related withdrawal reactions and possibility of addiction) and anxiety over disapproval by regulatory bodies. 4 The prevalence of CNCP varies according to the type of pain and the population studied. A study conducted in the United Kingdom in a community in the greater London area to quantify the prevalence of chronic pain found that 46.5% of the general population reported chronic pain; low-back problems and arthritis were the leading causes. 5 A recent epidemiological study in Denmark 6 found that nearly 130 000 adults, corresponding to 3% of the Danish population, regularly used opioids. CNCP had a prevalence of 19%, and 12% of those who had CNCP used opioid medications. The objectives of this review were 4-fold: to determine the efficacy of opioids for CNCP compared with placebo; to compare the effectiveness of opioids for CNCP with that of other drugs; to identify categories of CNCP with better response to opioids; and to determine the most common side effects and complications of opioid therapy for CNCP, including incidences of opioid addiction and sexual dysfunction. Methods We followed the QUOROM guidelines for reporting metaanalyses of randomized controlled trials. 7 We searched the literature up to May 2005 through the OVID interface: MEDLINE (from 1960), EMBASE (from 1988), the Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Register (CENTRAL), the ACP Journal Club and DARE. We also reviewed the reference lists in the articles, reviews and textbooks retrieved. Our search strategies for MEDLINE and EMBASE are available online as Appendix 1 and Appendix 2, respectively (all appendices for this article are available at www.cmaj.ca /cgi/content/full/174/11/1589/DC1). A single reviewer (J.A.S.) ran the electronic searches and entered the data into Reference Manager 10, removing all duplicates. Each of 2 independent reviewers (A.D.F., J.A.S.) screened

The Canadian Journal of Psychiatry, Dec 1, 1986

Among many excellent chapters, there are a few which are superb an~ wo~th particular mention. Syr... more Among many excellent chapters, there are a few which are superb an~ wo~th particular mention. Syrjala and Chapman, m their chapter on "measurement of clinical pain" present a careful review of various approaches in pain measurement, and a critical appraisal of each of these with helpful suggestions for prospective researchers. Butler has provided a very comprehensive review with an excellent bibliography dealing with use of tricyclic antidepressants in c~ronic pain therapy. Following an introductory chapter by RIchard Sternbach, Turner and Romano have written a very helpful review of psychological interventions for chronic pain. This, in fact, is a follow-up of the very comprehensive review by Turner in 1982. The strategy for their review is to examine outcome studies and to use a "meta analysis" to compare outcomes and elements to which we might attribute success. Methods compared include relaxation therapy, biofeedback therapy, operant conditioning, hypnosis, and cognitive behavioral therapies. This is followed by a discussion of methods and logical issues that ought to be useful for anyone either considering reviewing literature on this and similar topics, or engaging in research. This chapter complements nicely, the earlier chapter on the measurement of clinical pain. There. are also other chapters which are worth reading. Procacci and Maresca have written a very scholarly history of the pain concept in Western civilization. Terman et al consid.er pain inhibition by various mechanisms, especially stress induced analgesia. Yaksh, et ai, review neurochemistry related to pain, which ought to be of interst to psychopharmacologists and those with an interest in neurophysiology. Harkins, et al have produced a chapter on "pain and the elderly" with a good bibliography. Turner and Roman? review ~he prevalence of coexisting pain and depression. There IS a chapter dealing with multidisciplinary approach to pain management and several other chapters dealing with acute pain, cancer and post-operative pains with due consideration given to psychological factors and approaches that might be combined with medical and surgical methods. Perhaps the only point of criticism I found in this book was in the chapter by Brena and Chapman dealing with "chro.nic pain states and compensable disability an algorithmic approach". Among other things, in this chapter they try to propose an "inconsistency profile" for discerning malingering. Their intentions are good, but such an approach is apt to be shallow. Very often, the reasons for i~consistent behavior are not apparent, and the patient himself may be unaware of the psychological forces which determine his symptoms that may, on the face of it seem inconsistent. It is precisely here that psychiatric and psychodynamic expertise is needed to help patients with chronic pain and coexisting psychosocial dysfunction and disability. It is the need for this recognition that has led many of our psychiatric colleagues to' take a real interest in pain management and research, and for them, this book will ove.rall, provide a very helpful and up-to-date review of vanous aspects of the pain field, including several aspects relevant to psychiatric practice.

The Canadian Journal of Psychiatry, Dec 1, 2002

This book is comprehensive and up to date, with thousands of references, and will be appreciated ... more This book is comprehensive and up to date, with thousands of references, and will be appreciated especially by those working in consultation-liaison psychiatry, by residents preparing for exams, and by neuropsychologists. The text is an excellent value.

The Canadian Journal of Psychiatry, Apr 1, 2008

Rheumatic Diseases Clinics of North America, Aug 1, 1996

This article addresses issues related to multimodal pain programs and unimodal treatments, partic... more This article addresses issues related to multimodal pain programs and unimodal treatments, particularly those that deal with persistent musculoskeletal pain. Factors including prevalence, morbidity, and prognosis are examined. The research evidence for physical therapy modalities, psychological treatments, and vocational and pharmacologic interventions is critically appraised. A clinical decision algorithm for persistent pain management until referral to a multimodal chronic pain program is presented.

The International journal of the addictions, 1991

When reviewing the broad area that relates environments to addiction one is faced with an enormou... more When reviewing the broad area that relates environments to addiction one is faced with an enormous volume of research with differing environmental and psychosocial factors, contrasting populations, a variety of addictive substances, and a range of addiction processes. For all these factors, there are important outcome variables. To survey this disparate literature, it is helpful to use a multiaxial model as a framework or taxonomy. In this way it is possible to see the effects that environments, broadly conceived, exert on addictive behaviors. A variety of environments is considered: interpersonal, organizational, cultural and physical, as one axis or dimension. The influence of this dimension on a second dimension relating to type of addiction is also examined. Finally, a dimension pertaining to the "life history" of addictions, from acquisition through maintenance, cessation, and relapse is considered in relation to the first two dimensions. While a variety of environmental factors affect addictive behaviors, current research indicates the need to take individual differences, cognitive mediation, and the interaction of the person with the environment into account. Significant areas that need further exploration are the failure of addictions to occur in some environments, and the development of secondary prevention approaches. Implications for intervention and directions for future research are suggested.

Journal of Nervous and Mental Disease, 1977

The literature has long demonstrated an association between certain behavioral problems and EEG a... more The literature has long demonstrated an association between certain behavioral problems and EEG abnormalities, particularly the association of aggressive and sometimes violent behavior with foci in the temporal lobes. The concept of "dyscontrol syndromes" has also been established and it is possible that some instances of the dyscontrol syndrome arise from an abnormal sensitization of the limbic system, due to disturbance in or near the temporal lobes. Carbamazepine is an interesting new drug, with both anticonvulsant and psychotropic properties, for which both the behavioral effects and pharmacological actions have been defined. The properties of carbamazepine for blocking polysynaptic reflexes and suppressing post-tetanic potentiation are discussed with respect to this limbic system dysfunction in the dyscontrol syndrome. It is also proposed that this drug might be considered for its psychotropic effect in certain instances of dyscontrol, with or without clinical diagnosis of epilepsy. An illustrative case is cited.

PubMed, Aug 1, 1985

Stabbing paroxysmal pain due to neurological disease can often be controlled by anticonvulsants, ... more Stabbing paroxysmal pain due to neurological disease can often be controlled by anticonvulsants, whereas steady burning pain is often responsive to tricyclic antidepressants, and to neuroleptics. Overuse of opiates may actually aggravate the pain, necessitating detoxification. Transcutaneous electrical nerve stimulation is helpful for conditions in which pain is localized, especially if there is a 'trigger area' or neuroma, or if paresthesias can be stimulated within the painful area. Local anesthetic injection, possibly with corticosteroid, relieves painful scars and neuromas, neuritis, and tender trigger points. Sympathetic blocks are used for post-herpetic neuralgia and sympathetic dystrophies. Relaxation therapy is a very useful psychological treatment.

Japanese journal of psychosomatic medicine, 1984

Journal of the Canadian Chiropractic Association, Dec 1, 1999

ABSTRACT The understanding and treatment of chronic pain is a challenge not easily met. By the ti... more ABSTRACT The understanding and treatment of chronic pain is a challenge not easily met. By the time the patients arrive at a clinic, they have usually lived in that condition for a substantial length of time. The etiological factors are buried under a variety of radiographic, neurological, orthopaedic and psychological investigation. The patients tend to believe that they have a serious physical infirmity. . . . Unfortunately, some patients will not prove to have a disease to be removed, or pain that can be cured. The end results of prolonged disability associated with chronic pain are psychological, social, economic, and familial. Removal of pain is often an unattainable goal. The rationale for intervention with chronic pain patients must be sought in terms of enabling them to develop more effective ways of coping, and in the restoration of roles and functions, which tend to be eroded as the patient assumes his semi-invalid role. Here we see the polarity between the medical model and the rehabilitative viewpoint. The former aims to eradicate the disease that causes the complaint, whereas the latter takes the pain-disability problem as the focus of concern. Chronic pain is an inherently complex human experience, and by necessity, requires the use of diverse and sophisticated conceptual models to account for all its facets. The current literature reflects this complexity, with an ever-expanding body of basic theory and techniques; workers from many different medical and nonmedical disciplines have been applying their own language and theoretical frameworks. There is a growing awareness of the need for systems to conceptually link these varied approaches for the purposes of integrating and using the unique contributions of these coexisting methods of analysis. This attitude that strives for integration provides the "glue" that allows for ecological validity, and provision of a more comprehensive understanding, in our approach to chronic pain disability. It is important to realize that not all "pain treatments" are equally efficacious, and that questions must be asked regarding specificity—"which therapies, for which patients, and for what purposes?" With further refinements in thinking about pain, there has been development and perfection of research methodologies and measurement techniques, which are critical in evaluation of interventions for pain. In the succeeding chapters, the psychosocial factors relevant to the rehabilitation of the chronic pain patient are dealt with from various viewpoints. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Journal of Pain and Symptom Management, 1992

Pain Research & Management, 1997

P ersistent (or chronic) pain occurs with a prevalence of about 10% in the adult population, and ... more P ersistent (or chronic) pain occurs with a prevalence of about 10% in the adult population, and chronic soft tissue pain is especially problematic. Criteria for diagnosis of soft tissue pain disorders suffer from specificity problems, even though they appear to be sensitive in distinguishing between normal and soft tissue pain sufferers. THE PROBLEM OF DIAGNOSIS IN CHRONIC SOFT TISSUE PAIN We are contending with an increasing number of terms or labels for poorly understood chronic conditions such as chronic fibromyalgia, fibrositis, myofascial pain, chronic pain syndrome, chronic fatigue syndrome, myalgic encephalomyelitis, nonarticular rheuma-This paper is based on a presentation at a workshop on consciousness, pain and behaviour at the annual meeting of the

PubMed, Feb 19, 2002

Background: The effect of low-intensity ultrasonography on fracture healing is controversial, and... more Background: The effect of low-intensity ultrasonography on fracture healing is controversial, and current management of fractures does not generally involve the use of ultrasound therapy. We describe a systematic review and meta-analysis of randomized controlled trials of low-intensity pulsed ultrasound therapy for healing of fractures. Methods: We searched 5 electronic databases (MEDLINE, EMBASE, Cochrane Database of Randomised Clinical Trials, HealthSTAR and CINAHL) for trials of ultrasonography and fracture healing, in any language, published from 1966 to December 2000. In addition, selected journals published from 1996 to December 2000 were searched by hand for relevant articles, and attempts were made to contact content experts in the area of ultrasound therapy and fracture healing as well as primary authors of reviewed trials. Trials selected for review met the following criteria: random allocation of treatments; inclusion of skeletally mature patients of either sex with 1 or more fractures; blinding of both the patient and the assessor(s) as to fracture healing; administration of low-intensity pulsed ultrasound treatments to at least 1 of the treatment groups; and assessment of time to fracture healing, as determined radiographically by bridging of 3 or 4 cortices. Two reviewers independently applied selection criteria to blinded articles, and selected articles were scored for methodologic quality. The internal validity of each trial was assessed with the use of a 5-point scale that evaluates the quality of trial method on the basis of description and appropriateness of randomization and double-blinding, and assessment of study withdrawals and likelihood of bias. Results: We identified 138 potentially eligible studies, of which 6 met our inclusion criteria. Agreement beyond chance of quality assessments of the 6 trials was good (intraclass correlation coefficient 0.77, p = 0.03). One trial was a repeat analysis of previously reported data, and 2 trials appeared to report on a shared group of subjects. Three trials, representing 158 fractures, were of sufficient homogeneity for pooling. The pooled results showed that time to fracture healing was significantly shorter in the groups receiving low-intensity ultrasound therapy than in the control groups. The weighted average effect size was 6.41 (95% confidence interval 1.01-11.81), which converts to a mean difference in healing time of 64 days between the treatment and control groups. Interpretation: There is evidence from randomized trials that low-intensity pulsed ultrasound treatment may significantly reduce the time to fracture healing for fractures treated nonoperatively. There does not appear to be any additional benefit to ultrasound treatment following intramedullary nailing with prior reaming. Larger trials are needed to resolve this issue.

The Canadian Journal of Psychiatry, Apr 1, 2008

Background: Chronic pain is a prevalent and costly problem that eludes adequate treatment. Persis... more Background: Chronic pain is a prevalent and costly problem that eludes adequate treatment. Persistent pain affects all domains of people's lives and in the absence of cure, success will greatly depend on adaptation to symptoms and self-management. Method: We reviewed the psychological models that have been used to conceptualize chronic pain-psychodynamic, behavioural (respondent and operant), and cognitive-behavioural. Treatments based on these models, including insight, external reinforcement, motivational interviewing, relaxation, meditation, biofeedback, guided imagery, and hypnosis are described. Results: The cognitive-behavioural perspective has the greatest amount of research supports the effectiveness of this approach with chronic pain patients. Importantly, we differentiate the cognitive-behavioural perspective from cognitive and behavioural techniques and suggest that the perspective on the role of patients' beliefs, attitudes, and expectations in the maintenance and exacerbation of symptoms are more important than the specific techniques. The techniques are all geared to fostering self-control and self-management that will encourage a patient to replace their feelings of passivity, dependence, and hopelessness with activity, independence, and resourcefulness. Conclusions: Psychosocial and behavioural factors play a significant role in the experience, maintenance, and exacerbation of pain. Self-management is an important complement to biomedical approaches. Cognitive-behavioural therapy alone or within the context of an interdisciplinary pain rehabilitation program has the greatest empirical evidence for success. As none of the most commonly prescribed treatment regimens are sufficient to eliminate pain, a more realistic approach will likely combine pharmacological, physical, and psychological components tailored to each patient's needs.

Health care and disease management, Aug 20, 2008

Pain, Aug 1, 1988

Coping' as a concept has achieved wide modem usage both in common parlance and also in the psycho... more Coping' as a concept has achieved wide modem usage both in common parlance and also in the psychological literature. To those of us in clinical practice, there is something very attractive about using the idea of 'coping' in formulation and in treatment. It provides a psychological construct that includes behavioral and cognitive events, permits a prescription for learning by the patient, and helps to distinguish successful from unsuccessful patients. For example, much of the 'coping' literature notes that subjects and patients have poor tolerance to pain if they are 'catastrophizers' (i.e., individuals who seem to exaggerate the significance of a 'stressor' for themselves). Yet, the concept of 'coping' still needs some fundamental clarification. Close to 3 decades of research has led to little unanimity regarding what constitutes 'coping,' how to identify or measure it. The form of the measures and research methodologies have not changed greatly since 'coping' research began, and major advances have been few, raising the possibility that the concept may have reached its heuristic limit. We appeal to the concept of 'coping' in our clinical experience in which we encounter individuals who transform calamities into opportunities for growth, while we encounter others who transform everyday 'hassles' into overwhelming adversities. However, it is impossible to consistently demonstrate differences in 'coping strategies' that would characterize both

Clinical Rheumatology, Dec 1, 1989

Pain threshold was measured using a pressure algometer in 126 subjects, of whom 54 were females a... more Pain threshold was measured using a pressure algometer in 126 subjects, of whom 54 were females and 72 males. These subjects included 18 males and 18 females with rheumatoid arthritis, 18 males and 18females with osteoarthritis, 18 males with ankylosing spondylitis, and 18 male and 18 female healthy control volunteers. Six points were studied on each side of the body : 2 cm above the eyebrow on the forehead, lateral aspect of the arm at the insertion of the deltoid muscle, midpoint of the ulna, hypothenar eminence in the palm, midpoint of the quadriceps muscle, and midpoint of the antero-medial aspect of the tibia. None of these points corresponded to the "'trigger"points in fibromyalgia. The pain threshold was statistically significantly higher in patients with ankylosing spondylitis than in patients with osteoarthritis, and these in turn were statistically higher than in the normal subjects. Patients with rheumatoid arthritis had significantly lower pain thresholds than the normal subjects. No laterality in pain threshold was identified, but females had in general a lower pain threshold.

Canadian Medical Association Journal, May 23, 2006

C hronic non-cancer-related pain (CNCP) includes chronic pain of a nociceptive or neuropathic nat... more C hronic non-cancer-related pain (CNCP) includes chronic pain of a nociceptive or neuropathic nature with variable influence by psychological and socioenvironmental factors. Opioids are the most potent analgesics available and are well established for the treatment of severe acute, 1 surgical 2 and cancer pain. 3 However, their use to ameliorate CNCP is still controversial because of the side effects of opioids, the physical tolerance they build up (with the related withdrawal reactions and possibility of addiction) and anxiety over disapproval by regulatory bodies. 4 The prevalence of CNCP varies according to the type of pain and the population studied. A study conducted in the United Kingdom in a community in the greater London area to quantify the prevalence of chronic pain found that 46.5% of the general population reported chronic pain; low-back problems and arthritis were the leading causes. 5 A recent epidemiological study in Denmark 6 found that nearly 130 000 adults, corresponding to 3% of the Danish population, regularly used opioids. CNCP had a prevalence of 19%, and 12% of those who had CNCP used opioid medications. The objectives of this review were 4-fold: to determine the efficacy of opioids for CNCP compared with placebo; to compare the effectiveness of opioids for CNCP with that of other drugs; to identify categories of CNCP with better response to opioids; and to determine the most common side effects and complications of opioid therapy for CNCP, including incidences of opioid addiction and sexual dysfunction. Methods We followed the QUOROM guidelines for reporting metaanalyses of randomized controlled trials. 7 We searched the literature up to May 2005 through the OVID interface: MEDLINE (from 1960), EMBASE (from 1988), the Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Register (CENTRAL), the ACP Journal Club and DARE. We also reviewed the reference lists in the articles, reviews and textbooks retrieved. Our search strategies for MEDLINE and EMBASE are available online as Appendix 1 and Appendix 2, respectively (all appendices for this article are available at www.cmaj.ca /cgi/content/full/174/11/1589/DC1). A single reviewer (J.A.S.) ran the electronic searches and entered the data into Reference Manager 10, removing all duplicates. Each of 2 independent reviewers (A.D.F., J.A.S.) screened

The Canadian Journal of Psychiatry, Dec 1, 1986

Among many excellent chapters, there are a few which are superb an~ wo~th particular mention. Syr... more Among many excellent chapters, there are a few which are superb an~ wo~th particular mention. Syrjala and Chapman, m their chapter on "measurement of clinical pain" present a careful review of various approaches in pain measurement, and a critical appraisal of each of these with helpful suggestions for prospective researchers. Butler has provided a very comprehensive review with an excellent bibliography dealing with use of tricyclic antidepressants in c~ronic pain therapy. Following an introductory chapter by RIchard Sternbach, Turner and Romano have written a very helpful review of psychological interventions for chronic pain. This, in fact, is a follow-up of the very comprehensive review by Turner in 1982. The strategy for their review is to examine outcome studies and to use a "meta analysis" to compare outcomes and elements to which we might attribute success. Methods compared include relaxation therapy, biofeedback therapy, operant conditioning, hypnosis, and cognitive behavioral therapies. This is followed by a discussion of methods and logical issues that ought to be useful for anyone either considering reviewing literature on this and similar topics, or engaging in research. This chapter complements nicely, the earlier chapter on the measurement of clinical pain. There. are also other chapters which are worth reading. Procacci and Maresca have written a very scholarly history of the pain concept in Western civilization. Terman et al consid.er pain inhibition by various mechanisms, especially stress induced analgesia. Yaksh, et ai, review neurochemistry related to pain, which ought to be of interst to psychopharmacologists and those with an interest in neurophysiology. Harkins, et al have produced a chapter on "pain and the elderly" with a good bibliography. Turner and Roman? review ~he prevalence of coexisting pain and depression. There IS a chapter dealing with multidisciplinary approach to pain management and several other chapters dealing with acute pain, cancer and post-operative pains with due consideration given to psychological factors and approaches that might be combined with medical and surgical methods. Perhaps the only point of criticism I found in this book was in the chapter by Brena and Chapman dealing with "chro.nic pain states and compensable disability an algorithmic approach". Among other things, in this chapter they try to propose an "inconsistency profile" for discerning malingering. Their intentions are good, but such an approach is apt to be shallow. Very often, the reasons for i~consistent behavior are not apparent, and the patient himself may be unaware of the psychological forces which determine his symptoms that may, on the face of it seem inconsistent. It is precisely here that psychiatric and psychodynamic expertise is needed to help patients with chronic pain and coexisting psychosocial dysfunction and disability. It is the need for this recognition that has led many of our psychiatric colleagues to' take a real interest in pain management and research, and for them, this book will ove.rall, provide a very helpful and up-to-date review of vanous aspects of the pain field, including several aspects relevant to psychiatric practice.

The Canadian Journal of Psychiatry, Dec 1, 2002

This book is comprehensive and up to date, with thousands of references, and will be appreciated ... more This book is comprehensive and up to date, with thousands of references, and will be appreciated especially by those working in consultation-liaison psychiatry, by residents preparing for exams, and by neuropsychologists. The text is an excellent value.

The Canadian Journal of Psychiatry, Apr 1, 2008

Rheumatic Diseases Clinics of North America, Aug 1, 1996

This article addresses issues related to multimodal pain programs and unimodal treatments, partic... more This article addresses issues related to multimodal pain programs and unimodal treatments, particularly those that deal with persistent musculoskeletal pain. Factors including prevalence, morbidity, and prognosis are examined. The research evidence for physical therapy modalities, psychological treatments, and vocational and pharmacologic interventions is critically appraised. A clinical decision algorithm for persistent pain management until referral to a multimodal chronic pain program is presented.

The International journal of the addictions, 1991

When reviewing the broad area that relates environments to addiction one is faced with an enormou... more When reviewing the broad area that relates environments to addiction one is faced with an enormous volume of research with differing environmental and psychosocial factors, contrasting populations, a variety of addictive substances, and a range of addiction processes. For all these factors, there are important outcome variables. To survey this disparate literature, it is helpful to use a multiaxial model as a framework or taxonomy. In this way it is possible to see the effects that environments, broadly conceived, exert on addictive behaviors. A variety of environments is considered: interpersonal, organizational, cultural and physical, as one axis or dimension. The influence of this dimension on a second dimension relating to type of addiction is also examined. Finally, a dimension pertaining to the "life history" of addictions, from acquisition through maintenance, cessation, and relapse is considered in relation to the first two dimensions. While a variety of environmental factors affect addictive behaviors, current research indicates the need to take individual differences, cognitive mediation, and the interaction of the person with the environment into account. Significant areas that need further exploration are the failure of addictions to occur in some environments, and the development of secondary prevention approaches. Implications for intervention and directions for future research are suggested.

Journal of Nervous and Mental Disease, 1977

The literature has long demonstrated an association between certain behavioral problems and EEG a... more The literature has long demonstrated an association between certain behavioral problems and EEG abnormalities, particularly the association of aggressive and sometimes violent behavior with foci in the temporal lobes. The concept of "dyscontrol syndromes" has also been established and it is possible that some instances of the dyscontrol syndrome arise from an abnormal sensitization of the limbic system, due to disturbance in or near the temporal lobes. Carbamazepine is an interesting new drug, with both anticonvulsant and psychotropic properties, for which both the behavioral effects and pharmacological actions have been defined. The properties of carbamazepine for blocking polysynaptic reflexes and suppressing post-tetanic potentiation are discussed with respect to this limbic system dysfunction in the dyscontrol syndrome. It is also proposed that this drug might be considered for its psychotropic effect in certain instances of dyscontrol, with or without clinical diagnosis of epilepsy. An illustrative case is cited.