subjective pain experience of people with chronic back pain

13
Subjective pain experience of people with chronic back pain LORRAINE H DE SOUZA Centre for Research in Rehabilitation, Brunel University, UK Andrew O FRANK Northwick Park Hospital and Institute for Medical Research, Middlesex, UK ABSTRACT Background and Purpose. Studies into the effect of pain experience on those who have it have largely focused on the views and interpretations of researchers gained by the use of assessment tools aimed at measuring pain. The purpose of this study was to explore and describe pain, as experienced by those with chronic back pain, and to document ‘insider’ accounts of how pain is perceived and understood by those who have it. Method. Unstructured interviews using the framework approach. Subjects were sampled for age, sex, ethnicity and occupation, from new referrals with back pain to a rheumatology outpatient clinic. Eleven subjects (5 M; 6 F) agreed to be interviewed. Interviews were unstructured, but followed a topic guide. Subjects were interviewed in English (nine) or their preferred language (two). Tape-recordings of interviews were transcribed verbatim and read in depth twice to identify the topics or concepts. Data were extracted in the form of words and phrases by use of thematic content analysis. The themes were pain description and amount of pain. An independent researcher reviewed the data and confirmed or con- tended the analysis. Results. All subjects, except one, provided descriptors of the quality of their pain. The use of simile was common to emphasize both what the pain was, and what it was not. Five subjects expressed a loss of words in trying to describe their pain. Only 13 of 29 different pain descriptors used were commensurate with those in the McGill Pain Questionnaire (Melzack, 1983). Subjects had great difficulty quantifying their pain inten- sity. Several explained how the pain fluctuated, thus, quantifying pain at one point in time was problematic. Only one subject offered a numerical description of pain intensity. Conclusions. Subjects provided graphic and in-depth descriptions of their pain experience, but these bore little resemblance to commonly used assessment tools. The findings challenge the appropriateness of such formal instruments. Key words: chronic back pain, McGill Pain Questionnaire, pain descriptions, qualita- tive research 207 Physiotherapy Research International, 5(4) 207–219, 2000 © Whurr Publishers Ltd

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Page 1: Subjective pain experience of people with chronic back pain

Subjective pain experience of peoplewith chronic back pain

LORRAINE H DE SOUZA Centre for Research in Rehabilitation, BrunelUniversity, UK

Andrew O FRANK Northwick Park Hospital and Institute for Medical Research,Middlesex, UK

ABSTRACT Background and Purpose. Studies into the effect of pain experience onthose who have it have largely focused on the views and interpretations of researchers gainedby the use of assessment tools aimed at measuring pain. The purpose of this study was toexplore and describe pain, as experienced by those with chronic back pain, and to document‘insider’ accounts of how pain is perceived and understood by those who have it.Method. Unstructured interviews using the framework approach. Subjects were sampledfor age, sex, ethnicity and occupation, from new referrals with back pain to a rheumatologyoutpatient clinic. Eleven subjects (5 M; 6 F) agreed to be interviewed. Interviews wereunstructured, but followed a topic guide. Subjects were interviewed in English (nine) ortheir preferred language (two). Tape-recordings of interviews were transcribed verbatim andread in depth twice to identify the topics or concepts. Data were extracted in the form ofwords and phrases by use of thematic content analysis. The themes were pain descriptionand amount of pain. An independent researcher reviewed the data and confirmed or con-tended the analysis. Results. All subjects, except one, provided descriptors of the quality oftheir pain. The use of simile was common to emphasize both what the pain was, and what itwas not. Five subjects expressed a loss of words in trying to describe their pain. Only 13 of29 different pain descriptors used were commensurate with those in the McGill PainQuestionnaire (Melzack, 1983). Subjects had great difficulty quantifying their pain inten-sity. Several explained how the pain fluctuated, thus, quantifying pain at one point in timewas problematic. Only one subject offered a numerical description of pain intensity.Conclusions. Subjects provided graphic and in-depth descriptions of their pain experience,but these bore little resemblance to commonly used assessment tools. The findings challengethe appropriateness of such formal instruments.

Key words: chronic back pain, McGill Pain Questionnaire, pain descriptions, qualita-tive research

207Physiotherapy Research International, 5(4) 207–219, 2000 © Whurr Publishers Ltd

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INTRODUCTION

Back pain is a health problem of vast dimensions, not only in terms of the propor-tion of people affected and the subsequent economic costs to the National HealthService (NHS) and Social Services (Clinical Standards Advisory Group, 1994;AHCPR, 1994) but also in terms of the physical and psychological distress sufferedby those who have the condition (Waddell, 1987; Frank, 1993).

Although back pain has been studied extensively (Van Tulder et al., 1997), theexperience of those living with pain remains inadequately understood. This is sur-prising as there seems to be general acknowledgement that pain is a subjective expe-rience, that subjectivity is ‘a vital, central and integral part of pain measurement’(Skevington, 1995) and that back pain may have important consequences for thelives of individuals and their families (Spitzer et al., 1987).

Studies into the effects of pain experience on those who have it have, in general,focused on the views and interpretations of the researchers gained by the use of vari-ous assessment tools aimed at measuring pain (Turk and Melzack, 1992). Little hasbeen published that seeks to understand the ‘insider’ account of chronic back pain(Walker et al., 1999). Most accounts have described patients’ experiences from aprofessional viewpoint (Spitzer, 1987; Waddell, 1987; Turk and Melzack, 1992;Frank, 1993). People may present with back pain for various reasons, not all relatingto the spine (Waddell, 1982). Furthermore, it is unclear whether individuals’accounts of their pain may be influenced by the underlying pathology.

Given the subjective nature of pain, it is important to investigate how it is per-ceived and understood by those who have it. These issues could be even moreimportant in a multi-cultural population where differing health beliefs exist. Theaims of this study were to explore the views and experiences of people with chronicback pain and to document their descriptions of the quality and intensity of theirpain. The objective was to understand individuals’ experiences of chronic pain inorder to gain further knowledge about motivation and non-compliance with therapy(Walker et al., 1999).

METHOD

Subjects

Subjects were back pain sufferers newly referred to a rheumatology outpatient clinicby their general practitioners. They were sampled purposively to ensure that a rangeof characteristics was represented. These characteristics were sex, age, ethnicity andoccupation (Table 1). Ethical approval for the study was gained and selected subjectswere contacted before their clinic appointments. Sixteen subjects were approachedand 12 agreed to be interviewed and to have their interview tape-recorded. How-ever, one interview could not be recorded due to equipment failure. Therefore, 11subjects (five male and six female provided tape-recorded interviews that constituteddata for analysis.

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Subjects were interviewed be for their hospital visits, by appointment in theirown homes by two experienced interviewers of different ethnic backgrounds. Inter-views were unstructured, allowing subjects to raise topics and issues they consideredimportant. The interviewers would pick up on issues broached by subjects in order tofurther explore their views. Important topics not raised by subjects were suggested ina noncommittal way. These included pain description and the amount of pain.

Each interview lasted from 45 to 90 minutes, depending on how much subjectswere willing to reveal. One interviewer was fluent in appropriate Indian languagesand subjects had the choice of responding in their mother tongue. Interviews weretranslated from tape-recordings by one researcher with appropriate linguistic skill,and the translations were later checked independently by another researcher fluentin the languages used. All 11 interviews were transcribed verbatim.

Further data were collected at a routine outpatient clinic one or two weeks laterby use of formal questionnaires (Table 1). These data consisted of total duration ofpain, duration of the current episode of pain, Quebec Task Force (QTF) classifica-tion of pain (Spitzer, 1987) and subjects’ self-reported ethnicity (McAuley et al.,1996). Chronic pain was defined as continuous back pain for a period of three monthsor more (Frank, 1993), modified from the QTF recommendation (Spitzer et al.,1987) and now widely accepted (Van Tulder et al., 1997). One individual (Subject2), who clearly identified a definite change in the character of his pain, had the dateof the change documented as the date of the current attack (that is acute-on-chronicpain; Frank, 1993).

All subjects were asked the time of their ‘first ever’ attack of back pain (totalduration of back pain), whether they had been free of pain for a period of one weekor longer and, if so, when their current attack began (duration of current episode ofpain).

Subjects were subjected to a standard medical history and musculo-skeletal exam-ination. They were investigated with blood tests and radiology in accordance withclinical need. Indications for radiology have been described previously (Frank,1993). Medical and radiological records were subsequently reviewed to extract dataon clinical findings and diagnosis.

Subjective pain experience of chronic back pain patients 209

TABLE 1: Demographic data of 11 subjects with chronic back pain

Pain duration

Mean age (years) Mean total (years) Mean episode (months)(SD, range) (SD) (SD)

Men (n = 5) 51.2 (4.3, 45–57) 11.2 (3.0) 24.0 (40.4)Women (n = 6) 47.7 (21.0, 27–79) 9.7 (12.0) 10.8 (10.3)Total (n = 11) 49.3 (15.2, 27–79) 10.4 (8.7) 16.8 (27.5)

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Analysis

Thematic content analysis was applied to the transcriptions of the interviews. Theprocess described by Ritchie and Spencer (1994) for the analysis of contextual quali-tative data was applied. This method tends to be more structured than would be thenorm for much other qualitative research and the analytical process tends to bemore explicit and strongly informed by a priori reasoning (Pope et al., 2000). Eachtranscript was read in detail twice and on each occasion data (consisting of subjects’words) were extracted for each theme. These were ‘pain description’ and the‘amount of pain’. Subsequent primary analysis of the extracted data indicated therange and pattern of the accounts given by subjects when addressing issues withinthese themes. Further analysis grouped descriptions according to type to formulatecategories. The type and range of pain descriptors given by subjects were comparedto those in the McGill Pain Questionnaire (MPQ) (Melzack, 1983). Medical and radi-ological records were reviewed to document the clinical and radiological diagnosesand management of each subject.

RESULTS

Subject characteristics

Characteristics of the subjects are given in Table 1. None of the men were workingat the time of interview. All the women were still working except Subject 8 who wasretired. Subject 6 always had been a full-time housewife and mother. Only one sub-ject (Subject 9) had post-traumatic pain and was involved in litigation.

Clinical findings and diagnoses of subjects are provided in Table 2. Investigationsconfirmed that all subjects were experiencing pain arising from the spine due tomechanical or degenerative problems. All subjects except Subject 9 were found tohave low back pain as the major problem; Subject 9 had pain arising from the neck.Only two subjects warranted a surgical opinion. Subject 1 proceeded to have a disc-ectomy. Subject 3 declined a surgical opinion or a referral to a pain clinic in spite ofa walking tolerance of only 50 yards. Other subjects were managed as mechanicallow back pain. All were referred to physiotherapy except Subject 1 and attended fortreatment, with the exception of Subject 10 who failed to keep the appointment.

Interviews

Only two subjects (Subject 6 and Subject 7) chose to speak in a language other thanEnglish. Analysis of the descriptive accounts of pain given by subjects identified fourcategories of description. These were:

• Use of simile.• Positive and negative descriptors.• Loss of words.• Intensity and quantity.

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Pain descriptors

All subjects except one (Subject 10) attempted to describe the quality of their pain.Most subjects offered more than one description, and some differentiated betweenthe type of pain in their back and the type of pain in their leg:

… just like somebody’s sawed a chunk of flesh off and left it raw. [about the back]… it’s like something walking up and down my leg. [about the leg]… this pain is a … is very dull [about the back]… It’s a sharp paining you see. [about the leg]

One of the common ways of describing the pain was to employ simile identifiable bythe use of the word like. The use of simile provides graphic descriptions of the qualityof pain experienced by subjects (Table 3).

A second type of description emphasized both what the pain was — and wasnot. In the latter cases the words chosen by subjects contained a negative expres-sion. All subjects except one (Subject 10) provided these types of descriptions(Table 4). Five of the 11 subjects expressed their loss of words in trying to describetheir pain (Table 5), thereby indicating how difficult it was for them to put wordsto their pain experience.

De Souza and Frank212

TABLE 3: Subjects’ use of simile to describe pain

Subject Simile

1 … like somebody poking a needle through it*… like somebody making a hole and putting a copper tube (in) and twisting it about*… like somebody pulling you apart … just stretching and pulling from all sides … it’s that sort of pain*

2 It’s like an internal muscle pain.… it’s a pain like as if two things are rubbingI felt like a pin got in my spine. [on bending]

3 … like someone has poked a needle in the muscles or in the veins*

6 … when you sit on the plane, then you know the kind of basic pain you get? That’s what it’s like.

8 … just like somebody’s sawed a chunk of flesh off and left it raw [about the back]… it’s like something walking up and down my leg [about the leg]

9 … sometimes it’s like someone’s sticking a skewer into you*… feels like you’re bruised and been kicked by a horse*

11 It’s like an enormous bruise, or, er, maybe the feeling that your vertebrae may besticking too much to each other.

*Subjects with possible root compression.

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Subjective pain experience of chronic back pain patients 213

TABLE 4: Positive and negative descriptions of back pain

Subject Description

1 … a sort of niggling pain* [how back pain started]2 I feel like it’s a muscle … it’s very sort of tender, like a severe cramp

… it’s the back pain, not on the, its not on the bone or anything.The back pain, like I say … it really feels crippling

3 … it’s not a burning pain … its a stitching pain*4 … not like needles. It is a — totally pain.

… it’s not, not a little pain … constantly, continuously, pain is there5 … you are always aching, you know. I can say it’s not pain, its a sort of ache, you know,

in the bodyYou see, it’s not a pain, you knowThis pain is a … is very dull. [about the back]It’s a sharp paining you see. [about the leg]

6 … it burns, it burns insideSometimes I get sharp pain …Well, here, you see, I sometimes get very short, sharp pains … other times the pain is constant, here. And here, I don’t get any short sharp pains, no.

7 I just don’t feel comfortable, it just keeps hurting.8 … it’s just like tingles [about the leg]

… that creepy feeling up your leg9 … the pain is red, d’you know what I mean? Hot and spiky.*

… shooting pain*… burning, whatever*

11 … aching all over the bodyOh, I had a terrible pain. On the side.… it was some shooting, shouting pain, you knowIt feels painful.It’s painful to touch. Is sore … and I feel the pain.

*Subjects with possible root compression.Negative descriptors in italics.

TABLE 5: Loss of words for pain descriptions

Subject Description

1 I think pain is an individual thing really. …In my mind I know what sort of pain it was, but in your mind you might interpret in a different way.

3 … this pain is very abstract. It’s very difficult to explain.Because pain has got no definition.It’s very difficult to express pain. It’s a feeling that hurts oneself. I don’t know how to clarify this point.

5 I don’t know how I can differentiate the pain. I can’t put any specific words to describe it.6 Pain like, you know … How can I explain it?7 But what kind of pain? How do you say? I don’t know.

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Within the freeform accounts given, 12 different descriptors of pain used by thesubjects were the same as those offered by the MPQ (Melzack, 1983), but another 16different descriptors utilized were not (Table 6). Of the descriptors which were in theMPQ, burning was used the most often (three subjects), aching, sharp and shootingwere each used by two subjects and the remainder were only expressed once.Descriptors not contained in the MPQ were generally used only once, except poking(subjects 1 and 3) and sticking (subjects 9 and 11) which were each expressed by twosubjects.

Pain intensity

Overall, subjects had some difficulty describing their pain intensity and quantifyingthe amount of pain. Their accounts illustrated that the pain was not a static phe-nomenon in time. However, all except one (Subject 2), provided descriptions oftheir pain intensity and quantity (Table 7). Several subjects explained how painfluctuated both during the day and over longer times (subjects 6 and 7). This maybe a reason why quantifying the pain was so hard. Two women compared their painto childbirth (subjects 6 and 7) as a way of communicating the intensity. Only onesubject (Subject 9), who had had previous experience of being asked to quantifythe intensity of her pain, applied a numerical scale. Conversely, another subject(Subject 3) went to some length to explain that his pain could not be measurednumerically.

De Souza and Frank214

TABLE 6: Comparison of subjects’ pain descriptors with those of the MPQ

Subject Descriptors used: in the MPQ Descriptors used: not in the MPQ

1 pulling poking, twisting, niggling, stretching

2 tender rubbing, severe, crippling

3 cramp stitching, poked

4 burning

5 aching, dull, sharp

6 burns, sharp

7 hurting

8 tingles sawed, raw, creepy

9 shooting, burning, hot sticking, red, spiky

11 aching, shooting, sore terrible, shouting, sticking

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TABLE 7: Descriptions of pain intensity and quantity

Subject Description

1 … this is really terrible. Very, very bad.… and recently, it has got worse and worse

3 Sometimes the pain can be very severe, very severe.But, now it comes and goes, comes and goes, comes and goes.… how can you measure the pain? It is abstract, the pain. The intensity has got nodimensions.It cannot be measured with a foot ruler … it has 12 inches long pain. Foot, which is long pain. Thirteen inches, long pain.

4 It is a [pause] … totally pain.It’s not a little pain, but the pain, constantly, continuously, pain is there. You know, daytime or night time, anything.… pain is there. Pain is pain is pain.

5 It’s a terrible experience …6 Sometimes the pain is very bad, and sometimes the pain is less. Like that.

Sometimes the pain just gets so bad I can’t bear it. Then sometimes it comes back and it can get better. That’s how it is, but it never completely gets better.When a baby is born, that one is worse, This one [back and leg pain] is less.

7 Sometimes it hurts a little less, sometimes it hurts more.Well, is slightly less than that, but still, that pain [childbirth] you know it’s only for a short while, but this [back pain] has become an everyday thing.

8 The pain has been awful.9 I said ‘Right. This is my pain. On a scale of one to ten, at best it’s eight, at worst it’s nine’,

you know [relating experience of being assessed by a physiotherapist]10 Big problem.11 Lot of back pain … and it’s getting worse and worse.

It was very painful, and it would be slightly better, then become painful again, yes. After wards the pain went a bit silent, but it was always there.

DISCUSSION

As pain is an unpleasant sensory and emotional experience associated with actual orpotential tissue damage or described in terms of such tissue damage (IASP, 1979), itis not surprising that individuals communicate their experience of pain as damage totheir body. However, the language used may not fit into accepted terminology forhealth professionals.

This study demonstrates that the ‘insider’ account of chronic back pain revealsthe unpleasant nature of the experiences of back pain sufferers. Most subjects inter-preted these experiences in terms of tissue damage. Therefore, the IASP (1979) defi-nition of pain has some lay, as well as professional, validity. However, the ways bywhich formal instruments of assessment seek to reveal the qualities and quantities ofpain may exclude much of the nature of pain as experienced by those who have it.

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Comparison with the MPQ

The present results, gained through unstructured interview techniques, show thatindividuals with chronic back pain are equally likely to use their own as the MPQdescriptors to communicate the quality of their pain experience (Table 6). They alsoranged wider in their descriptions than the MPQ would have allowed them to do,expressing their pain as visual (red) and auditory (shouting) sensations. Our subjectseschewed whole categories of MPQ descriptors (for example, punctate, pressure) toutilize their own descriptors to communicate the same concept of ‘puncturing’ (forexample, poking, spiky and stitching).

The differences may reflect the varied cultural background of subjects in the pre-sent study (Swami et al., 1991) as compared to the Canadians from whom the MPQdescriptors were derived. Although widely used, the MPQ has been criticized for itscontent (derived mainly from clinical literature) and its validity, the suggestionbeing that it should have been derived by surveying adjectives used by subjects tocommunicate their pain (Skevington, 1995). Our study does not survey widelyenough to derive such a classification of pain descriptors, but illustrates the rangeand variety of adjectives used by chronic back pain sufferers.

Subjects may have used descriptors that approximated previous painful experi-ences, such as burning (from a hot object or food), stitching (having a ‘stitch’ in theside) or raw (having a skin abrasion). Similarly, they did not use descriptors of whichthey had no previous experience, such as stabbing or gnawing (MPQ; Melzack, 1983).Some MPQ descriptors may not have been used due to undesirable social connota-tions implying previous experience of the sensation. Thus, beating or smarting couldimply physical punishment.

Interviews are social interactions. What subjects reveal has as much to do withtheir perception and evaluation of the interviewers as it has to do with the subjectunder discussion. Age, sex, race and social class of interviewers may influence disclo-sure by subjects (Woodrow et al., 1972) and hence their ability to empathize withthose from different ethnic backgrounds. This is an inherent limitation in face-to-face interviews.

The emotional experience of pain is thought to be a fundamental aspect of itscomplex overall perception (Melzack, 1983; Waddell, 1992). Subjects in the presentstudy did not use any of the pain descriptors offered in the ‘affective’ section of theMPQ, but rather used words such as terrible, awful and crippling. However, not all sub-jects used single words or short phrases to express their emotional experiences. Theexperiences of pain may also be told in a narrative or story (Ehrlich, 1985) whichour subjects did and this dimension will be reported later.

Simile as descriptors

Seven subjects described their pain as tissue damage. Skevington (1995) aptly com-mented that many of these types of descriptors do not accurately represent the phe-nomenon being described. Therefore, Subject 9 did not have a priori experience ofthe pain caused from a bruise having been kicked by a horse. Conversely, Subject 6

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may well have provided an accurate description of her pain on the basis of previousexperiences of aeroplane travel.

The imagined tissue damage reported in this study can be categorized as ‘impale-ments’ (with needles, copper tube, pin and skewer), ‘forces’ (by pulling, stretching, bruis-ing, kicking and sitting) and ‘abrasions’ (rubbing, sawing and sticking). Subjects’reporting impalements with needles (subjects 2 and 3), copper tube (Subject 1) andskewer (Subject 9) were those with radiological findings suggesting root compression(Table 2). These types of descriptor may therefore reflect the particular underlyingpathology of nerve root compression. The types of tissue reported to feel damagedwere muscle (subjects 2 and 3), spine (Subject 2) veins (Subject 3), flesh (Subject 8)and vertebrae (Subject 11).

Some subjects were imprecise as to whereabouts they had pain. Some identifiedthe leg (Subject 8, Subject 5), the side (Subject 11) and the back (Subject 2).Others referred only to the body (subjects 5 and 11). All these subjects showed radio-logical signs of degenerative spine pathology (Table 2). It is possible that pain fromdegenerative pathology is difficult for individuals to localize. This difficulty may pre-sent as vague and confusing and may not reflect any pattern of pain recognized byprofessionals.

Intensity of pain

By asking the subjects to describe the amount or intensity of pain they were experi-encing the interviewers may have expected the respondents to synthesize a complexphenomenon into a single overall concept and report it succinctly. Most of the sub-jects resisted this and provided multifaceted accounts. This way of responding maybe due to individuals’ inability to discriminate between various components of pain(Swami et al., 1991).

Some subjects described the way the pain fluctuated (subjects 3, 5 and 7)implying that the pain may not be amenable to quantification as the level keptshifting. Some used spatial characteristics to quantify their pain stating that it wasnot little (Subject 4), was big (Subject 10), was a lot of (Subject 11) or was eight on ascale of one to ten (Subject 9). This last subject drew on her experience of beingassessed by a physiotherapist. Other subjects used time dimensions of constantly,continuously (Subject 4), an everyday thing (Subject 7), always there (Subject 11)and never completely gets better (Subject 6) to explain how much pain they experi-enced. Although duration of back pain and duration of episode of pain are bothused clinically as important pain measures (Spitzer et al., 1987), it is often notrealized that subjects may envisage the amount of pain they experience as a con-cept of time.

Several subjects expressed the amount of their pain in terms of its seriousness, bysaying it was very, very bad (Subject 1), very severe, very severe (Subject 3), totallypain and pain is pain is pain (Subject 4), terrible (Subject 5), very bad (Subject 6) andawful (Subject 8). Two subjects (Subject 1 and Subject 11) gave added assurancesthat their pain was worsening.

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Two women compared their pain intensity with childbirth (subjects 6 and 7).They both judged their chronic back pain to be less than their experience of labour,but for different reasons. Hapidou and Catanzaro (1992) have suggested that womenwho have experienced labour use it as an anchoring event against which to judgeother painful experiences. Skevington (1995) opines that, similarly, other remem-bered painful events may also be used as ‘anchors’ for judgements of pain intensity.

One subject (Subject 3) was clear that, The intensity has got no dimensions, goingon to explain the meaninglessness of trying to measure pain in inches.

Thus, subjects used a range of concepts to quantify their pain. It may be thatasking chronic back pain subjects to describe the intensity, or amount, of their painrequires a type of categorical thinking that is usually not applied to sensations orfeelings in everyday life.

CONCLUSIONS

The number of subjects interviewed was small, therefore no claim is made that find-ings are representative of all chronic back pain patients. However, the number andrange of descriptions provided by subjects about the quality and quantity of theirpain experience provide considerable insight into the subjective dimensions of per-ceived pain. Overall, the results show that the ‘insider’ accounts of chronic backpain provide rich and graphic descriptions of the unpleasant nature of the experi-ences of sufferers, and that these descriptions of the qualities and quantities of painbear little resemblance to formal tools of assessment.

In clinical practice, there is a tendency to rely on measures because they are easyor widely used (visual analogue scales for pain rating, the MPQ). Therefore clini-cians expect that formal assessments provide clear and succinct information of indi-viduals’ pain. This research indicates how erroneous such a view of formal painassessment tools may be. It has highlighted the depth of perception and understand-ing subjects had about their chronic back pain and the degree of insight they hadinto the nature of their pain and how it affected their lives.

Physiotherapists treating chronic back pain patients need to place far moreemphasis on the so-called ‘subjective’ part of their diagnostic assessments and allowthe experiences and insights of chronic pain sufferers to inform treatment. Bydemonstrating an understanding of individuals’ perceptions of pain, and incorporat-ing their views into treatment plans, therapists may be able to enhance communica-tion with their patients. There is a need to explore further, and in greater depth,subjective accounts of pain and to realize the limitations of quantification.

ACKNOWLEDGEMENTS

The authors acknowledge the contributions of Jayne Neville, Kalpa Kharicha and Vidyut Sharma, andwould like to thank Professor Chris J Main for helpful comments on a draft of the paper.

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REFERENCES

Agency for Health Care Policy and Research (AHCPR). Management Guidelines for Acute Back Pain,US Dept of Health and Human Services, 1994.

Clinical Standards Advisory Group. Back Pain. London: HMSO, 1994.Ehrlich K. The language of pain. Theoretical Medicine 1985; 6: 177–187.Frank, AO. Low back pain. British Medical Journal 1993; 306: 901–909.Hapidou EG, Catanzaro D. Responsiveness to laboratory pain in women as a function of age and child-

birth experience. Pain 1992; 48: 177–181.International Association for the Study of Pain (IASP). Pain terms: a list with definitions and notes on

usage. Pain 1979; 6: 249–252.McAuley JH, De Souza LH, Sharma V, Robinson I, Main CJ, Frank AO. Self-defined ethnicity is

unhelpful. British Medical Journal 1996; 313: 425.Melzack R. The McGill Pain Questionnaire. In: Melzack R (Ed.). Pain Measurement and Assessment.

New York: Raven Press, 1983; 41–47.Pope C, Ziebland S, Mays N. Analysing qualitative data. British Medical Journal 2000; 320: 114–116.Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess R

(eds). Analysing Qualitative Data. London: Routledge, 1994; 173–194.Skevington SM. Measuring painful sensations. In: Skevington SM. Psychology of Pain. Chichester:

John Wiley and Sons, 1995; 24–58.Spitzer WO, Leblanc FE, Dupuis M, Abemheim L, Belanger AY, Block R et al. Scientific approach to

the assessment and management of activity-related spinal disorders: a monograph for physicians.Report of the Quebec Task Force on Spinal Disorders. Spine 1987; 12 (Suppl. 7): S1–59.

Swami DR, Nathawat SS, Solanki RK, Bhojak MM. Factorial validation of McGill Pain Questionnaire.Indian Journal of Clinical Psychology 1991; 18: 15–18.

Turk DC, Melzack R. Handbook of Pain Assessment. New York and London: The Guildford Press,1992.

Van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic non-specific lowback pain. Spine 1997; 22: 2128–2156.

Waddell G. An approach to backache. British Journal of Hospital Medicine 1982; 187–219.Waddell G. A new clinical model for the treatment of low back pain. Spine 1987; 12: 632–643.Waddell G. Biopsychosocial analysis of low back pain. In: Baillière’s Clinical Rheumatology 1992; 6:

523–557.Walker J, Holloway I, Sofaer B. In the system: the lived experience of chronic back pain from the per-

spectives of those seeking help from pain clinics. Pain 1999; 80: 621–628.Woodrow RM, Friedman GD, Siegelaub AB, Collen MF. Pain tolerance: differences according to age,

sex and race. Psychosomatic Medicine 1972; 34: 548–556.

Address correspondence to: Professor L H De Souza, Chair of Rehabilitation, Centre for Research in Rehabili-tation, Department of Health Studies, Brunel University, Osterley Campus, Isleworth, Middlesex, TW75DU, UK (Email lorraine.desouza@ brunel.ac.uk).

(Submitted June 1999; accepted April 2000)

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