Comprehensive management of chronic pain syndrome

Material Information

Comprehensive management of chronic pain syndrome
Jordan, Sharon Louise
Publication Date:
Physical Description:
v, 61, [1] leaves : ; 29 cm

Thesis/Dissertation Information

Master of arts
Degree Grantor:
University of Colorado Denver
Degree Divisions:
Department of Anthropology, CU Denver
Degree Disciplines:


Subjects / Keywords:
Intractable pain ( lcsh )
Intractable pain -- Treatment ( lcsh )
Intractable pain ( fast )
Intractable pain -- Treatment ( fast )
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )


Includes bibliographical references (leaves 55-59).
General Note:
Submitted in partial fulfillment of the requirements for the degree, Master of Arts, Department of Anthropology.
General Note:
Department of Anthropology
Statement of Responsibility:
by Sharon Louise Jordan.

Record Information

Source Institution:
|University of Colorado Denver
Holding Location:
Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
22879640 ( OCLC )
LD1190.L43 1990m .J67 ( lcc )

Full Text
Sharon Louise Jordan
B.S., University of Buffalo, 1972
A thesis submitted to the
Faculty of the Graduate School of the
University of Colorado in partial fulfillment
of the requirements for the degree of
Master of Arts
Department of Anthropology

This thesis for the Master of Arts degree by
Sharon Louise Jordan
has been approved for the
Department of

Jordan, Sharon Louise (M.A., Anthropology)
Comprehensive Management of Chronic Pain Syndrome
Thesis directed by Professor Lorna G. Moore
The purpose of this thesis is to examine the
management of chronic pain syndrome in the health care
system. Chronic pain syndrome refers to persistent,
debilitating pain which affects the sufferer physically,
emotionally and spiritually. The multidimensional
characteristics of chronic pain syndrome require a
management approach different from the traditional pain
Both health practitioners and patients generally
consider pain as a symptom that can be relieved with
medical attention. Treatment of chronic pain syndrome
does not meet this expectation. As a result it is no
longer considered a symptom but rather a disease itself.
Multidisciplinary pain centers have been
established to manage the multiple aspects of chronic
pain syndrome. However, in the current system, the
patient's entry to a pain center is often the last resort
in treatment. Before that time, unnecessary treatments
have often been administered by well-meaning health
practitioners unfamiliar with the characteristics of the
chronic pain syndrome.

This thesis proposes three criteria for the
comprehensive management of chronic pain syndrome.
First, the centralist pain model is presented as best
incorporating the peripheral and central inputs
contributory to the pain problem. Second, the
spacetime health model is introduced as having broader
explanatory capabilites than the traditional biomedical
model. Third, the redefinition of health and wellness
offers a wellness goal that can be attained in spite of
It is postulated that early recognition of the
chronic pain syndrome by independent practitioners will
decrease unnecessary treatments and will provide
appropriate care much sooner to the patient. Educating
the patient to the particulars of chronic pain syndrome
would help redirect expectations relative to the
disorder. In addition, health practitioners, insurance
companies, lawyers, policymakers and the public in
general need to be informed as to their role in the
development and the perpetuation of the chronic pain
The form and content of this abstract are approved. I
recommend its publication.

I. INTRODUCTION..................................... 1
III. DEFINITIONS OF PAIN............................. 13
Acute Pain.................................... 15
Chronic Pain.................................. 15
Chronic Pain Condition..................... 15
Chronic Pain Syndrome...................... 16
V. CHRONIC PAIN MODELS......................... 3 0
Peripheral ist Model...................... 3 0
Centralist Model.............................. 31
VI. HEALTH CARE MODELS.............................. 35
Biomedical Model.............................. 35
Holistic Model................................ 39
Spacetime Model............................... 42
VIII. CONCLUSION...................................... 51
BIBLIOGRAPHY....................................... 55
A. HOLISTIC HEALTH MODEL........................... 60

Pain is a universal human experience and is one
of the most common reasons that people seek medical
attention. Patients with pain represent both individual
and societal problems in terms of their suffering, the
effect on their social and family interactions, time lost
from work, medical expenses and costs associated with
litigation and disability compensation (Holzman and Turk
1986:ix). The relief of pain is one of the primary goals
of health care practitioners. As a physical therapist, I
rarely see a patient who does not have pain as a primary
complaint. Pain complaints can be acute and short term
in duration, lasting only a few days or weeks after the
initial onset. Acute pain responds well to traditional
biomedical treatments, such as surgery, analgesic
medications and physical therapy. Medical attention can
alleviate the intensity of pain as well as hasten the
healing process. Some acute pain problems resolve
without medical treatment.
Chronic pain can persist for three months or
longer after the initial onset and often results in

partial or total disability of the chronic pain sufferer.
Chronic pain is the third leading cause of disability in
the United States following cancer and heart disease
(Smoller and Schulman 1982) Chronic pain is not life
threatening; nor is it a deteriorating condition like
cancer pain. Chronic pain afflicts about 30% of all
Americans and represents a cost to our economy of close
to $80 billion per year in loss of productivity and in
disability payments (Sternbach 1987). The chronic pain
patient has often sought relief from numerous health care
practitioners. The patient often receives medication
after medication with resultant drug abuse. Unnecessary
surgeries may have been performed with dismal results.
Physical therapy treatments may continue for months with
little change in the pain complaints. The patient is
often unemployed with dim prospects for future
employment. Concurrent depression and low self-esteem
interfere with satisfying family and social
relationships. In short, chronic pain impairs the
quality of life of many individuals.
As a health care practitioner, I have experienced
difficulties in significantly reducing chronic pain in
intensity or duration. Other members of the health care
community: physicians, osteopaths, chiropractors,

dentists and psychologists for example, share similar
frustrations in treating chronic pain. Treatment
techniques efficacious for the short term pain conditions
do not provide the same outcome for the long term
I will argue in this thesis that chronic pain
can not be treated as simply an extended acute pain
problem. Chronic pain has multi-dimensional
characteristics that necessitate a different treatment
regime than the now dominant biomedical approach.
According to Bressler (1979:57), the chronic pain
experience can be affected by childhood experiences,
ethnic and cultural variables, socioeconomic factors,
genetic predisposition, birth order, gender and a host of
other physical, perceptual, cognitive and emotional
In good faith, biomedical practitioners have
administered treatments efficacious for acute pain to the
chronic pain situation. When these fail, or provide only
minimal relief, a more diligent search for a physical
cause of the pain often ensues. This biomedical strategy
is reflected in the following Sufi parable: while
searching on hands and knees for his key under the street
light a friend approached and asked the enlightened

fabled teacher: "You lost your key here?" "No", the
teacher replied, "I lost it in my house." "Then, why
are you looking here?" asked the friend. "Because, the
light is better here". (Dossey 1982:60).
In searching for relief of chronic pain, the
medical profession has looked where the light is good,
under the biomedical spotlight. However, the outer,
darker fringes of the spotlight seem to contain the key
for comprehensive management of chronic pain. The
emotional and spiritual concerns of the chronic pain
sufferer are represented in this less well-illuminated
field of vision. A broader field of vision is needed to
include the emotional and spiritual aspects along with
the physical aspects of the patient's chronic pain
experience. The health care system wherein the
management of chronic pain lies must also be examined.
The recent proliferation of interdisciplinary
pain centers demonstrates that there is need for a
multidimensional chronic pain model. The chronic pain
patient generally enters the interdisciplinary pain
center after the traditional avenue of individual
practitioners has failed. The chronic pain center is the
last resort for the patient. Earlier recognition of the
chronic pain patient would prevent unnecessary treatment

and would facilitate the delivery of appropriate care
much sooner in the patient's pain course. Entry into a
pain center may not be necessary if individual
practitioners identified the chronic pain patient at the
outset and employed treatment techniques beneficial for
the chronic pain sufferer.
This thesis will consider two aspects of chronic
pain, the chronic pain condition and the chronic pain
syndrome. Ongoing cancer pain will not be addressed. A
review of the literature will present existing chronic
pain models and will explore current health care models.
Finally, criteria for the comprehensive management of the
chronic pain syndrome will be established.

Before defining chronic pain, a brief overview of
the history of the evolution of the current understanding
of pain will be presented. Ross and Ross (1988:7-18)
trace the history of pain from what they label
"primitive" times to present day. As cited in Ross and
Ross (1988), Fairley identifies that "primitive man"
distinguished between pain from obvious external causes
and pain from unknown or unexplainable causes. Internal
pains with no obvious cause were believed due to magic
fluids or evil spirits. Trepanning, making a hole in the
skull, was performed to release the demon from the skull.
As reported in Ross and Ross (1988) Siegerist cites
evidence from fossilized bones and tools from 40,000 B.C.
and from rock paintings in southern France and Africa
from about 2,000 B.C. that suggest many of the same pains
that afflict humans today troubled early humans. In the
17th century pain was viewed as a single sensory
dimension, much like hearing and smelling. By the late
1800s, it was recognized that almost any sensation, if
strong enough could result in pain.

By the 1950s, a two dimensional model including
physiological and psychological input was proposed. John
Bonica, in his classic 1953 textbook, The Management of
Pain, described the chronic pain syndrome and how
cognitive and behavioral changes contributed to its self-
perpetuating character. Seemingly before his time,
Bonica advocated a multidisciplinary approach to chronic
pain which did not materialize on other fronts until the
mid 1970s. A qualitative anthropological study on
cultural differences in pain experience was conducted in
1952 and will be presented in Chapter V.
In 1965, Melzack and Wall proposed the "gate
control theory" in understanding the mechanism of pain.
Basically, the gate theory proposed that neural
mechanisms in the spinal cord act like a gate that open
or close to different nerve impulses from the periphery
to the brain. Psychological factors and environmental
factors were recognized as influencing the flow of pain
information through the gate.
In the 1960s, psychologists proposed learning
processes, such as operant and classic conditioning and
social modeling, as significant in the development of
learned chronic pain syndrome. In a pain-producing
situation, unconditioned pathological (injury or disease)

stimuli can be paired by the sufferer to an infinite
number of conditioned environmental or sociologic
(physical inactivity or weather) stimuli, but not in a
cause-and-effect relationship (Brena and Chapman 1981).
As a result, the pain behavior originally elicited by
pathology can become associated with the environmental or
sociological cue. Such behaviors become learned or
conditioned particularly when positively reinforced.
For instance, rest becomes a reinforcer when the strategy
to reduce pain is to cease the activity underway when
the pain occurred. This appears to be a useful strategy
with acute pain but not chronic pain. Pain behaviors
such as complaining, seeking pain-relieving medications,
limping and physical inactivity can continue after the
pathological condition has healed. Eventually, it could
be argued that prolonged physical inactivity has a more
direct cause and effect role in pain symptomatology.
Bortz (1984) identifies the debilitating characteristics
of the disuse syndrome as cardiovascular vulnerability,
obesity, musculoskeletal fragility, depression and
premature aging.
In addition, patient interaction with health care
practitioners who lack an understanding of the
neurophysiological, psychological and environmental

components of chronic pain was viewed as contributory to
learned pain behavior. Inexperienced practitioners can
be quite reactive to those patients who respond with
strong vocalization, emotional upset and physical
resistance. Such behavior implying extreme pain often
elicits corresponding practitioner efforts to decrease
the pain. Learning theory-based treatment strategies,
such as behavioral modification, hypnosis and
biofeedback, became more widely used as the
ineffectiveness of traditional methods were acknowledged.
In the 1960s, clinicians and researchers
recognized that acute pain and chronic pain were
distinctly different entities involving different
physiological mechanisms and therefore different
treatment. Chronic pain models of treatment began to
evolve to address the characteristics of chronic pain.
Rising health care costs also prompted the development of
cost efficient treatment programs. Chronic pain models
will be discussed in Chapter V.
In the 1970s and 1980s several important advances
in the field of pain study were made (Ross and Ross
1988). In the mid 1970s interdisciplinary communication
was fostered with the advent of interdisciplinary teams
of health care providers in pain centers. In addition,

the International Association for the Study of Pain was
founded and PAIN, the first professional journal was
In 1975 an exciting discovery of an endogenous
analgesic system in the central nervous system was made.
The natural, pain-relieving substances, similar in
composition to morphine, called endorphins, act to turn
off pain in the brain. Decreased levels of endorphins
have been measured in chronic pain patients (Ross and
Ross 1980). It has been suggested that endorphin
secretion is stimulated by acupuncture, the placebo
effect, guided imagery and other alternative non-invasive
procedures (Bressler 1979:222). Press (1982) asserts
that there is no reason to doubt that symbolic phenomena
(imagery, hypnosis) and the placebo effect may affect the
brain's ability to produce and disperse endorphins.
Since the initial discovery of the endogenous compounds
and opiate receptor sites, research has expanded
exponentially. Three distinct types of compounds appear
to be part of a complex system of neurochemicals that
have multiple potential interactions with other
neuroregulators (Noel and Nemeroff 1988:55). These are
the beta-endorphins/ACTH precursor, enkephalin precursor,
and dynorphin/neo-endorphin precursor. Research

continues to study how endorphins work and how
individuals can maximize use of the body's own pain
reducing substances.
In other areas of pain research, traditional
facts about pain problems have been reevaluated. Tension
and migraine headaches are showing similar etiological
processes. Childhood pain study has reached consensus
that neonates and infants experience pain dispelling the
previous belief that they did not (Ross and Ross
1988:29). Interest in childhood pain has increased as a
means to learn more about the normal development of pain
perception and response. There appears to be a
correlation of child abuse victims and chronic pain
syndrome as adults (Payne and Norfleet 1986). Ross and
Ross (1988:304) propose a childhood pain prevention
program starting at the preschool level to improve the
child's understanding of adaptive and maladaptive usage
of pain and thereby improve coping skills.
This brief overview has provided the reader with
an introduction to the evolution of the current
understanding of pain. Significant biomedical research
has offered greater understanding of complex
neurophysiological processes. At the same time the
advancement of behavioral, cognitive and learning

theories promotes wider acceptance of the psycho-social-
cultural aspects of pain. Anthropological perspectives
on pain will presented in Chapter IV. As
interdisciplinary research and communication continues,
the interconnectedness of the multifactoral puzzle of
pain will become better understood.

According to Gildenberg and De Vaul (1985), there
is no standard definition for pain. Scientists define
pain according to what they see and measure. Pain may be
a moralizing force to the philosopher and theologian.
The anthropologist may view it as an expression of
cultural norms. The physiologist may focus on the
physical sensation of pain perception, while the
psychologist looks at the emotional aspects. Pain
sufferers define pain according to what they feel. Pain
is not a simple, well-defined sensation like hearing or
touch. Pain is attended by greater emotional response
than these primary sensations. In other words, pain is
complex and subject to individual interpretation.
Individuals may react differently to the same noxious
sensation experienced at different times. Also marked
differences in reactivity to the same stimulus exist
among individuals. In light of the influences of the
social and physical environment on the pain experience,
pain must be viewed in context.
As cited in Brena and Chapman (1981), IASP
defines pain as an unpleasant sensory and emotional

experience associated with actual or potential tissue
damage or described in terms of such damage. Two
separate components of pain are considered in this
definition: (1) a possible painful stimulation triggered
by changes in tissue homeostasis and (2) a perceptual
interpretation of actual or imagined pain which leads to
emotional arousal.
Although pain is an abstract and relative concept
with many definitions, two important levels of
measurement can be distinguished: threshold and
tolerance. Pain threshold refers to the level of
intensity at which the stimulus is first perceived to be
painful; pain tolerance represents the ability to
maintain control over one's self despite the pain. Pain
threshold appears to be influenced primarily by
physiological variables; pain tolerance appears to be
associated with the psychological state of the individual
and can be manipulated by drugs or the environmental
situation. Pain tolerance shows the greater inter-
individual variability related to such factors as age,
cultural training, past experiences and emotional state.
For example, pain tolerance is lowered with emotional
Classification of pain based on duration has
proven to be therapeutically useful. As stated earlier,

pain researchers now recognize that there is quite a
difference between acute and chronic pain.
Acute Pain
Acute pain is generally acknowledged as primarily
a warning signal that body tissues are being or have been
injured. Acute pain is easily produced and studied in
the laboratory. Acute pain lasts less than three months
and has a well-defined cause such as a bone fracture.
Once tissue healing has occurred pain abates.
Chronic Pain
Chronic pain can persist long after the initial
injury has healed, or as associated with presently
incurable conditions such as arthritis. Chronic pain has
been studied only clinically. The pain often spreads
from the original site to adjacent or distant areas.
Chronic pain may or may not have an identifiable cause.
Ross and Ross (1988:20-21) describe two aspects of
chronic pain, chronic pain condition and chronic pain
Chronic pain condition. The chronic pain
condition is considered to be a symptom of the original
condition. Arthritic pain following a traumatic knee
injury would be an example of a chronic pain condition,

providing the patient copes well with the pain. In spite
of partial or complete disability, this patient accepts
the persistent or recurrent pain condition with
equanimity. This patient lives life to the fullest
capabilites within the bounds of the dysfunction. Social
and family relationships are satisfying and enjoyable.
This individual remains relatively physically active and
follows a lifestyle of health maintenance. This type of
chronic pain patient is rarely seen in the pain centers.
However, this level of functioning can be considered a
goal for the following type of patient.
Chronic pain syndrome Chronic pain syndrome is
not necessarily a symptom of the original condition, but
is considered a disease and illness in and of itself.
The original etiology does not appear to be the primary
factor in maintaining the chronic pain syndrome. Pain
may have started with the aforementioned example of the
arthritic painful knee. But now the pain assumes
disproportionate significance in the person's life.
It is important to note here that the following
characteristics are more often seen in "benign" pain
patients than in those with "malignant" diseases
(Sternbach 1989). Malignant pain patients more often
function better despite their pain. As they go into

decline, pain may become a serious problem but still
without many of the features found in chronic pain
This patient is excessively preoccupied with
multiple pain complaints. There is a history of numerous
contacts with health practitioners and a resultant array
of ineffective treatments and possible iatrogenic
complications. Multiple and inappropriate drug use is
common. The patient is often unable to complete physical
therapies that require active participation and diligent
effort. Sleep disturbance leads to chronic fatigue.
Significant physical changes occur as a result of
prolonged inactivity. Muscles atropy from disuse;
muscles and soft tissues shorten and become painful
within normal ranges of motion; poor muscle endurance is
unable to sustain simple activities of daily living.
Feelings of helplessness and hopelessness lead to
significant psychosocial changes. Self-esteem erodes;
depression and anxiety increase. The ability to enjoy
life is clouded by preoccupation with the pain problem.
As the physical and emotional abilities to participate in
social and family activites decrease, the social and
family relationships deteriorate. Family and friends
often become enablers for the dependency behavior of the
chronic pain syndrome.

The following case study will illustrate how a
post traumatic arthritic knee condition is embraced
differently than in the chronic pain condition.
Mike, a blue collar worker, was injured on the
job one and a half years ago. He sustained a
hyperextension injury to his right knee. He has had
three arthroscopic surgeries with the most recent being
most successful. Previous physical therapy treatments
apparently failed. "Anything they tried made my knee
swell and hurt more." He has been on workers
compensation benefits since the injury and does not plan
to return to his former job. Alternative employment
plans are "out of the question with my knee in this
shape." He has been ambulating with two crutches until
recently; he now uses one crutch.
On his doctor's recommendation, Mike is willing
to try physical therapy again at a different clinic.
Subjectively, Mike referred to his knee as if it had a
mind of its own. "It just won't cooperate; it swells up
for no reason; it hurts period." He was quite
descriptive and detailed about different types of pain
and their locations around and inside the knee. He
reported constant pain that limited him in most all his
activities. He expects a total knee replacement within

five years even though the doctor can not say for sure.
All in all, he seemed to have a negative outlook about
his abilities to function with his injured knee.
Clinically, there was no palpation tenderness;
passive range of motion was full; edema was absent. The
most outstanding sign was muscle weakness. He used his
hand to protectively move his right leg on and off the
table. Based on clinical findings and experience, his
functional limitations seemed excessive for the
condition. His complaints of pain disabled him more than
the clinical signs warranted.
Mike does not display the feeling of hopelessness
and depression common in chronic pain syndrome. In fact,
his decreased physical abilities did not seem to distress
him. He does not trust that workers' compensation has
his best, interests in mind. He has an attorney
representing his case. There appears to be little
financial incentive for him to change his current
functional status, particularly in regards to work. Both
he and his wife receive workers' compensation and
disability benefits.
It seems widely believed among clinicians that
litigation and disability proceedings contribute to a
prolonged physical therapy program. Patients often seem

to lack motivation to improve when proof of disability is
favorable for the settlement. One study has shown that
New Zealand's compensation and disability system
contributes to less emotional and behavioral disruption
of claimants than the American system, as there is
no-fault compensation (Carron et al. 1985).
Another interesting point in this case study was
that Mike's gait pattern demonstrated similar
characteristics to his disabled wife's ambulation.
Mohamed et al. (1978) found that spouses of chronic pain
patients are also likely to develop pain problems
themselves and often in the same bodily location as their
It seems intuitively evident that simply a
physical treatment approach to such a complex problem is
incomplete and will not address the other issues in this
case example. According to Waddell et al. (1984), Mike's
exaggerated symptoms and signs demonstrate magnified
illness behavior. Mike's own perception of his
disability is far greater than his physical impairment.
Although the illness behavior may develop secondarily to
the original physical problem, the resulting illness
behavior may become the major management problem. This
realization emphasizes the importance of treating the

patient and his/her illness and not just the physical
disorder. How management of chronic pain syndrome
occurs is dependent on the understanding of the
multi-dimensional problem. Sociocultural aspects will be
presented in the following chapter on the anthropological
perspectives on pain.

Although pain is frequently mentioned in
anthropological literature on cultural groups, there is a
dearth of published anthropological studies specifically
dealing with pain response and cultural factors. Mark
Zborowski was a pioneer in investigating cultural
components in response to pain. In the early 1950s,
Zborowski (1978) interviewed male hospital patients who
belonged to 4 ethnic groups: Irish, Italian, Jewish and
Old American (Anglo-Saxon). He wanted to identify
whether or not ethnicity was consistently related to the
patient's pain response and what meanings were given to
the pain symptoms.
The study found that Jewish and Italian patients
were similar in their emotional display and description
of pain. The Irish and Old American patients were less
emotional, more reserved and tended to withdraw from
others when in pain. Intraethnic differences were not
addressed in this study. However, Zborowski observed
that the degree of acculturation, the socioeconomic
status, age and level of education seemed important

factors in the individual's response to pain.
Wolff and Langley (1978) criticized Zborowski's
study as lacking in experimental control of pain but did
agree that there was evidence of attitudinal factors
influencing the pain response within cultural groups.
Zborowski (1978) recognized in his 1952 report that the
analysis of cultural factors in response to pain was
tentative and incomplete. At that time he recommended
more collaboration between the social sciences and
medicine for better understanding of pain problems.
Researchers of other disciplines have explored
the relationship of ethnicity and pain response. Zola
(1966) conducted an interethnic study concerning patient
responses and attitudes to symptoms including pain.
Similar to Zborowski's study, Irish patients tended to
deny pain and Italian patients tended to emphasize pain.
Anglo-Saxon patients' responses were in between these two
groups but closer to the Irish responses.
A study by Sternbach and Tursky (1965) failed to
find differences in the way ethnic groups estimated the
magnitude of pain (pain threshold) but did find
differences in pain tolerance. From a sensory point of
view, pain evaluation was found to be similar among
ethnic groups, but how the pain was tolerated differed.

Weisenberg et al. (1975) studied anxiety and
attitude towards pain in the head and oral cavity in
Blacks, Caucasian and Puerto Rican patients. Blacks and
Caucasian patients were similar in attitudes to pain but
differed from Puerto Rican patients.
In 1984, Koopman et al. replicated the work of
Zola and the results supported the significance of
ethnicity in the reporting of pain. The variables of age
and sex were found to mediate ethnic differences probably
because older and female patients carried on ethnic
traditions more than the younger and male patients.
Lipton and Marbach (1984) looked at both
interethnic.and intraethnic differences in the pain
experience of Blacks, Irish, Italians, Jews and Puerto
Ricans. Intraethnic variation was found to be related to
the degree of acculturation to the American health system
and to the socioeconomic and educational status of the
patients. This supported Zborowski's (1978) earlier
Moore and Dworkin (1988) attempted to improve on
the Zborowski ethnographic interview method by matching
subjects across groups by major social variables (age,
sex, education and economic status) and ethnic
identifications. They also interviewed subjects who were

not experiencing pain at the time. Their two major
ethnic groups were Chinese and Western (Anglo-Americans
and Scandinavians) patients and dentists. The study's
primary goal was to evaluate two variables: (1)
professional socialization (how dentists describe pain as
compared to patients) and (2) ethnicity in pain
It was determined that cultural factors played a
stronger part in pain perception than professional
socialization. The authors recommended that clinicians
must be aware of their own limitations and biases when
assessing pain patients who have different cultural
backgrounds from their own. Consequently, questionnaires
and test instruments for the description and measurement
pain must be culturally relative.
According to Zborowski (1978), culture becomes
the conditioning influence in the formation of the
individual reaction patterns to pain. Pain is accepted
or avoided, regardless of its intensity, according to the
cultural significance attributed to the pain and to the
situations involved with pain (Zborowski 1969). Culture
defines situations in which pain is expected or not.
The only universal feeling about pain is that no
normal human likes it (Zborowski 1969:31). Human

cultural groups differ in both pain expectancy and in
pain acceptance. Zborowski (1969:30) defines pain
expectancy as the anticipation of pain specific to a
physical, social and cultural situation; and pain
acceptance is the willingness to tolerate pain
sensation. Pain acceptance and pain expectancy play a
role in the patient's behavioral and emotional responses
to pain. Kotarba (1983) contends that a patient's coping
strategy is shaped largely by the degree to which the
patient accepts the inevitability of suffering. This
acceptance is usually made within the context of a belief
system that serves for emotional support and spiritual
strength as well as provide meaning for the intractable
In order to manage chronic pain, Kleinman (1982)
emphasizes that anthropological assessment of the context
of meanings and social relationships within which chronic
pain occurs is as important as are the biomedical and
psychiatric evaluations. As a clinician, he recommends
open-ended questions and an empathetic ear in order to
elicit the patients' understanding of the cause of their
pain. Obtaining the patient's explanatory model in this
way is not as rigorous or exhaustive as ethnographic
interviewing. However, in a clinical setting, it is
often "good enough" for improving patient care.

In a recent anthropological study, Corbett (1986)
examined the cultural dimensions of the frustration for
both patient and practitioner in the management of
chronic back pain patients. Data were obtained from
interviews with back pain sufferers and with
practitioners treating these patients and from
observations of multidisciplinary pain patient
The author asserts that frustration with chronic
back pain management stems not only from the intractable
nature of chronic pain, but also from cultural
perceptions about chronic pain and from constraints of
the dominant biomedical system which reinforce and
perpetuate those cultural meanings.
Corbett (1986:373) identifies contradictions in
both the conceptual and practical levels of the
biomedical system's management of chronic back pain.
Many practitioners profess a comprehensive understanding
of chronic pain yet persist in reducing it to biomedical
mechanisms. According to Corbett, practitioners'
opinions are fraught with moral judgments and unconscious
cultural expectations when determining legitimation of
pain. Also the pain of many patients can be integrally
related to inefficacy of treatment as well as to

iatrogenesis. Ironically, the health system that seeks
to alleviate chronic pain can be held partially
responsible for contributing to it through failed
treatments, repeated medical encounters, lengthy
litigation proceedings and the constraints of the
disability and workers' compensation system.
Kotarba and Seidel (1984) examine the
organizational response in medicine to the problem pain
patient. The team of health care practitioners in pain
centers is identified as social control agents who label
the pain patient often to fit the practitioners'
expectations. This label creates the social identity of
the problem pain patients often as a morally stigmatized
and deviant patient population. Kotarba and Seidel
(1984) implicate the cultural system as placing
unrealistically high expectations on healers to eliminate
pain and suffering, and on the health care system,
especially third party payors, that reimburses those
that try. As cited in Ross and Ross (1988), Abelson
states that demand for care is nearly infinite when the
major part of medical costs is carried by a third party.
Waddell (1987) noted that newly introduced
orthopedic services in the developing country of Oman
resulted in patients with low back disability. Prior to

that people with low back pain continued to work and
function in daily activities. It is speculated that they
considered back pain to be a part of life and therefore
expected to slow down. Also there had not been access to
disability care.
Corbett (1986:368) articulates clearly what I, as
a practitioner treating chronic pain syndrome patients,
have often witnessed: the health care system, myself
included, is a significant part of the problem.
Therefore, just as the patient is being asked to take
responsibility, so should health practitioners, insurance
companies, politicians and the society at large take
responsibility for the chronic pain syndrome.
Chronic pain models will be discussed in the
following chapter. The centralist model will be shown to
provide a comprehensive model for the treatment and
management of the chronic pain syndrome.

Crue (1983) describes two conceptual frameworks
for managing chronic pain, the peripheralist model and
the centralist model.
Peripheralist Model
Peripheralists work from the concept in which
treatment useful for acute pain is applied for a longer
period of time and is continued at the site of injury or
complaint. Chronic pain is considered to be caused by
continued nociceptive input from a presumed peripheral
pathology. Some peripheralists propose that the original
pathology has not healed properly for some reason.
Others suggest that the chronic pain message serves no
useful biological function (Gildenberg and De Vaul 1985).
Under this model, treatment is often intended to
interrupt the peripheral input so that the pain message
is obliterated. Bressler (1979) likens this approach to
cutting the wires of a ringing fire alarm rather than
putting out the fire. Practitioners strongly entrenched
in this school of thought are likely to disregard any
other aspects of the pain experience. Bressler does view

chronic pain as a useful message of possible difficulties
in other areas (besides physical) of the patient's life.
The peripheralist model does not consider these issues.
Centralist Model
The centralist conceptual framework considers
chronic pain syndrome to be a central pain phenomenon
which includes self-sustaining neural activity within the
central nervous system that subserves memory-like
processes related to pain (Melzack 1986). This memory-
like system may account for pain when there is no lesion
or peripheral pathology identified. Also once the
abnormal central generating process is established, if
there is any peripheral input, it assumes less
importance. Melzack (1986) sees proof of this in
numerous examples of patients who continue to have severe
pain after removal of peripheral input such as in
discectomies and spinal cord transections. Once the
central pattern generating systems produce pain, any
input may act as a stimulus for pain. This differs
greatly from the acute pain with its one cause one
effect conceptual framework.
Therapy based on the central phenomenon of
chronic pain will be directed towards modulating the
inputs that affect the pain generating system. These

inputs include emotional inputs from both past and
present experiences and physical inputs from organic
lesions such as scar tissue, contracted muscles or nerve
In addition to understanding these inputs, it is
worthy to explore predisposing central factors that may
both initiate and perpetuate the chronic pain syndrome.
Crue (1983) describes these as organic lesions within the
central and peripheral nervous system, possible genetic
inherited defects and childhood learning experiences with
pain. He suggests the possibility of a pain-prone
personality is difficult for both patients and health
practitioners to accept who expect to "fix" pain.
Ignoring predisposing factors can result in inappropriate
and unnecessary treatments.
Other centralist-like theories have been proposed
based on cognitive and behavioral influences. For
example, Fordyce et al. (1973) proposes that the operant
conditioning model is effective with individuals whose
chronic pain syndrome is elicited and maintained by
reinforcing consequences such as money problems,
attention from others and avoidance of threatening
physical and/or emotional situations.
As cited in Ross and Ross (1988), Engelbart and
Vrancken's systems theory model operates on the premise

that the chronic pain syndrome results from the reactions
of an already psychologically unhealthy person to painful
conditions. Psychoanalytic and intrapsychic models view
pain as primarily a psychological disorder that
represents the patients attempt to cope with
intrapsychic conflicts.
From work with childhood pain, Ross and Ross
(1988) propose a social ecological model to understand an
individual's reaction to pain. This model includes the
role of childhood learning processes, the context or
situation in which pain is experienced and environmental
social and non-social factors.
Both peripheral and central systems are likely
involved with any given pain problem. In light of the
complexity of chronic pain, the formulation of a single
framework seems improbable and undesirable. The
challenge for the field of pain study is to determine
which is the most important system acting at any given
time in a particular case of human suffering.
Considering the numerous inputs in the central pain
generating systems, combinations of therapeutic
procedures seem a preferred approach to singular
application of techniques.
I favor the centralist pain model as representing
the most current and reasonable understanding of the

multiple characteristics of chronic pain. Peripheral
inputs are considered in the centralist model but the
peripheralist model does not consider central input. The
social ecological model offers great potential for
understanding individual differences in pain reactivity
and thereby its management. This model is particularly
helpful in maintaining a perspective on the importance of
the situation or context within which pain is expressed.
The pain complaint in the physical therapy office can be
quite different from the same individual in the
courtroom, where economic reward is expected. Corbett's
(1986) astute observations of the role of the health care
system in contributing to and perpetuating chronic pain
syndrome would be included in the centralist model.
The following chapter will discuss health care models.

The health care system within which a
comprehensive pain model operates must foster a broad
vision to include the complexities of the chronic pain
syndrome. This chapter will explore three health care
models: the biomedical model, the holistic model and the
spacetime model.
Biomedical Model
Fabrega (1975) views the traditional biomedical
model as the dominant folk model of the Western world.
This model operates from the perspective that the origin
of all human illness without exception is rooted in
matter (Dossey 1982).
In considering an alternative biopsychosocial
model, Engel (1977) identified the shortcomings of the
biomedical model as follows: (1) It requires that
disease, both physical and mental, be conceptualized in
terms of derangement of underlying physical mechanisms
(reductionism). Whatever is not capable of being
explained must be excluded from the category of disease
(exclusionism). (2) There is no room for social,

cultural, psychological or environmental dimensions of
illness (body/mind dualism).
Many clinicians consider the patient's
psychological and social history as irrelevant to the
"real" diagnosis. Corbett's (1986) observations of
multidisciplinary pain conferences showed that
practitioners accepted the patient's pain as real even
when a biomedical diagnosis was not found. However, she
also noted that psychological and social aspects of pain
were considered less significant when an organic etiology
was determined. This is related to the Western tendency
to place more legitimacy on the physical rather than
emotional aspects of illness.
Body/mind dualism dates back to the seventeenth
century philosopher, Descartes, who considered humans to
have two separate parts: mind and body. The mind was
believed to have more to do with the soul which was
within the domain of the church. Ng (1980) states that
this separation allowed scientists to study the body
without concern for the mind and consequently sanctioned
advances in science and medicine. This direction of
study in anatomy and physiology gave rise to the
viewpoint that the body was a machine and that disease
was due to mechanical failure or a defective part.

Grossinger (1987) asserts that the body/mind
dichotomy neglects a wealth of information from the
entity that is both body and mind. Biomedical
methodology of diagnosis and treatment reflects the
Western conception of how the body and mind exist. The
dominance of this Cartesian dualism is a cultural and
historical construction and is not universally shared by
other cultures (Scheper-Hughes and Lock 1987).
In the biomedical model, disease often came to be
considered as something that happens to individuals over
which they have no control. This perspective on disease
has had an enormous influence on the direction of both
the health care system and medical research. Medical
researchers seek to eradicate and/or cure diseases;
patients expect to be treated and to be cured of their
problems. Emphasis is placed on diagnosing (labeling)
and treating consensually validated disease categories in
an episodic and generally short term time frame. Such an
approach has yielded successful treatment in the area of
infectious disease.
However, biomedicine has been given more credit
than may be due in decreasing mortality from infectious
disease. Historical, epidemiological and sociological
evidence indicates that improvements in such

socioeconomic conditions as education, nutrition,
housing, sanitation and working conditions combined to
bring about mortality reductions and increased life
expectancy (Powles 1973).
Paradoxically, the control of infectious diseases
and the increased life expectancy, in general and after
severe injury, has created a growing population, both
young and old, with chronic pain and/or chronic
degenerative musculoskeletal conditions (Brena 1978). In
light of the multifactoral nature of chronic pain, the
mechanistic and episodic biomedical approach falls short
in providing comprehensive health care to this patient
population. Both the holistic and spacetime models allow
for integration of the mind, body and spirit. For
example, the social and psychological dimensions of the
patient's history are considered to be a primary or equal
factor in the chronic pain syndrome. The reader is
referred to Appendix. A and Appendix B for comparisons of
the traditional model with the holistic model and the
spacetime model respectively.
I do not recommend that biomedicine be discounted
entirely. Biomedical research has led to greater
understanding of the complex neurophysiological pathways
involved in chronic pain syndrome. Biomedical research

is answering the challenge to learn more about chronic
pain syndrome.
Recently biomedical researchers are recognizing
that psychosocial factors may be more important than the
physical disorder in the rising incidence of low back
disability. Waddell (1987) presented statistics of the
increasing prevalence of low back disability in Western
countries that is not explained by any demonstrable
physical change. Bigos (1990) identified job
satisfaction as one of the strongest indicators for low
back disability claims. Nachemson (1990) emphasized that
physicians be more aware of the psychosocial needs of
their patients and perform surgery only on very strict
Holistic Model
Ferguson (1980) feels that the failure of
biomedical care in chronic disorders provided the impetus
for a new direction in health care. The holistic
health care approach considers the interaction of the
mind, body and environment. The term holistic describes
an attitude that views the whole person in the context of
the total environment. As cited in Sobel (1979), the
term was first used in the 1920s by Jans Christiaan Smuts

who maintained that study of the parts of a system
cannot explain the whole system.
As cited in Sobel (1979), the holistic approach
had its most comprehensive development in the 1930s as
part of the General Systems Theory as advanced by Ludwig
von Bertallanfy. Systems theory views all aspects of
nature as being interconnected; and therefore parts
cannot be studied in isolation but must be considered in
a contextual perspective. Due to interaction of
variables, cause and effect cannot be separated.
In the 1950s, the pitfalls of conformity in
American society were widely expressed and a curiosity
about the significance of consciousness grew (Ferguson
1980). The 1960s gave rise to widespread social changes
as well as to a more humanistic health care movement.
Pioneering health seekers no longer viewed the "doctor"
as the dominant authority in medical care. Eastern
philosophies, with their ecological world view, became
popular among those who no longer believed more
technology meant better health.
By the mid 1970s, even the conservative American
Medical Association urged their constituents to integrate
holistic approaches in their practices (Ferguson 1980).
Holistic health has continued into the 1980s and is being

supported by research on body/mind interaction within
several disciplines. Many of the holistic assumptions
have parallels with scientific discoveries in modern
physics. Ferguson contrasts the assumptions of the
holistic health paradigm with the biomedical paradigm
(see Appendix A). The expansive quality of the holistic
paradigm incorporates the valuable technological advances
of modern medicine while validating the role of mind,
spirit, and environment in health.
Ferguson (1980:74-76) states that the
traditional approach of dealing with pain is one of
denial or avoidance through medication and/or
distraction. She asserts that pain is transformation
trying to happen. Properly attended to, pain can quide
the sufferer to a restructuring of her/his perspective on
the problem. This attention actively involves the
sufferer in the healing process rather than expecting
someone else to resolve the pain for her/him.
Medical anthropologist, Corbett (1986), asserts
that holism shares biomedicines's lack of interest in the
role of social institutions, of economics and of the
family in the origin and maintenance of illness.
Zborowski (1969) considers the sociocultural dimension
distinct from the physiological and psychological

interpretations of the pain experience. Grossinger
(1987) views the holistic movement as giving a false
sense of newness and breakthrough. He points out that in
both stone-age tribes and countercultural clinics, the
human is considered a single entity of mind and body in a
biological and cultural context from which he cannot be
separated. His term "Planet Medicine" represents both
prehistoric and contemporary systems of health that
consider disease as a fundamental disorder of meaning and
Spacetime Model
Dossey (1982) asserts that modern physics
challenges the dominant biomedical world view that the
body occupies a specific space and exists in finite time.
He proposes a spacetime model of health and disease to
reflect the world view of modern physics (see Appendix
B). Similar to the holistic model, the spacetime model
does not reject the biomedical approach but expands it.
Accordingly, since the "parts" of the body now
appear more as patterns and processes it does not seem
logical to continue regarding the body as an object
separate in space and time from other physical bodies.
There exists an endless exchange of chemical elements
between the body and the environment referred to as the

"biodance" (Dossey 1982:74). This constant energy
exchange does not support the definition of a fixed,
static body. This interaction suggests health is a
shared phenomenon rather than an individual one. Like
disease, health can be spread.
The perception of time greatly influences health
and disease and must be also revised in the world view of
modern physics (Dossey 1982). Newton's mechanical model
of the universe considered time as absolute and flowing
uniformly (past, present and future) with no connection
with the external world. Modern physics shows that time
is bound to our senses and is not separate and absolute.
Dominated by the classical view of time, Western
people have become fixated on watching time. By paying
constant attention, one is continually reminded of time
"running out" in the aging process. Persons in pain
ordinarily live in a contracted time sense; time drags
with minutes seeming like hours. From a durational
standpoint, pain becomes magnified. Dossey (1982)
asserts that the key to manipulating pain perception is
to "stop" time. The sense of time is malleable and
therefore can be used for positive gain.
As described in mystic, religious and poetic
literature a perception of time as static and nonflowing

is one of tranquility, peace and serenity (Dossey
1982:179). This description of time is not new but has
been overshadowed by the predominant perception of
flowing time. However, it has been recently reappearing
in the form of time stopping therapies such as imagery
and meditation.
The present author favors Dossey's spacetime
model because of its functional integration of recent
discoveries in modern physics, its holism and its
parallel with Eastern philosophies. Dossey, a physician,
challenges scientific critics not to reject or disclaim
what can not be explained scientifically at this time.
He encourages health practitioners to consider the
importance of spirit in the understanding of disease and
wellness. The spirit is usually ignored in spite of its
presence in encountering patients and in every patient1s
encounter with illness. However, as much as he
encourages the consideration of mind and spirit, he
equally cautions holistic practitioners not to ignore
biomedical concerns in favor of pan-psychism (wherein
mind and spirit are everything).
Dossey (1984) asserts that the spirit is not
responsible for physical well-being. He views spirit as
beyond health; it includes all qualities health and

illness, pain and pleasure. It is by entering into the
vastness of being that we go beyond identification with
the body and mind and experience a change in pain (Levine
1982). The importance here is that spiritual enhancement
can be achieved without change in a physical dysfunction.
The following chapter will expand on this concept of
being well with chronic pain.

Both the holistic and spacetime health care
models suggest a redefinition of health and wellness.
The biomedical approach places dominant attention on
disease. In this light, health is generally viewed as an
absence of disease or dysfunction. This either/or
definition does not suggest that health can exist in the
presence of disease such as in the chronic pain syndrome.
A broader definition, suggesting a process rather than a
state, considers health as an individual's ability to
adapt to the environment by biological and/or behavioral
means (Moore et al. 1980). Conversely, disease reflects
a failure to adapt to the environment.
Because of the attention on disease in defining
good health, individuals are more versed on what not to
do to avoid being sick than with what to do to be well
(Bruhn et al. 1977). These authors do not view wellness
and good health as synonymous concepts. Wellness is
related to learning and development whereas good health
is a description of how the person is doing at any given

Wellness depends on the active participation of
the individual in utilizing the social, psychological,
cultural, spiritual and physiological resources (Bruhn et
al. 1977:211); good health may exist despite one's
efforts. More importantly wellness encompasses all
aspects (physical, mental and spiritual) of an
individual's heatlh. Wellness and illness are not
mutually exclusive. The potential for wellness is
available even when one is terminally ill. One can be
physically ill but be well in the mental and spiritual
When considered in this way, chronic pain
syndrome patients are both ill and not well; all aspects
of the person's health are affected by this syndrome. On
the other hand, chronic pain condition patients are ill
and well as they are categorized as coping satisfactorily
with the dysfunction. Different wellness thresholds
exist for different chronic disorders. The wellness
threshold is also influenced by the individual's cultural
background. According to Capra (1982), individuals can
be held responsible for their wellness only to the extent
that they have the freedom in their social and cultural
system to look after themselves. It is often necessary
to take collective action to change economic and

political factors that limit our choices for wellness and
The aforementioned redefinition of health and
wellness is congruent with the assumptions of both the
holistic and spacetime models. From clinical practice,
I have experienced the futility and the frustation of
attempting to "cure" the pain of a chronic pain syndrome
patient. Pain has been better alleviated by increasing
the patient1s physical endurance and functional
abilities, i.e. by promoting physical wellness in spite
of pain.
Rather than emphasize "treatment" with passive
biomedical techniques, the patient is taught movement
skills and problem solving principles in order to
function more efficiently and prevent further strain.
Rehabilitation is aimed at achieving maximum well-being.
As long as practitioners fail to recognize the
multi-dimensional characteristics of chronic pain
syndrome and continue to pursue eradication of chronic
pain in a uni-dimensional approach, patients will
undoubtedly persist to seek the "cure". Levine (1982)
asserts that much of our pain is reinforced by those
around us who wish us not to be in pain. Furthermore,
those who have little room for their pain, seldom
encourage another to enter directly into his/her

experience to soften the resistance and holding that so
intensifies suffering.
We live in a society programmed to escape pain at
any cost. Our drug advertisements seduce many
(practitioners and patients) into trying the "new" pain
medication for the "quick fix" rather than examining the
multi-characteristics of pain in one's life. Capra
(1982) bases the overuse of drugs in the United States on
the biomedical and economic models of reductionism. It
seems unreasonable to expect a patient "accept" his/her
pain in a society that does not accept pain. Capra's
(1982), The Turning Point details our gradual cultural
transformation away from the biomedical/reductionist
paradigm into the sytems/integrative paradigm.
Levine (1982) suggests that individuals working
with someone in pain recognize that the only work we have
to do is on ourselves. By accepting that each of us
relate to pain in our own way, there is no room to label
one who does not embrace our advice as "weak" and one who
does as "strong". It allows us to open our hearts with
compassion and understanding to the chronic pain syndrome
patient even when there is "nothing" that can be done
about pain in the biomedical approach. It behooves
practitioners to accept that patients are free to chose

the alternatives offered them. There will be those
patients who will stay in the ill and not well category
on the wellness/health continuum; and there will be those
patients who will be well in spite of the physical

I have proposed that the following criteria are
essential in providing comprehensive management for the
chronic pain syndrome:
1. centralist pain model
2. spacetime health model
3. redefinition of health and wellness
These criteria do not provide a specific
treatment protocol but rather suggest conceptual
guidelines for more appropriate management of this
refractory syndrome. These guidelines require a
fundamental change in our thoughts, perceptions and
values about health care in general and chronic pain
specifically. The literature cited in this thesis
suggests that a new paradigm has been developing but is
still practiced by the minority.
It is essential that more health practitioners
understand the ramifications of the chronic pain
syndrome. The relentless application of treatment
techniques appropriate for acute pain to the chronic pain
syndrome must be abandoned. There is not one single

medical treatment alone for chronic pain. In the
biomedical way of thinking, this fact is often difficult
for patient and practitioner to accept.
Practitioners would be wise to discontinue
unnecessary treatment and establish more appropriate
diagnosis and treatment guidelines. Early recognition of
this syndrome seems a realistic goal. Practitioners need
not wait for a certain amount of time to pass or
treatments to fail before considering the diagnosis of
chronic pain syndrome. As has been argued in this
thesis, other parameters besides length of duration
contribute to the chronic pain syndrome.
Cultural, sociological, biological, familial,
psychological and environmental parameters can serve as
indicators to the practitioner. A prechronic pain
patient is likely to complain of pain at multiple sites;
is usually highly anxious; and is preoccupied with pain
(Murphy and Cornish 1984).
As stated earlier, the patient as well as the
health care system (professionals and consumers) must be
educated about the multidimensional characteristics of
chronic pain syndrome. Regardless of the pain origin,
patients would be wise to understand that stress,
depression, fatigue and poor general general health lower

pain tolerance. They can learn cognitive techniques to
alter pain perception. Relaxation and stress management
will assist in reducing related high muscle tension.
Movement reeducation and general reconditioning will
reduce the contributory factors of inactivity. Proper
nutrition and rest are essential. Appropriate drug use,
if at all, and the effects of the "system" on the course
of the chronic pain syndrome must also be discussed.
Employers would be wise to provide light duty
activities in order to facilitate early return to work
even with some pain but which would not be aggravated by
light activities. The insurance and workers'
compensation industries could also assist the worker in
early return to work with job modifications, retraining
and financial incentives. The litigation system's
adversarial position must be modified in order to not
just provide appropriate compensation but to also promote
the client's total well-being. Education about the
multi-dimensions of pain would benefit the general
Last, but not least, is the acceptance of the
intractable nature of chonic pain syndrome by the
sufferer and all concerned. In this way, the patient and
all those encountered in the health care system will be

working towards appropriate coping skills (physical,
mental and spiritual) to modify the pain and related
The literature reviewed uniformly calls for
further research into the multidimensional realm of
chronic pain. At a recent interdisciplinary seminar on
Back Pain in the Nineties, it was stated that research
priorities for this decade will be given to psychosocial
issues, biomechanics and pain physiology. As an
anthropologist/physical therapist, the present author
suggests research to examine the effects that the
comprehensive management of chronic pain syndrome, as
argued in this thesis, would have on the following
1. Would health care costs for managing
chronic pain syndrome decrease?
2. Would utilization of pain centers decrease
or increase?
3. What adaptive skills are necessary to cope
successfully with chronic pain?

Bigos, Stanley
1990 Back Pain in the Nineties: New Solutions to Old
Problems? Interdisciplinary Conference. Denver:
March 16-17.
Bonica, John J.
1953 The Management of Pain. Philadelphia: Lea &
Bortz, Walter M.
1984 The Disuse Syndrome. Western Journal of
Medicine 141:691-694.
Brena, Stephen F.
1978 Chronic Pain: America's Hidden Epidemic. New
York: Simon & Schuster.
Brena, Stephen F., and Stanley L. Chapman
1981 The "learned pain syndrome." Postgraduate
Medicine 69:53-64.
Bressler, David
1979 Free Yourself from Pain. New York: Simon &
Bruhn, John G., et al.
1977 The Wellness Process. Journal of Community
Health 2:209-221.
Capra, Fritjof
1982 The Turning Point. Toronto: Bantam Books
Carron, Harold, et al.
1985 A Comparison of Low Back Pain Patients in the
United States and New Zealand: Psychosocial and
Economic Factors Affecting Severity of Disability.
Pain 21:77-89.
Corbett, Kitty King
1986 Adding Insult to Injury: Cultural Dimensions of
Frustration in the Management of Chronic Back Pain.
Ph.D. dissertation, Department of Anthropology,
University of California, Berkeley.

Crue, Benjamin J.
1983 The Neurophysiology and Taxonomy of Pain. In
Management of Patients with Chronic Pain. Stephen
Brena and Stanley Chapman, eds. Pp 21-31. New York:
S.P. Medical & Scientific Books.
Dossey, Larry
1982 Space, Time & Medicine. Boston: New Science
1984 Beyond Illness. Boston: New Science Library.
Engel, George L.
1977 The Need for a New Medical Model: A Challenge for
Biomedicine. Science 196:129-136.
Fabrega, Horacio
1975 The Need for an Ethnomedical Science.
Science 189:969-975
Ferguson, Marilyn
1980 The Aquarian Conspiracy. Los Angeles: J.P.
Fordyce, Wilbert E., et al.
1973 Operant Conditioning in the Treatment of Chronic
Pain. Archives of Physical Medicine Rehabilitation
Gildenberg, Philip, and Richard A. De Vaul
1985 The Chronic Pain Patient: Evaluation and
Manangement. New York: Krager.
Grossinger, Richard
1987 Planet Medicine. Revised Edition. Berkeley:
North Atlantic Books.
Holzman, Arnold, and Dennis C. Turk, eds.
1986 Pain Management: A Handbook of Psychological
Treatment Approaches. New York: Pergamon.
Kleinman, Arthur
1982 The Teaching of Clinically Applied Medical
Anthropology on a Psychiatric Consultation-Liaison
Service. In Clinically Applied Anthropology. Noel
Chrisman and Thomas Maretski, eds. Pp. 83-115.
Dordrecht: Reidel.

Koopman Cheryl, et al.
1984 Ethnicity in the Reported Pain, Emotional
Distress and Requests of Medical Outpatients.
Social Science Medicine 18:487-490.
Kotarba, Joseph A.
1983 Perceptions of Death, Belief Systems and the
Process of Coping with Chronic Pain. Social Science
Medicine 17:681-689.
Kotarba, Joseph A., and John V. Seidel
1984 Managing the Problem Pain Patient: Compliance or
Social Control? Social Science Medicine 19:1393-1400.
Levine, Stephen
1982 Who Dies? New York: Doubleday
Lipton, James A., and Joseph Marbach
1984 Ethnicity and the Pain Experience. Social Science
Medicine 19:1279-1298.
Melzack, Ronald
1986 Neurophysiology of Pain. In Psychology of Pain.
2nd Ed. Richard Sternbach, ed. Pp. 1-24. New York:
Raven Press.
Melzack, Ronald and Patrick Wall
1965 Pain Mechanisms: A New Theory.
Science 50:971-979.
Mohamed, S.N., et al.
1978 The Relationship of Chronic Pain to Depression,
Marital Status and Family Dynamics. Pain 5:285-292.
Moore, Lorna G., et al.
1980 The Biocultural Basis of Health: Expanding Views
of Medical Anthropology. St. Louis: C.V. Mosby.
Moore, Rodney, and Samuel F. Dworkin
1988 Ethnographic Methodologic Assessment of Pain
Perceptions by Verbal Description. Pain 34:195-204.
Murphy, Kevin A., and Richard D. Cornish
1984 Prediction of Chronicity in Acute Low Back Pain.
Archives of Physical Medicine Rehabilitation 65:334-

Nachemson, Alf
1990 Back Pain in the Nineties: New Solutions to Old
Problems? Interdisciplinary Conference. Denver
March 16-17.
Ng, Lorenz K.Y.
1980 The Challenge of Biomedicine. In Pain, Discomfort
and Humanitarian Care. Lorenz K.Y. Ng and John
Bonica, eds. Pp. 353-365. New York: Elsevier\North-
Noel, Merry, and Charles Nemeroff
1988 Endogenous Opiates in Chronic Pain. In Chronic
Pain. Randall France and K. Ranga Krishnan, eds.
Pp. 54-65. Washington, DC: American Psychiatric
Payne, Bonnie, and Mary Ann Norfleet
1986 Chronic Pian and the Family: A Review.
Pain 26:1-22.
Powles, J.
1973 On the Limitations of Modern Medicine. Science,
Medicine and Man 1:601-636.
Press, Irwin
1982 Witch Doctor's Legacy: Some Anthropological
Implications for the Practice of Clinical Medicine.
In Clinically Applied Anthropology. Noel Chrisman and
Thomas Maretski, eds. Pp. 179-198. Dordrecht: Reidel.
Ross, Dorothea M., and Shiela A. Ross
1988 Childhood Pain: Current Issues, Research and
Management. Baltimore: Urban & Schwarzenberg.
Scheper-Hughes, Nancy, and Margaret M. Lock
1987 The Mindful Body: A Prolegomenon to Future Work
in Medical Anthropology. Medical Anthropology
Quarterly 1:6-41.
Smoller Brian, and Bruce Schulman
1982 Pain Control: The Bethesda Program. Garden
City, NY:Doubleday.
Sobel, David S.
1979 Ways of Health. New York: Harcourt Brace

Sternbach, Richard A.
1987 Mastering Pain. New York: Ballantine Books.
1989 Acute versus Chronic Pain. In Textbook of Pain.
2nd Ed. Patrick D. Wall and Ronald Melzack, eds.
Pp. 242-246. Edinburgh: Churchhill-Livingston.
Sternbach, Richard A., and B. Tursky
1965 Ethnic Differences among Housewives in
Psychophysical and Skin Potential Responses to
Electric Shock. Psychophysiology 1:241-246.
Waddell, Gordon
1987 A New Clinical Model for the Treatment of
Low-Back Pain. Spine 12:632-644.
Waddell, Gordon, et al.
1984 Chronic Low-Back Pain, Psychologic Distress and
Illness Behavior. Spine 9:209-213.
Weisenberg, M., et al.
1975 Pain: Anxiety and Attitudes in Black, White and
Puerto Rican Patients. Psychosomatic Medicine 37:
Wolff, B. Berthold, and Sarah Langley
1977 Cultural Factors and The Response to Pain. In
Culture, Disease, and Healing. David Landy, ed.
Pp. 313-319. New York: Macmillan.
Zborowski, Mark
1969 People in Pain. San Francisco: Jossey-Bass.
1978[1952] Cultural Components in Responses to Pain.
In Health and the Human Condition. Michael Logan and
Edward Hunt, Jr., eds. Pp. 281-294. North Scituate,
MA: Duxbury Press.
Zola, Irving K.
1966 Culture and Symptoms: An Analysis of Patient's
Presenting Complaints. American Sociological Review

Assumptions of the
Biomedical Model
1. treatment of symptoms
2. specialized
3. emphasis on efficiency
4. emotional neutrality of
5. pain and disease are
wholly negative
6. primary intervention
with drugs and surgery
7. body seen as machine
8. disease and diability
seen as separate entity
9. emphasis on eliminating
symptoms, disease
10. patient is dependent
11. professional is
Assumptions of the
Holistic Model
1. search for patterns
and causes
2. integrated, concerned
with entire person
3. emphasis on human
4. compassionate caring
of professsional
5. pain and disease
provide valuable
information about
6. minimal intervention
with appropriate and
7. body seen as dynamic
system, field of
energy in other
8. disease and
disability seen as
9. emphasis on achieving
maximum well-being
10. patient is autonomous
11. professional is
therapeutic partner

12. body and mind separate;
psychosomatic illness is
domain of psychiatry
13. mind is secondary factor
in organic illness
12. body/mind
illness is domain
of all professionals
13. mind is primary or
coequal factor in
all illness
14. placebo effect shows
power of suggestion
14. placebo effect shows
mind's role in
15. primary reliance on quanti-
tative information; high
16. prevention largely environ-
ment: vitamins, exercise
15. primary reliance on
qualitative informa-
tion; quantitative
16. prevention all
encompassing: spirit
Condensed from Ferguson, M. 1980. The Aquarian
Conspiracy. Los Angeles: J.P. Tarcher.

Traditional View
1. body is an object in
a specific space
2. body is isolated
3. health is individual
4. illness is individual
5. therapy affects indivi-
dual bodies
6. health maintenance is
7. birth and death are
life demarcations
8. time flows; is a
natural event
9. matter is absolute is individual
Modern Physics View
1. body is not an object
not in a specific
2. body is in dynamic re-
lationship biodance
3. health is shared
4. illness is shared
5. therapy affects all
6. health maintenance is
7. no time demarcations
8. time is psychological
9. matter is relative
10. life is universal
Condensed from Dossey, L. 1980. Space, Time and Medicine.
Boston: New Science Library.