Issues of Chronic Pain Management of an Invisible Illness

2938 words (12 pages) Essay

8th Feb 2020 Health Reference this

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Introduction

Pain is the single most cited reason people access health care in the United States

today. It is estimated 25.3 million adults, experience pain, daily. (Robinson 2016) Individuals

experiencing chronic pain (CP), have worse health, use the healthcare system more, and

have a higher amount of disabilities, then those with less severe pain. Financially, CP is

a burden to the economy. Medical costs associated with CP average $635 billion

annually, considering treatment and lost productivity. (“Americans are in Pain” 2015; Breivik, Eisenberg, & O’Brien 2013)Chronic pain is a major public health problem, producing a substantial monetary and social burden. (“Americans are in Pain” 2015) These burdens fall on the patient, their families, friends, and the healthcare system. (Osterweis, Kleinman, & Mechanic 1987) Diseases are often interrelated causing physiological, psychological, and interpersonal issues. (Dueñas, Ojeda, Salazar, Mico, & Failde 2016) Chronic pain is inversely associated with other diseases which in turn, affect pain greatly. Treating CP is not easy, as the pathologic embodiment of the disease is not the only problem there are many factors facing the healthcare system and its patients. (Breivik, Eisenberg, & O’Brien 2013; Buljan 2009; Hilbert 1984)

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 In addition to socioeconomic burdens, three other forces which create a larger problem for the healthcare system are:1) limited sources for healthcare workers and individuals with CP, 2) pain as a personal experience, and 3) pain having a cultural factor. These factors all have been thoroughly researched in the past and given researchers a far more in depth understanding of the multifaceted nature of CP. However, it could be argued that there is a fourth force adding to the problem of chronic pain: how to create shared meaning regarding pain.

Literature Review

Chronic pain is a highly researched area of interest for the health care industry. To appreciate the problem of pain and CP, more fully we must understand the complexities of pain, and the cultural perceptions of pain which accompany it. (Hart, Fink, Kwilosz, Passik, & Starkey 2011; Hilbert 1984) A common misconception regarding pain in the United States, and in many other cultures is that eventually, it will subside or be treatable. This is why CP is so interesting and important in understanding how people understand pain, as it is ongoing and often permanent condition. When pain persists despite treatment, those with CP must summon resources extrinsic to basic pain folklore to organize their experiences. First, they depend on diagnosis. As such, one of the guiding questions for this research is:

RQ1: What is the role of diagnosis, and is it still functional?

More importantly, while culture does not tell people how to identify and experience CP, sufferers must construct supplemental realities within which pain can be understood, the key to which is social interaction. (Hilbert 1984) This is important as it confirms the idea that pain finds its home in culture, as interaction takes place within cultures and new meanings and realities are mutually created. This raises a secondary complication regarding the complexity of an illness like CP, which is the personalized experience of pain. (Evans, Bronfort, Maiers, Schulz, & Hartvigsen 2014) Relating the severity of the pain to their physician is one problem with diagnosing the disease because each patient has a different threshold for pain, and each case of CP for physicians is different. An additional problem identified by physicians is that patients can hold varying interpretations of pain, influenced by their cultural environment, which delays diagnosis. Doctors explain, a patient’s unwillingness to accept smaller degrees of pain suggests another, acultural dimension of the experience of pain. (Hilbert 1984) CP sufferers are not just unwilling, but unable to accept CP as it is unavailable to them because patients attempt to experience it as normal, un-lasting, pain. As understanding CP is problematic for many patients, learning to accept CP pain can require new cognitive resources. (Buljan 2009) Patient understanding, and acceptance is evidence of the importance of the mere label of CP to reduce the patients’ anxieties. The experience of CP represents the individuality of cases, reinforcing CP sufferers are suspended in an ongoing senseless experience, which no one else can share or comprehend, placing them in social isolation. Which guides the research question…

 RQ2: How do people manage their pain in social settings?

However individualized the pain is experienced by an individual, the CP subculture is vastly important. This subculture enables those with CP to experience pain as typical and understandable, albeit unwelcome.  This then creates the reality that CP is a normal dimension of working in a high-risk occupation. (Hilbert 1984) This is also extremely important in understanding how to handle it, experience it, and express it. More over those who are isolated from such subcultures, the problem of meaning is particularly acute. This is because pain presents a special case due to its perceived location inside the individual, meaning, it emanates from internal processes that cannot be verified from the outside, and for the sufferer that cannot be denied or ignored. Moreover, if pain is an incorrigible fact to CP patients, pain is beyond their abilities to experience as a fact in the social sense, but as an item of knowledge. The effect that chronic pain then has on a person’s experience as a whole is that patients have to organize pain into knowledgeable yet private reality in the absence of social interaction or feedback, private knowledge (Hilbert 1984; Evans, Bronfort, Maiers, Schulz, & Hartvigsen 2014).

Sometimes sufferers exhaust normal means of constructing reality, mainly concerning the description of their pain, even the location of their condition as normal or manageable in social settings. It’s a common question as to why these individuals cannot organize these experiences on their own, especially since it’s been confirmed by other sufferers and physicians that pain is a uniquely private experience.  Supported by the idea that no one can feel or experience someone else’s pain, no one understands the characteristics of pain with the exception of the sufferer. Hence private knowledge, private access to the specifics of their private pain including its subtle patterns. The final solution to which is retreating into their own private experience, though few do this, as it’s a frustrating process rattled with difficulties concerned with not conforming to societal norms.  It is the use of cultural resources in reality production that are sanctioned by the society.  What this means is that not just any description is allowed to be validated. For those with CP popular ideas of pain as private reality undermine the possibility of their ever knowing that reality. It doesn’t allow them to interpret or negotiate, which is essential in knowable reality. Although people do not need verification of all their experiences, in order to live it as an objective reality, all experience must at least be verifiable and experienced in that way. Yet, if pain is private and unavailable to others, nothing counts as verification or as a correct description of how pain feels. Under these circumstances attempts to describe an objective internal reality provides no criteria for correct or in correct description, sufferers then propose to themselves an investigation without criterion for success. Which means that reality and by association pain can only be, if the societies culture confirms it. This inspires the final research question…

RQ3: How do people create shared meaning regarding the atypical experience chronic pain?

Methodology

Recruitment

I secured Institutional Review Board (IRB) approval for the following recruitment

procedure. My primary means of enrollment was sending emails containing a recruitment memo, participation consent form, and a copy of the primary interview questions. I sent the emails to individuals that I had knew privately. I also acquired permission from IRB to snow ball my participants. After I received responses to my recruitment emails, I invited them to forward the information to other prospective participants who met the qualifying inclusion criteria being; between 18-100 years of age, and been diagnosed with chronic pain or have experienced persistent pain, for at least 12 consecutive weeks, to contact me. Those parties agreeing to participate returned the participation consent form to me, and an individual appointment time was made for an interview.

Participants

#/# participants were experiencing pain at the time of the interview, and had been suffering for an average of # months/years, with a range of # months/years. None of the participants had publicly visible signs of physical problems, or terminal illness. # could trace the origin of their pain to a specific event. # failed to receive a positive medical diagnosis for their pain; # had definitive diagnoses including, x, y, z. Participants were divided in sex by # females : #males , with ages averaging # years.

Data Collection and Analysis

I conducted one on one interviews with “#” individuals and # phone interviews. The interviewees responded to 10 primary questions, and any additional follow up questions asked by the interviewer to clarify or elaborate upon a previous answer. Primary Questions solicited, case histories, and information regarding interactions between the individual and their physician, or other people within social or personal settings. Interviews lasted from 15 to 60 minutes each, were audio taped and orthographically transcribed.

References

  1. Robinson, A. (2016). Causes and management of chronic pain. Prescriber, 27(7), 39–43. https://doi.org/10.1002/psb.1482
  2. NIH Analysis Shows Americans Are In Pain. National Center for Complementary

and Integrative Health. https://nccih.nih.gov/news/press/08112015. Published August 11, 2015

  1. Breivik, H., Eisenberg, E., & O’Brien, T. (2013). The individual and societal burden of chronic pain in Europe: the case for strategic prioritisation and action to improve knowledge and availability of appropriate care. BMC Public Health, 13, 1229. https://doi.org/10.1186/1471-2458-13-1229
  2. Osterweis, M., Kleinman, A., & Mechanic, D. (1987). Pain and Disability: Clinical, Behavioral, and Public Policy Perspectives. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=mnh&AN=25032476&site=ehost-live&scope=site
  3. Dueñas, M., Ojeda, B., Salazar, A., Mico, J. A., & Failde, I. (2016). A review of chronic pain impact on patients, their social environment and the health care system. Journal Of Pain Research, 9, 457–467.

 https://doi.org/10.2147/JPR.S105892

  1. Robinson, K., Kennedy, N., & Harmon, D. (2011). Review of occupational therapy for people with chronic pain. Australian Occupational Therapy Journal, 58(2), 74–81. https://doi.org/10.1111/j.1440-1630.2010.00889.x
  2. Müllersdorf M, & Söderback I. (2002). Occupational therapists’ assessment of adults with long-term pain: the Swedish experience. Occupational Therapy International, 9(1), 1–23. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=rzh&AN=106943256&site=ehost-live&scope=site
  3. Persson, D., Andersson, I., & Eklund, M. (2011). Defying aches and revaluating daily doing: Occupational perspectives on adjusting to chronic pain. Scandinavian Journal of Occupational Therapy, 18(3), 188–197.

 https://doi.org/10.3109/11038128.2010.509810

  1. Buljan, D. (2009). Psychological and Psychiatric Factors of Chronic Pain. Rad Hrvatske Akademije Znanosti i Umjetnosti. Medicinske Znanosti, 501(33), 129–140. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=aph&AN=52448121&site=ehost-live&scope=site
  2. Rice, K., & Webster, F. (2017). Care interrupted: Poverty, in-migration, and primary care in rural resource towns. Social Science & Medicine, 191, 77–83. https://doi.org/10.1016/j.socscimed.2017.08.044
  3. Hilbert, R. A. (1984). The Acultural Dimensions of Chronic Pain: Flawed Reality Construction and the Problem of Meaning. Social Problems, 31(4), 365. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=sih&AN=4836479&site=ehost-live&scope=site
  1. Hart, J., Fink, K., Kwilosz, D. M., Passik, S. D., & Starkey, J. (2011). Roundtable Discussion: Managing Pain in Primary Care Patients: Challenges and Opportunities. Alternative & Complementary Therapies, 17(1), 32–36. https://doi.org/10.1089/act.2011.17108
  2. Evans, R., Bronfort, G., Maiers, M., Schulz, C., & Hartvigsen, J. (2014). “I know it’s changed”: a mixed-methods study of the meaning of Global Perceived Effect in chronic neck pain patients. European Spine Journal: Official Publication Of The European Spine Society, The European Spinal Deformity Society, And The European Section Of The Cervical Spine Research Society, 23(4), 888–897.

https://doi.org/10.1007/s00586-013-3149-y

  1. Persson, D., Andersson, I., & Eklund, M. (2011). Defying aches and revaluating daily doing: Occupational perspectives on adjusting to chronic pain. Scandinavian Journal of Occupational Therapy, 18(3), 188–197.

https://doi.org/10.3109/11038128.2010.509810

  1. van Huet, H., Innes, E., & Stancliffe, R. (2013). Occupational therapists perspectives of factors influencing chronic pain management. Australian Occupational Therapy Journal, 60(1), 56–65.

https://doi.org/10.1111/1440-1630.12011

  1. Hart, J., Fink, K., Kwilosz, D. M., Passik, S. D., & Starkey, J. (2011). Roundtable Discussion: Managing Pain in Primary Care Patients: Challenges and Opportunities. Alternative & Complementary Therapies, 17(10,32-36.

https://doiorg.pioproxy.carrollu.edu/10.1089/act.2011017108

  1. Evans, R., Bronfort, G., Maiers, M., Schulz, C., & Hartvigsen, J. (2014). “I know it’s changed”: a mixed-methods study of the meaning of Global Perceived Effect in chronic neck pain patients. European Spine Journal: Official Publication Of The European Spine Society, The European Spinal Deformity Society, And The European Section Of The Cervical Spine Research Society23(4), 888–897.

https://doi-org.pioproxy.carrollu.edu/10.1007/s00586-013-3149-y

Introduction

Pain is the single most cited reason people access health care in the United States

today. It is estimated 25.3 million adults, experience pain, daily. (Robinson 2016) Individuals

experiencing chronic pain (CP), have worse health, use the healthcare system more, and

have a higher amount of disabilities, then those with less severe pain. Financially, CP is

a burden to the economy. Medical costs associated with CP average $635 billion

annually, considering treatment and lost productivity. (“Americans are in Pain” 2015; Breivik, Eisenberg, & O’Brien 2013)Chronic pain is a major public health problem, producing a substantial monetary and social burden. (“Americans are in Pain” 2015) These burdens fall on the patient, their families, friends, and the healthcare system. (Osterweis, Kleinman, & Mechanic 1987) Diseases are often interrelated causing physiological, psychological, and interpersonal issues. (Dueñas, Ojeda, Salazar, Mico, & Failde 2016) Chronic pain is inversely associated with other diseases which in turn, affect pain greatly. Treating CP is not easy, as the pathologic embodiment of the disease is not the only problem there are many factors facing the healthcare system and its patients. (Breivik, Eisenberg, & O’Brien 2013; Buljan 2009; Hilbert 1984)

 In addition to socioeconomic burdens, three other forces which create a larger problem for the healthcare system are:1) limited sources for healthcare workers and individuals with CP, 2) pain as a personal experience, and 3) pain having a cultural factor. These factors all have been thoroughly researched in the past and given researchers a far more in depth understanding of the multifaceted nature of CP. However, it could be argued that there is a fourth force adding to the problem of chronic pain: how to create shared meaning regarding pain.

Literature Review

Chronic pain is a highly researched area of interest for the health care industry. To appreciate the problem of pain and CP, more fully we must understand the complexities of pain, and the cultural perceptions of pain which accompany it. (Hart, Fink, Kwilosz, Passik, & Starkey 2011; Hilbert 1984) A common misconception regarding pain in the United States, and in many other cultures is that eventually, it will subside or be treatable. This is why CP is so interesting and important in understanding how people understand pain, as it is ongoing and often permanent condition. When pain persists despite treatment, those with CP must summon resources extrinsic to basic pain folklore to organize their experiences. First, they depend on diagnosis. As such, one of the guiding questions for this research is:

RQ1: What is the role of diagnosis, and is it still functional?

More importantly, while culture does not tell people how to identify and experience CP, sufferers must construct supplemental realities within which pain can be understood, the key to which is social interaction. (Hilbert 1984) This is important as it confirms the idea that pain finds its home in culture, as interaction takes place within cultures and new meanings and realities are mutually created. This raises a secondary complication regarding the complexity of an illness like CP, which is the personalized experience of pain. (Evans, Bronfort, Maiers, Schulz, & Hartvigsen 2014) Relating the severity of the pain to their physician is one problem with diagnosing the disease because each patient has a different threshold for pain, and each case of CP for physicians is different. An additional problem identified by physicians is that patients can hold varying interpretations of pain, influenced by their cultural environment, which delays diagnosis. Doctors explain, a patient’s unwillingness to accept smaller degrees of pain suggests another, acultural dimension of the experience of pain. (Hilbert 1984) CP sufferers are not just unwilling, but unable to accept CP as it is unavailable to them because patients attempt to experience it as normal, un-lasting, pain. As understanding CP is problematic for many patients, learning to accept CP pain can require new cognitive resources. (Buljan 2009) Patient understanding, and acceptance is evidence of the importance of the mere label of CP to reduce the patients’ anxieties. The experience of CP represents the individuality of cases, reinforcing CP sufferers are suspended in an ongoing senseless experience, which no one else can share or comprehend, placing them in social isolation. Which guides the research question…

 RQ2: How do people manage their pain in social settings?

However individualized the pain is experienced by an individual, the CP subculture is vastly important. This subculture enables those with CP to experience pain as typical and understandable, albeit unwelcome.  This then creates the reality that CP is a normal dimension of working in a high-risk occupation. (Hilbert 1984) This is also extremely important in understanding how to handle it, experience it, and express it. More over those who are isolated from such subcultures, the problem of meaning is particularly acute. This is because pain presents a special case due to its perceived location inside the individual, meaning, it emanates from internal processes that cannot be verified from the outside, and for the sufferer that cannot be denied or ignored. Moreover, if pain is an incorrigible fact to CP patients, pain is beyond their abilities to experience as a fact in the social sense, but as an item of knowledge. The effect that chronic pain then has on a person’s experience as a whole is that patients have to organize pain into knowledgeable yet private reality in the absence of social interaction or feedback, private knowledge (Hilbert 1984; Evans, Bronfort, Maiers, Schulz, & Hartvigsen 2014).

Sometimes sufferers exhaust normal means of constructing reality, mainly concerning the description of their pain, even the location of their condition as normal or manageable in social settings. It’s a common question as to why these individuals cannot organize these experiences on their own, especially since it’s been confirmed by other sufferers and physicians that pain is a uniquely private experience.  Supported by the idea that no one can feel or experience someone else’s pain, no one understands the characteristics of pain with the exception of the sufferer. Hence private knowledge, private access to the specifics of their private pain including its subtle patterns. The final solution to which is retreating into their own private experience, though few do this, as it’s a frustrating process rattled with difficulties concerned with not conforming to societal norms.  It is the use of cultural resources in reality production that are sanctioned by the society.  What this means is that not just any description is allowed to be validated. For those with CP popular ideas of pain as private reality undermine the possibility of their ever knowing that reality. It doesn’t allow them to interpret or negotiate, which is essential in knowable reality. Although people do not need verification of all their experiences, in order to live it as an objective reality, all experience must at least be verifiable and experienced in that way. Yet, if pain is private and unavailable to others, nothing counts as verification or as a correct description of how pain feels. Under these circumstances attempts to describe an objective internal reality provides no criteria for correct or in correct description, sufferers then propose to themselves an investigation without criterion for success. Which means that reality and by association pain can only be, if the societies culture confirms it. This inspires the final research question…

RQ3: How do people create shared meaning regarding the atypical experience chronic pain?

Methodology

Recruitment

I secured Institutional Review Board (IRB) approval for the following recruitment

procedure. My primary means of enrollment was sending emails containing a recruitment memo, participation consent form, and a copy of the primary interview questions. I sent the emails to individuals that I had knew privately. I also acquired permission from IRB to snow ball my participants. After I received responses to my recruitment emails, I invited them to forward the information to other prospective participants who met the qualifying inclusion criteria being; between 18-100 years of age, and been diagnosed with chronic pain or have experienced persistent pain, for at least 12 consecutive weeks, to contact me. Those parties agreeing to participate returned the participation consent form to me, and an individual appointment time was made for an interview.

Participants

#/# participants were experiencing pain at the time of the interview, and had been suffering for an average of # months/years, with a range of # months/years. None of the participants had publicly visible signs of physical problems, or terminal illness. # could trace the origin of their pain to a specific event. # failed to receive a positive medical diagnosis for their pain; # had definitive diagnoses including, x, y, z. Participants were divided in sex by # females : #males , with ages averaging # years.

Data Collection and Analysis

I conducted one on one interviews with “#” individuals and # phone interviews. The interviewees responded to 10 primary questions, and any additional follow up questions asked by the interviewer to clarify or elaborate upon a previous answer. Primary Questions solicited, case histories, and information regarding interactions between the individual and their physician, or other people within social or personal settings. Interviews lasted from 15 to 60 minutes each, were audio taped and orthographically transcribed.

References

  1. Robinson, A. (2016). Causes and management of chronic pain. Prescriber, 27(7), 39–43. https://doi.org/10.1002/psb.1482
  2. NIH Analysis Shows Americans Are In Pain. National Center for Complementary

and Integrative Health. https://nccih.nih.gov/news/press/08112015. Published August 11, 2015

  1. Breivik, H., Eisenberg, E., & O’Brien, T. (2013). The individual and societal burden of chronic pain in Europe: the case for strategic prioritisation and action to improve knowledge and availability of appropriate care. BMC Public Health, 13, 1229. https://doi.org/10.1186/1471-2458-13-1229
  2. Osterweis, M., Kleinman, A., & Mechanic, D. (1987). Pain and Disability: Clinical, Behavioral, and Public Policy Perspectives. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=mnh&AN=25032476&site=ehost-live&scope=site
  3. Dueñas, M., Ojeda, B., Salazar, A., Mico, J. A., & Failde, I. (2016). A review of chronic pain impact on patients, their social environment and the health care system. Journal Of Pain Research, 9, 457–467.

 https://doi.org/10.2147/JPR.S105892

  1. Robinson, K., Kennedy, N., & Harmon, D. (2011). Review of occupational therapy for people with chronic pain. Australian Occupational Therapy Journal, 58(2), 74–81. https://doi.org/10.1111/j.1440-1630.2010.00889.x
  2. Müllersdorf M, & Söderback I. (2002). Occupational therapists’ assessment of adults with long-term pain: the Swedish experience. Occupational Therapy International, 9(1), 1–23. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=rzh&AN=106943256&site=ehost-live&scope=site
  3. Persson, D., Andersson, I., & Eklund, M. (2011). Defying aches and revaluating daily doing: Occupational perspectives on adjusting to chronic pain. Scandinavian Journal of Occupational Therapy, 18(3), 188–197.

 https://doi.org/10.3109/11038128.2010.509810

  1. Buljan, D. (2009). Psychological and Psychiatric Factors of Chronic Pain. Rad Hrvatske Akademije Znanosti i Umjetnosti. Medicinske Znanosti, 501(33), 129–140. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=aph&AN=52448121&site=ehost-live&scope=site
  2. Rice, K., & Webster, F. (2017). Care interrupted: Poverty, in-migration, and primary care in rural resource towns. Social Science & Medicine, 191, 77–83. https://doi.org/10.1016/j.socscimed.2017.08.044
  3. Hilbert, R. A. (1984). The Acultural Dimensions of Chronic Pain: Flawed Reality Construction and the Problem of Meaning. Social Problems, 31(4), 365. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=sih&AN=4836479&site=ehost-live&scope=site
  1. Hart, J., Fink, K., Kwilosz, D. M., Passik, S. D., & Starkey, J. (2011). Roundtable Discussion: Managing Pain in Primary Care Patients: Challenges and Opportunities. Alternative & Complementary Therapies, 17(1), 32–36. https://doi.org/10.1089/act.2011.17108
  2. Evans, R., Bronfort, G., Maiers, M., Schulz, C., & Hartvigsen, J. (2014). “I know it’s changed”: a mixed-methods study of the meaning of Global Perceived Effect in chronic neck pain patients. European Spine Journal: Official Publication Of The European Spine Society, The European Spinal Deformity Society, And The European Section Of The Cervical Spine Research Society, 23(4), 888–897.

https://doi.org/10.1007/s00586-013-3149-y

  1. Persson, D., Andersson, I., & Eklund, M. (2011). Defying aches and revaluating daily doing: Occupational perspectives on adjusting to chronic pain. Scandinavian Journal of Occupational Therapy, 18(3), 188–197.

https://doi.org/10.3109/11038128.2010.509810

  1. van Huet, H., Innes, E., & Stancliffe, R. (2013). Occupational therapists perspectives of factors influencing chronic pain management. Australian Occupational Therapy Journal, 60(1), 56–65.

https://doi.org/10.1111/1440-1630.12011

  1. Hart, J., Fink, K., Kwilosz, D. M., Passik, S. D., & Starkey, J. (2011). Roundtable Discussion: Managing Pain in Primary Care Patients: Challenges and Opportunities. Alternative & Complementary Therapies, 17(10,32-36.

https://doiorg.pioproxy.carrollu.edu/10.1089/act.2011017108

  1. Evans, R., Bronfort, G., Maiers, M., Schulz, C., & Hartvigsen, J. (2014). “I know it’s changed”: a mixed-methods study of the meaning of Global Perceived Effect in chronic neck pain patients. European Spine Journal: Official Publication Of The European Spine Society, The European Spinal Deformity Society, And The European Section Of The Cervical Spine Research Society23(4), 888–897.

https://doi-org.pioproxy.carrollu.edu/10.1007/s00586-013-3149-y

  1. Buljan, D. (2009). Psychological and psychiatric factors of chronic pain. Medical Sciences33, 129-140.

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