JBJS -- Letters to the Editor for Ring et al., 87 (2) 374-380

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Letters to the Editor to:

Scientific Articles:
David Ring, John Kadzielski, Leah Malhotra, Sang-Gil P. Lee, and Jesse B. Jupiter
Psychological Factors Associated with Idiopathic Arm Pain
J Bone Joint Surg Am 2005; 87: 374-380 [Abstract] [Full text] [PDF]

Letters to the Editor: Submit a response to this article

Electronic letters published:

Update on Patients With Idiopathic Arm Pain: David Ring, M.D., J. Sebastiaan Souer, M.D. (12 December 2006)

Dr. Ring responds to Dr. Kummel: David Ring, M.D. (30 November 2006)

Management of idiopathic pain in the arm.: Bertram M. Kummel, M.D. (7 March 2005)

Update on Patients With Idiopathic Arm Pain 12 December 2006

David Ring, M.D.,
Orthopaedic Surgeon
Massachusetts General Hospital, Boston, MA,
J. Sebastiaan Souer, M.D.
Send letter to journal:
Re: Update on Patients With Idiopathic Arm Pain

dring{at}partners.org David Ring, M.D., et al.

To The Editor:
Following our publication of two papers on the subject of idiopathic arm pain in The Journal of Bone and Joint Surgery(1,2) I am often asked: �What happens to the patients that you diagnose with idiopathic arm pain. Do they eventually end up with a specific diagnosis and treatment? Does their pain resolve?�
In an attempt to answer these questions we undertook a mail survey of 466 of my patients diagnosed with idiopathic arm pain in 2002, 2003, 2004, and 2005 using an IRB-approved protocol. After a series of 3 mailings we got 87 responses (19%). Although this response rate was disappointing, there were no significant differences between responders and nonresponders with regard to age, gender, or zip code, and we believe the information obtained is of interest.
Seventy percent of patients still had pain. Only 15% had obtained a specific diagnosis including 3 with arthritis, 2 thoracic outlet syndrome, 2 repetitive strain injury, 2 ganglions, and one each carpal tunnel syndrome, trigger finger, and fibromyalgia. The majority of these diagnoses can be disputed, either in the existence of the diagnosis or the relationship of this diagnosis to vague, diffuse, arm pains. Only 3 patients had had surgery including 1 first rib resection, 1 ganglion excision, and one �partial carpectomy�.
Forty-six percent of patients felt that I had done my best for them. Fourteen percent of patients made positive comments regarding me personally including, �caring doctor�, �kept me from surgery�, and �scheduled follow-up�. Sixty-two percent of patients made a negative comment, including: �too much emphasis on the psychological over the physical�, �should order more tests�, �failed to identify the problem�, �didn�t operate on me�, �no cure�, and criticism of my behavior.
In my opinion, these survey data support the existence of chronic, nonspecific, medically unexplained arm pains. The majority of patients had persistent, undiagnosed pain, and continued to resent me specifically, and the medical profession in general, for not being able to solve their problem. Many of these patients were also uncomfortable with the manner in which I discussed the psychosocial influences on their illness. While I have made great efforts to improve in this, I have also called on the experts.
Building on the successful use of cognitive behavioral therapy in other chronic, nonspecific pain contexts, my colleagues and I have established a Multidisciplinary Arm Pain Program as part of the MGH Orthoapedic Hand and Upper Extremity service. Our team includes a non- operative musculoskeletal doctor (physiatrist), hand therapists, surgeons, and psychologists that specialize in cognitive behavioral therapy. A survey study recently published in the Journal of Hand Surgery suggested that most patients are receptive to considering the psychosocial aspects of their illness. My impression is that patients with idiopathic arm pain may be more reluctant than the average patient to consider psychological treatment, likely because they are guarded about the possibility that their problem is a somatoform disorder, and because psychological diagnoses and psychological treatments are often stigmatized in our society. In spite of these challenges, we are having substantial success and have developed effective relationships with many patients. I encourage the development of programs that give hope to patients with vague, diffuse, puzzling chronic arm pains. I strongly discourage the indiscriminant use of diagnoses and treatments of questionable validity.
In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from AO Foundation, Wright Medical, Biomet, Smith and Nephew, Small Bone Innovations. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
References:
1. Ring D, Kadzielski J, Malhotra L, Lee SGP, Jupiter JB. Psychological factors associated with idiopathic arm pain. J. Bone Surg Am. 2005;87:374-380.
2. Ring D, Guss D, Malhotra L, Jupiter JB. Idiopathic arm pain. J Bone Joint Surg Am. 2004;86:1387-1391.

Dr. Ring responds to Dr. Kummel 30 November 2006

David Ring, M.D.,
Orthopaedic Surgeon
Massachusetts General Hospital, Boston, MA
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Re: Dr. Ring responds to Dr. Kummel

dring{at}partners.org David Ring, M.D.

Dr. Kummel correctly notes that idiopathic arm pain is indeed a type of chronic pain. Medications are certainly one aspect of the treatment of chronic pain, and we all wish it were as easy as just finding the right pill. As it is, those who treat chronic pain regularly have recognized the importance of behavioral medicine or cognitive behavior therapy leading to enhanced coping skills. A growing amount of scientific evidence is establishing the effectiveness of these psychological interventions. One of the barriers to the effective application of cognitive behavioral therapy is the stigmatization of psychological diagnoses and treatments by both patients and their physicians.
In my opinion, Dr. Kummel's emphasis on medication (a "magic pill"?) is a reflection of this stigmatization. The approach to chronic pain should be multidisciplinary and should include the consideration and treatment of psychological distress (depression and anxiety) and ineffective coping skills.

Management of idiopathic pain in the arm. 7 March 2005

Bertram M. Kummel, M.D.,
Physician
Senior Friendship Centers
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Re: Management of idiopathic pain in the arm.

bertkummel{at}aol.com Bertram M. Kummel, M.D.

To the Editor:
The authors of the article, "Psychological factors associated with idiopathic arm pain," JBJS 87:374-381, 2005, performed a meticulous evaluation of the problem. However, they seem to indicate that treatment is unsatisfactory and the only available measures are relaxation training and cognitive-behavioural therapy.
Essentially, they appear to be discussing chronic pain but do not mention drugs which are very effective not only for the idiopathic sufferers but can also help those labelled as having discrete pain. Patients will accept such prescriptions when they are told that they can mitigate the pain, but not cure it. SSRIs, NSRIs, and other drugs affecting neural transmission often improve function when depression and/or anxiety are exhibited in the pain patient. When the medications are effective, the patient becomes more amenable to other measures such as cognitive-behavioural therapy.
Orthopedists can't ignore such situations as being out of their realm. That attitude and lack of concern causes the chronic pain patient to look to chiropractic and other alternatives for relief.