Ethnic Differences in Responses to Pain Management

John Bonica was among the first of the modern clinicians to critically evaluate pain as a medical complaint responsible for health care seeking (1). Subsequent early studies identified demographic and clinical differences between populations of patients with pain in primary and tertiary treatment settings (2–4). However, ethnic differences in pain perceptions or clinical outcomes for ethnically diverse patients were not included as variables (3). Very little has been done since then to address that question.

The lead research article for this issue of the Journal of Musculoskeletal Pain [JMP] comes from several academic institutions in the United States, including Johns Hopkins in Baltimore, Maryland; the University of Maryland in College Park, Maryland; and Harvard University in Boston, Massachusetts (5). The authors suspected that there may be important differences in pain management outcomes for patients from different ethnic backgrounds. They cited the paucity of available information to address this concern even though there was literature to suggest that differences in pain perception among persons of different ethnicity did meet significance criteria.

The current study intended to address potential differences in pain management outcomes among populations of African-Americans versus those of Caucasian ethnicity. The design was prospective in that the subjects consented to participation in an investigation prior to the baseline evaluations and subsequent interventions, but the numbers of participants in the separate ethnic groups were not prospectively matched. The findings supported the authors' hypothesis but several provisos were factored into their interpretations of the data. The reader is referred to the article for details regarding this socially important concept.

The second research contribution comes from academic investigators in Fullerton, California, who proposed to examine the impact of roles [i.e. employment, caregiving] on middle-aged and older individuals with and without fibromyalgia syndrome [FMS] (6). Their design was a two cohort comparison between FMS patients and healthy control individuals not meeting criteria for that diagnosis. Among the FMS group, the authors expected to find a positive interaction between the number of responsibility roles and the severity of the FMS. For the non-FMS group, they expected to find support for the “role enhancement hypothesis,” which associates increased numbers of roles with better well-being outcomes. By contrast, they predicted that the FMS group might experience role enhancement when occupying only one role, but that FMS patients would likely undergo “role strain” when occupying more than one role.

Perhaps the most controversial issue surrounding people with FMS is that of disability. This is probably true because the implication of disability is that “someone must pay.” Physicians are usually uncertain about whether it will be of benefit or harmful to support a FMS patient's bid for disability status. This study approached the question from a different viewpoint, by asking the question whether having responsibility for one or more role[s] in the home or in society is associated with better or poorer outcomes. Their findings will surprise the reader and are likely to prompt further study of this concept.

The third research study report comes from academic investigators working in Meram/Konya, Turkey (7). They proposed to compare the efficacies of treating cervical myofascial pain syndrome [MPS] with different types of therapeutic transcutaneous electrical nerve stimulation [TENS] in contrast with sham therapy. Group 1 was treated with a conventional TENS with a frequency of 100 Hz, 40 µs duration, low amplitude; Group 2 with an acupuncture-like TENS with a frequency of 4 Hz, 250 µs duration, high amplitude; Group 3 received burst TENS with high [100 Hz] and low [2 Hz] frequency, 40 µs and high amplitude. Group 4 [sham] was treated with very brief electrical stimulation that lasted only long enough for the patient to feel it, and then the current was interrupted with a bland deception inferring that it actually had continued. Patients were assessed with a visual analog scale and the bodily pain subscale of the Short Form Health Survey-36 scale. Readers will want to carefully examine the original article to assess the results. This is a very important study for clinicians treating MPS of the head/neck area. Indeed, this report is reminiscent of one published in the New England Journal of Medicine in 1990, when the question pertained to the use of TENS for management of low back pain (8).

Academic investigators from Taichung, Taiwan submitted a case report to describe the management of chronic MPS in the gluteal region secondary to a lumbar facet joint lesion (9). The patient was found to have attachment trigger points in the origin and insertion sites of the gluteus medius and the gluteus minimus muscles that responded to injection therapy with complete and lasting relief of the pain symptoms.

Readers of the JMP are again provided columns with summaries of the important developments in soft tissue pain published in other medical journals. These features not only provide a comprehensive review of what is new in the field, but also allow readers to benefit from illuminating commentary by experts from two continents.

There is a Research Ideas contribution in this issue that comes from Hatukaichi-city, Hiroshima, Japan (10). In this paper, the author addresses his view of the relationship between chronic regional and chronic widespread pain. A requirement for publication of a manuscript in the Research Ideas section of the JMP is that the author must provide a proposed research plan to answer one or more of the critical questions addressed by their paper. Readers of JMP are encouraged to view the author's model as a challenge to the current understanding of the MPS and to respond in the form of Letters to the Editor. The reader is asked to assess whether the key points of the author's model have merit and whether his approach would add importantly to future expertise in the field.

Notice the interesting Letter to the Editor (11) from academic clinicians in Porto Alegre, Brazil. Their report pertains to a reactive oligoarthritis that was apparently prompted by a myiasis infection in a histocompatability locus antigen [HLA]-B27 positive patient. Readers are encouraged to offer their own insights regarding this application of myiasis to the reactive arthritis model. In essence, this organism might join a variety of infections capable of causing reactive arthritis in HLA-B27 positive patients. If so, it would clearly expand the syndrome to etiologies far beyond the relatively concise numbers of organisms typically implicated in this process.

There are no book reviews in this issue but note that there is a listing of books relevant to the study of soft tissue pain conditions that were received by the JMP for reader consideration.

As always, readers of the JMP are invited to submit original manuscripts for blinded peer review, case reports of general interest, research ideas to promote further investigation, and letters to keep us all informed. The JMP editorial office frequently receives relevant books to be evaluated by and for the benefit of our readers. Book reviewers are allowed keep the featured book after the evaluation report is completed. If you would be interested in being a book reviewer for the JMP, please communicate that to the editor. There is always a need for reviewers of scientific manuscripts. Submissions to the JMP and all communications between the authors, reviewers, and the JMP staff are accomplished online. Please visit http://mc.manuscriptcentral.com/wjmp for more details.

This journal is the print media voice of the International MYOPAIN Society [IMS]. A clear mandate of the IMS is to perpetuate the international meeting that has traditionally been held alternately in Europe or the United States every three years since 1989. The most recent International MYOPAIN meeting was held in Toledo, Spain on October 3–7, 2010. The manuscripts from the invited speakers at that meeting were published in the JMP 18(3,4) as a combined special symposium issue. Those IMS members who were unable to attend the meeting and attendees who wish to jog their memories regarding some aspects of a given presentation can refer to their copy of that issue. Members of the IMS can view the current and past issues on-line.

The next International MYOPAIN meeting is scheduled for 2013 in Seattle, Washington, USA. That city is renowned for its beautiful coastal scenery and its unique fish market. The IMS website www.myopain.com will offer details as they become available.

Some important decisions were made by the IMS Board during the meeting in Toledo. After the Seattle meeting, the frequency of IMS international meetings will increase to every two years and will involve Asian-Pacific countries, as well as Europe and the United States. In that light, the 2015 meeting will be held in Sydney, Australia. The IMS Board has also approved the establishment of regional associations under the umbrella of the IMS. Groups anywhere in the world wishing to begin organization in that way should submit a plan to the IMS Board of Directors. Finally, Barbara Runnels, who has been administrator of the IMS since its inception in 1995, wishes to retire and has asked the IMS Board to find a replacement. The Board has accepted her resignation with the provision that she continue for one year as advisor to new staffing. The Board is currently seeking a person or company to provide the needed administrative services. Time will tell how these innovations will play out. If readers have strong opinions regarding these IMS Board decisions, they are encouraged to send their comments to the JMP in the form of Letters to the Editor.

I. Jon Russell, MD, PhD

The Editor