When one considers the number of people in chronic pain, the socioeconomic effects do not only involve the cost of compensation and benefit. There is also the lost productivity, in terms of work; or of family support of work in terms of the effect on the family of the pain (Latham and Davis 1994). Estimates of the incidence of chronic pain in the USA for example include 23 million suffering from back ache and 24 million suffering from headache (Brena and Chapman 1983; Escobar 1985). Bonica (1974) estimated nearly 35 percent of Americans were affected by pain. Schmitt (198 5), estimated that 80 per cent of visits to physicians were for low back pain. Costs as high as $50 billion have been suggested (Schmitt 1985; Turk et al.
1983), and that 5 million Americans were pain-related beneficiaries of Social Security (Escobar 1985).
It has been suggested that up to 45 million working days are lost because of back pain each year with treatment for this condition costing approximately £193 million each year (Rigge 1990; and more recently confirmed by Waddell 1996). Following a recent review of the literature on prevalence of chronic benign pain, Verhaak et al. (1998) demonstrate a wide range of prevalence rates, which could not be explained by research methods nor definition of chronic pain. They tentatively suggest a prevalence of chronic pain of 10 per cent. They suggest also that the effects of the pain in terms of disability, loss of work, premature incapacity or unnecessary medical treatment as being more important than trying to find accurate estimates of the number of patients experiencing pain each day.
Reid et al. (1997) have reviewed several studies and estimate that some 95 per cent of people suffering from back pain return to work within 6-12 weeks. It would seem that relatively few of the chronic pain sufferers account for the majority of the costs, in terms of health-related costs and disability and compensation costs. The health-care costs are only a small proportion of the total costs (e.g. van Tulder et al. (1995) in the Netherlands, and the National Board of Health and Welfare in Sweden (1987)). In spite of this, that small proportion does not seem to be being well spent according to Linton (1998) who has reviewed the current situation. He argues for programmes of care that incorporate a multi-dimensional view of the problem. In particular it is suggested that the psycho-social aspects of the problem are emphasised, based on a thorough, 'low-tech', examination (p.166), plus a detailed feedback to the person in pain, and the development of a programme which is based on self-care. Also he argues for the reduction of anxiety, detailed recommendations about activities and graded exercises, and finally the non-medicalisation of the pain situation.
Many of the effects of chronic pain described above in fact relate to the quality of life of people in pain. This has been a major area of concern recently and many different health-care problems have been studied as to their effect on quality of life. One of the problems is that of definition. There have been many attempts, for example that of Williams (1985), who described a quality-adjusted life year as a measure of impact on life. Thus there might be a long life span predicted with a certain problem, but the crucial aspect according to Williams was the quality of those life years. Thus a long life, but with much reduced quality, might not be as good as a shorter life span, but with a much higher level of quality.
Another approach was that of Benner (1985) who discussed the quality of being in an attempt to incorporate more abstract aspects of life, and Revicky (1989) considered the issue of a health-related quality of life. A review of models by Meerburg (1993) with a concept analysis identified the following definition: a feeling of overall satisfaction as determined by the individual who is mentally alert. The person must be seen as living in conditions that are adequate and meeting basic needs.
There is a problem here with the interpretation of the term 'mentally alert'. Tarter et al. (1988) identified possession of behavioural and cognitive abilities; emotional well-being; and ability to perform domestic, vocational and social roles as comprising mental alertness. The importance of leisure was discussed by Tomlinson (1991) with social isolation seen very much as a negative factor (Rigge 1990). With a Danish sample of chronic patients, Becker et al. (1997) demonstrated a very poor quality of life for these patients, on a variety of dimensions, including sleep, anxiety and depression and general psychological and social well-being.
Skevington (1995) has reviewed this area and comments that there has been an emphasis on the development of instruments to measure the phenomenon of quality of life, without the development of a theoretical model to inform that development. Black (1992) has developed a model of chronic pain, however, and argues that the best measurement of quality of life in relation to pain is the view of the sufferer him or herself; this is supported by Hunt and McKenna (1992). Skevington (1998) has explored this area further using the WHOQOL instrument developed by the WHOQOL group, an international group set up by the WHO to develop such an instrument. Skevington's study attempted to use the instrument with pain patients. Pain and discomfort is one of the aspects of quality of life included in the instrument. Evidence of reliability and validity was found to support the use of the instrument with people in pain. With respect to the quality of life of people in pain the study found that a longer duration of pain was associated with increasingly poor quality of life and this was exacerbated by intense emotional aspects of the pain experience.
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