This Article  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citing articles on Web of Science (12)  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Topic Collections  • Pain  • Alert me on articles by topic  Social Bookmarking   What's this?

To the Editor: A newspaper story reported that by October 1, 2001, three weeks following the terrorist attacks on the United States, physicians in Washington, DC, were "inundated" by complaints of worsening pain in patients already diagnosed with chronic pain conditions.¹ This report claimed that the increase in pain was "clearly triggered by stress over the attacks" and insomnia. Subsequent studies have reported an increase in insomnia immediately after the attacks,² decreased parasympathetic tone in some individuals,³ and symptoms of posttraumatic stress disorder.⁴

No reports, however, have compared pain expression immediately prior to and following the attacks in patients with preexisting pain conditions. We had an opportunity to collect such data during a noninterventional feasibility study of a handheld computer–based data collection system to be used in an upcoming clinical trial. In this small pilot study, patients with fibromyalgia, a chronic pain condition known to be exacerbated by stress, were prompted several times a day to record a variety of symptoms.

Methods
Eight patients meeting American College of Rheumatology criteria for fibromyalgia⁵ were enrolled in a Washington, DC–based study between August 28 and September 25, 2001. Patients continued to use standard treatments for their symptoms; no new treatment was given as part of the study. Patients kept the handheld computer on their person as they participated in their daily activities. These individuals were asked to record their level of pain on a visual analog scale from 0 ("no pain") to 10 ("extreme pain") when randomly prompted, an average of 4 to 6 times per day. Patients also rated the quality of their sleep each morning on a scale from 0 ("very poor") to 10 ("excellent"). All data from the handheld computer were verifiably time-stamped. Finally, 7 of the 8 patients also assessed their current pain level on a scale of 0 to 10 during each of 2 monthly visits to our clinic, one in late August 2001 and one in late September 2001.

Results
For the sample, pain in the days after the attacks did not deviate significantly from preattack values (Wilcoxon signed rank test; P>.99) (Figure 1). Moreover, symptoms were not acutely worse in the hours or days immediately after the attacks. On average, sleep showed a slight improvement after the attacks but was not significantly different from preattack levels (P = .16). Finally, patients' pain reports during their monthly visits to the clinic showed a slight but nonsignificant improvement from the late August visit to the late September visit (visual analog scale scores of 7.4 vs 6.1, respectively; P = .17).

View larger version (45K): [in this window] [in a new window] Figure. Averaged Randomly Prompted Pain Ratings and Morning Recall of Sleep Quality For Each Patient Prior to, On, and Following September 11, 2001

Comment
In this study using real-time assessment methods, a cohort of patients with chronic pain did not note any worsening of symptoms as an immediate consequence of the September 11 attacks, even though these individuals were living in the Washington, DC, area during this time period. This result is consistent with previous work suggesting minor daily problems rather than major events may drive somatic symptom expression.⁶

Our conclusions are limited by our small sample size. Nonetheless, our data suggest that if there was truly an increase in health care use following September 11, this may have occurred independently of any actual change in symptomatology. For instance, seeking health care may be driven more by distress than by acute changes in symptoms.⁷

Funding/Support: This work was funded by Cypress Biosciences, and preparation of the manuscript was supported in part by Department of the Army grant DAMD17-00-2-0018.

David A. Williams, PhD; Scott C. Brown, PhD; Daniel J. Clauw, MD
Department of Internal Medicine
University of Michigan
Ann Arbor

R. Michael Gendreau, MD, PhD
Cypress Bioscience
San Diego, Calif

1. Goldstein A. Terrorism tied to jump in pain problems. Washington Post. October 1, 2001:A1. 2. Schuster MA, Stein BD, Jaycox L, et al. A national survey of stress reactions after the September 11, 2001, terrorist attacks. N Engl J Med. 2001;345:1507-1512. FREE FULL TEXT 3. Lampert R, Baron SJ, McPherson CA, Lee FA. Heart rate variability during the week of September 11, 2001. JAMA. 2002;288:575. FREE FULL TEXT 4. Schlenger WE, Caddell JM, Ebert L, et al. Psychological reactions to terrorist attacks: findings from the National Study of Americans' Reactions to September 11. JAMA. 2002;288:581-588. FREE FULL TEXT 5. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia: Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990;33:160-172. WEB OF SCIENCE | PUBMED 6. Dailey PA, Bishop GD, Russell IJ, Fletcher EM. Psychological stress and the fibrositis/fibromyalgia syndrome. J Rheumatol. 1990;17:1380-1385. PUBMED 7. Browne GB, Arpin K, Corey P, Fitch M, Gafni A. Individual correlates of health service utilization and the cost of poor adjustment to chronic illness. Med Care. 1990;28:43-58. WEB OF SCIENCE | PUBMED

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2003;289:1637-1638.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?