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Terrorism's Effect on Chronic Pain Perception: An Analysis of a Multi-center Cohort

This study retrospectively assesses the impact of the September 11 tragedy on Visual Analog Scale (VAS) scores among an aggregate group of chronic pain patients in Baltimore, New York, and Seattle.
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The impact of disaster and trauma on physical pain perception is a phenomenon that has received little attention in the medical literature. While the effect of trauma on psychological and emotional pain (post-traumatic stress syndrome) has been extensively reported in scientific investigations, there has been little written about the relationship of terrorism and other forms of trauma on chronic pain perception.

Overt acts of mass aggression, terrorism and other forms of disaster (both natural and man-made calamity) may exert a potent and enduring influence on physical pain perception. It has only been recently observed that traumatic acts of terrorism, such as the World Trade Center (WTC) and Pentagon attacks, can have a direct effect on pain perception among people with pre-existing chronic conditions such as arthritis and migraines.1 By triggering an acute stress reaction, acts of terrorism and barbarism can induce an amplification of pain-correlative symptoms such as muscle spasms, jumpiness, jitteriness, twitchiness, irritability and hyper-arousal. The cumulative impact of a possible sympathetic-mediated physiological response is to magnify pain perception.

Precipitous acts of terrorism and reckless brutality can also lead to a deterioration in cognitive and behavioral functions among its victims and observers. Often there is a reported deterioration in concentration, appetite, mood and sleep rhythm.1

Patients living with chronic pain who already face a variety of nefarious nociceptive challenges, may experience a dramatic worsening in their pain symptomatology. Since cataclysmic acts of terrorism have the potential to affect not only the direct victims of terror but also bystanders, friends, family, and witnesses, terrorism’s reprehensible “reach” can be far and wide. Terrorism’s traumatizing effects can often be felt vicariously through television, newspaper and radio dissemination.3

The recent Sept. 11 terrorism bombings provide a cogent model to assess the impact of this malevolent form of disaster on pain perception and to analyze demographic variables that may exert an effect on reported pain intensity.

The authors became interested in this research topic issue after observing a dramatic worsening in reported pain intensity among many of their patients after the Sept. 11 WTC and Pentagon catastrophes. The following illustrative case reports are included.

Case Reports

A 47-year-old African-American woman with a history of fibromylagia and chronic pain syndrome, whose pain symptoms had been consistently stable for a two-month period immediately preceding her follow-up visit on Sept. 13, 2001, experienced a profound worsening in her reported pain after viewing the Sept. 11 tragedy on television. The patient, who lived in Baltimore, reported additional difficulty with sleep, increased spasms and generalized discomfort.

A 53-year-old Asian-American woman, who was employed 3 blocks away from ground zero, reported a significant worsening of her chronic neck pain condition. She also indicated that she now experienced spasms, stiffness and generalized fatigue.

A 58-year-old male with paraplegia, who was a Vietnam veteran with a history of chronic pain, reported a dramatic worsening in his pain complaints and said that seeing the event on TV conjured up images and painful memories of his tour of duty.

Study Objectives

To investigate the hypothesis that acts of non-natural disaster and terrorism has an amplification affect on pain

To observe demographic trends and to determine whether gender, sex, age or geographic location is correlated with terrorism’s impact on pain.


A multi-center retrospective analysis of charts containing visual analog pain (VAS) data from ambulatory care pain management clinics situated in three distinct parts of the country (Baltimore, New York, and Seattle).

A systematic retrospective review was performed on all of the charts. Demographic data of all the subjects including age, gender, geographic locale and race was recorded.

Tabulation of self reported standardized Visual Analog Scale (VAS) data was made. The numeric gradations were 1-10 and patients were asked to assess their level of pain based on this scale. A total of 6 data points (VAS Scores) were analyzed for each patient; representing three separate clinic visits made prior to Sept. 11 and three after Sept. 11.

A composite “Pre-Sept. 11 “ score was calculated by averaging the three “Pre-Sept. 11” data points and a composite “Post-Sept. 11” score calculated by averaging the three “Post-Sept. 11” data points.

By triggering an acute stress reaction, acts of terrorism and barbarism can induce an amplification of pain-correlative symptoms such as muscle spasms, jumpiness, jitteriness, twitchiness, irritability and hyper-arousal.

Pre- and post- mean scores were compared. Data from a total of 129 patients was examined in the study. Also compared, was the score from patient assessment conducted immediately prior to Sept. 11 with the score immediately after Sept. 11.


Inclusion criteria

  • Men and women between the ages of 25-65.
  • Patients with pain present > 6 months (chronic pain syndrome).

Exclusion criteria

  • Any known acute medical condition that might adversely affect self reported pain score.
  • Active cancer.
  • Any psychological or psychiatric condition requiring active medication.

Total patients

A total of 129 patients were included in this study (n): # of women = 80
# of men = 49
# of Caucasians = 45
# of African-Americans= 59
# of Asian-Americans = 25

Data Analysis

  1. A Repeated Measures test run using “Pain Scores” as the dependent variable and “pre/post Sept. 11” as independent variable indicated a highly significant increase in the pain score after Sept. 11 (F=69.514, p=0.000).
  2. One Way ANOVA for Race: The result is non-significant (F=0.057, p=0.812), indicating no significant effect of race on pain scores.
  3. One Way ANOVA for geographic site: The result is non-significant (F=1.988, p=0.138), indicating no significant effect of geographic location on pain scores.
  4. Average pain scores for the aggregate study group increased approximately 27% after the Sept. 11 tragedy (see Figure 1).
  5. Women experienced an almost two-fold increase in pain scores immediately following the event with the pain increase dramatically higher both in relative and absolute terms compared to men (see Table 1).

Figure 1. The aggregate group effect of Sept. 11 on chronic pain perception.

Since a significant interaction effect between Sept. 11 and gender were identified, we continued to explore the gender affect in greater detail.

Last updated on: December 28, 2011
First published on: March 1, 2002