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4 Articles in Volume 2, Issue #2
Blocking Out the Pain
Chronic Opioid Treatments
Effective Approaches: Study Questionnaires
Terrorism's Effect on Chronic Pain Perception: An Analysis of a Multi-center Cohort

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.

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.

There is a highly significant interaction between the “pre/post Sept. 11” factor and the “gender” factor (F= 46.985, p=0.000). This means that men and women are influenced by the Sept. 11 events to a different extent. Men’s average pain scores of the three trials after Sept. 11 is lower than the previous 3 trials, despite showing an increase in trial 4, immediately following the event. However, women’s pain scores increased dramatically after Sept. 11 and sustained a higher level than prior to the event. We will explore the interaction effect between gender and Sept. 11 factor.

The present data suggests that the Sept. 11 event exerted an effect on both men and women, with women experiencing a much greater increase in VAS pain score then men during the initial post Sept. 11 trial (between visit three and four).

visit #3
visit #4
Male 5.45 6.53 1.08
Female 4.13 7.76 3.63

Table 1. Average VAS by gender: Clinic visits before and after Sept. 11 catastrophes.

Gender Recovery Impact

Although women continued to sustain a high degree of pain based on VAS scores following clinic visit #4, the magnitude of their pain decreased indicating an ongoing recovery process. It is notable that the average pain score for the last two pain trials following Sept. 11 (figure 3) are significantly higher then the three trails before Sept. 11, lending validity to the conclusion that women had not fully recovered from the Sept. 11 tragedy, even after the horrific impact of the day had passed.

Figure 2.Average VAS pain score by gender by sequential clinic visit.

In contrast, men experienced quicker recovery than women. Their pain scores in the last two trials are significantly lower then the three pain trials before Sept. 11, indicating that men were able to more swiftly recover from the initial shock.

While comparing the three trials before Sept. 11 and the three trials after Sept. 11, the Split-plot test with gender, race as between-group factor has identified a significant interaction between the “Pre/post Sept. 11” factor and the “gender” factor. The average pain score of females increased after Sept. 11, while the average pain score of males in the three trials after Sept. 11 decreased (see Table 2).

Before Sept. 11, the average pain score of females during the first three trials was lower than males. After Sept. 11, the average pain score of females exceeded males. This indicates that the Sept. 11 event affected women more dramatically than men.

  Pre 9/11 Post 9/11 Change
Male 5.56 5.39 -0.17
Female 4.34 6.68 2.34

Table 2. Average VAS by gender for all pre- and post- Sept. 11 clinic visits.


The effect of the Sept. 11 event on pain perception was quite dramatic for the group of chronic pain patients studied. Mean VAS scores, representing three clinic visits immediately after Sept. 11 were compared with mean pain scores of three clinic visits before Sept. 11 indicating a significant worsening in pain intensity after the event.

Although both men and women experienced large increases in their self-reported VAS immediately following Sept. 11, women experienced a greater intensity of pain amplification after Sept. 11, compared with men (6.68 vs. 5.39).

In terms of racial differences, there appeared to be no relationship between race and pain exacerbation.

Age appeared to have no influence on pain intensity.

In order to gauge the possible influence of location on pain intensification, this study included discrete data from ambulatory care clinics in three disparate and geographically scattered areas. Data from clinics in Baltimore, New York City (five blocks from ground zero) and Seattle was collected. Surprisingly, there appeared to be no relationship between particular location and pain perception and intensity. The location/site had no effect on pain score before and after. This lends credibility to the theory that Sept. 11 had a devastating effect on all Americans regardless of location. Interpretation of this finding however, may be limited because of the unequal distribution of subjects across various centers.

This study is complicated by several potential confounding factors: there was a large increase in patient visits after Sept. 11.

Although it is difficult to predict the psychological impact of the Sept. 11 tragedy on pain VAS scores, the authors theorized that those who were closest (geographically) to the locus of trauma (New York) might be most adversely affected by Sept. 11 if psychological and emotional factors were, in fact, a pain exacerbator. The results, however, did not support this hypothesis.

Terrorism’s Effect on Pain: A Proposed Mechanism

Terrorism provokes a state of hyper-arousal, thereby rallying the sympathetic nervous system and causing an array of physical responses including muscle tightness, spasms, numbness tingling. The feelings of sadness and depression associated with the event may dysfunctionally influence a person to adopt negative coping strategies including deferral of pain relieving strategies like exercise and pharmacotherapy. In this study, there were several patients who cancelled their clinic visits (including doctors appointments and PT visits) in order to watch the television coverage of the event. This may have had an additive affect on their pain deterioration.

There is also the distinct possibity that patients may have suffered a form of Post-Traumatic Stress Disorder (PTSD) which may manifest as “an exaggerated emotional and physical reaction to triggers that remind the person of the event.”7 In this situation, Sept. 11 may have triggered a pain re-activation. PTSD is known to affect women twice as frequently as men.8,9

Sept. 11 Impact on Pain: The Gender Divide

The finding that women felt worse pain after Sept. 11 than men and “held on” to their pain for a longer length of time (slower recovery) is corroborated by research showing that women feel more pain than men, have lower pain tolerance and lower pain thresholds.6 Despite this, women are more effective at coping with pain and are far more proactive in dealing with their pain. In fact, the National Institutes of Health (NIH) held a conference on gender and pain to provide a synopsis of the research developments in this area.4 Research presented there supported the following conclusions:

  • Women cope better with pain than men.
  • Women discuss pain more than men.
  • Women experience more pain than men.

Hormones also play an important role in one’s experience with pain. Many structural, developmental, and anatomic differences between men and women are due to the endocrine system and hormone levels. In both the peripheral and central nervous system, hormones contribute to processing nociceptive signals.5 Progesterone can influence norepinephrine, serotonin and dopamine levels. Neuromodulators such as substance P, glutamate, and gama-inobutyric acid, which are critical in pain processing, are also affected by progesterone. Endorphins may also be affected by sex hormones.6 The fluctuation of hormones during a woman’s menstrual cycle can have a dramatic effect on her pain experience.

Additionally, a person’s emotional and psychosocial well-being is also a key factor in gender-differences in pain. The ability to cope with the stress of an injury can affect pain perception. This in fact, may be the strongest link between the Sept. 11 attack and the observed gender disparity of this investigation. Depression and anxiety, which is more common among women than men, can contribute to a greater amount of pain and other somatic symptoms. However, a woman’s tendency to express her feelings with others and have more meaningful and personal relationships can help a great deal when trying to cope with pain.

Gender is now being recognized as a major biological determinant in how pain is experienced, how much pain is felt, what type of pain is experienced, and what the response to treatment will be. Women not only report more intense pain, they also suffer from more frequent pain and for a longer duration. The concept of a gender based “pain thermostat” is beginning to gain acceptance among researchers and pain practitioners.7


The tragedy of Sept. 11 has provided us with a compelling model to assess the impact of terrorism and disaster on pain intensification.

This study has provided us with evidence that the WTC attacks and the Pentagon attack of Sept. 11 led to a worsening in baseline pain scores for men and women. Women, however, were slower to recover.

The feelings of sadness and depression associated with the event may influence a person to adopt negative coping strategies including deferral of pain relieving strategies like exercise and pharmacotherapy.

The trauma of the terror attacks may have triggered a physiologic pain alarm in this population of chronic pain patients.

Subjects who were far removed geographically from the trauma site still demonstrated a significant pain score indicating that the psychological and emotional re-enforcers played little role in pain perception. However, since there was an unequal distribution of subjects among the three centers, it may confound this conclusion. Future investigation will explore this issue in greater depth.


Last updated on: December 28, 2011
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