Psychosocial factors and adjustment to chronic pain in persons with physical disabilities: a systematic review

The relationship between physical functional limitations, and psychological distress: Considering a possible mediating role of pain, social support and sense of mastery

The aim of this study was to examine associations between selected physical functional limitations related to performing daily activities and psychological distress. We also aimed to investigate if these associations vary across age (moderation), and to explore pain, sense of mastery and social support as potential moderators and mediators. The study was based on pooled data from two rounds (2008 and 2012) of a Norwegian nationally representative cross-sectional health survey (N = 8520) including individuals aged ≥ 16 years (Age groups = 16-44 and ≥ 45 years). Physical functional limitations comprised decreased ability to: i) climb stairs, ii) carry objects, or iii) both. Psychological distress was measured as anxiety and depressive symptoms occurring separately or in combination (CAD). Of respondents reporting physical functional limitations, 8-14% reported depressive symptoms, 5-7% anxiety symptoms, and 13-28% reported CAD. Physical functional limitations were significantly associated with all three forms of psychological distress, particularly among individuals 16-44 years, and were more strongly related to CAD than to anxiety or depression occurring separately. The association with CAD was twice as strong when both types of physical functional limitations were present. Pain, sense of mastery and social support were significant modifiers of depression, whereas all three were significant mediators of the relationship between physical functional limitations and anxiety, depression and CAD. Sense of mastery mediated the relationship between physical functional limitations and CAD, but most strongly among those 16-44 years. Social support was only a significant mediator among those [Formula: see text] 45 years. Close associations between physical functional limitations and psychological distress highlight special needs among individuals experiencing daily functional limitations. The results also suggest that pain, low social support, and low sense of mastery may contribute to aggravate psychological distress.

Psychosocial predictors of posttreatment pain after nonmetastatic breast cancer treatment: a systematic review and meta-analysis of prospective studies

Background

The search for risk factors of pain after breast cancer, which affects a considerable proportion of the women, has primarily focused on clinical factors. The aim of this meta-analysis was to explore the less well-studied psychosocial predictors of pain after breast cancer treatment.

Methods

Two independent searches were conducted in PubMed, PsycINFO, Web of Science, and CINAHL. Eligible studies were prospective, observational studies of women aged ≥18 years, diagnosed and treated for nonmetastatic breast cancer ≥3 months previously. Additional inclusion criteria were that studies had assessed at least one pain outcome and at least one psychosocial predictor. The psychosocial predictors investigated included: 1) psychological-behavioral states, 2) psychological traits, and 3) social support. Effect size correlations (ESr) were chosen as the effect size and pooled using a random effects model. We also explored a number of study characteristics as possible moderators of the effect with meta-regression.

Results

Of the total of 13 eligible studies identified, most studies measured psychosocial predictors at presurgery. Neither psychological-behavioral states (ESr: 0.05; p=0.13; K=11) nor psychological traits (ESr: 0.02; p=0.48; K=6) emerged as statistically significant predictors of pain. In contrast, higher levels of social support were statistically significantly associated with less pain (ESr: -0.24; p<0.001; K=4). In studies of psychological-behavioral states, longer follow-up was associated with smaller effect sizes (p=0.023). Furthermore, older mean sample age was associated with larger effect sizes for both psychological-behavioral states (p=0.0004) and psychological traits (p=0.035).

Conclusion

The results of this meta-analysis suggest that psychosocial factors measured at presurgery may only be of modest predictive value in identifying women at risk of developing pain after breast cancer treatment. While speculative, psychosocial factors may play a larger role in the postsurgery trajectory, which could be valuable to investigate in future studies.

The role of perceived family social support and parental solicitous responses in adjustment to bothersome pain in young people with physical disabilities

PURPOSE

Family social support and parental solicitous responses have been hypothesised to play an important role in paediatric pain. However, research testing the hypothesised associations between these social domains and measures of adjustment to pain in youths with disabilities and chronic pain is non-existent.

METHODS

About 111 youths with physical disabilities and bothersome pain were interviewed and asked to complete measures of average pain intensity, pain interference, family social support, parent solicitous responding, and catastrophising.

RESULTS

Children's perceptions of pain-related solicitous responses from their parent/guardian were associated both with more pain interference and greater pain-related catastrophising; perceived social support was negatively associated with pain interference.

CONCLUSIONS

The findings provide new information regarding the role that psychosocial factors have in predicting function and adjustment, and have important implications as to how youth with physical disabilities with pain might be most effectively treated. Implications for rehabilitation Little is known about the role of perceived family social support or parental solicitous responses in the adjustment to chronic pain in young people with physical disabilities. This study provides new and important findings that have significant theoretical and practical implications that could help to understand and manage function in these patients. Results show that it matters how parents respond to their children with disabilities who have pain, and raise the possibility that interventions which target these responses may result in significant benefits for the children.

Pain Beliefs and Quality of Life in Young People With Disabilities and Bothersome Pain

OBJECTIVES

Pain beliefs have been hypothesized to play an important role in pediatric pain. However, research examining the associations between pain-related beliefs and measures of function in youths with disabilities is limited.

METHODS

In total, 84 youths (mean age, 14.26 y; SD, 3.27) with physical disabilities who indicated they also had bothersome pain were interviewed and asked to rate their average pain intensity in the past week and to complete measures of pain-related beliefs and health-related quality of life.

RESULTS

A number of pain beliefs were associated with different physical and psychosocial function domains, although different beliefs appeared to play different roles, depending on the function domain examined. Across all of the health-related quality-of-life domains studied, a belief that pain is influenced by one's emotions was associated with lower levels of function. No differences were found in pain beliefs related to age. In addition, a small difference in pain beliefs was found for sex; specifically, girls were more likely than boys to endorse the belief that pain is influenced by emotions.

DISCUSSION

The findings provide new information regarding the role that pain beliefs have in predicting function and have important clinical implications regarding how youth with physical disabilities and pain might be most effectively treated.

Psychosocial Influences on Exercise-Induced Hypoalgesia

Objective

The purpose of this study was to examine psychosocial influences on exercise-induced hypoalgesia (EIH).

Design

Randomized controlled trial.

Setting

Clinical research unit in a hospital.

Subjects

Fifty-eight healthy men and women (mean age = 21 ± 3 years) participated in this study.

Methods

Participants were first asked to complete a series of baseline demographic and psychological questionnaires including the Pain Catastrophizing Scale, the Fear of Pain Questionnaire, and the Family Environment Scale. Following this, they were familiarized with both temporal summation of heat pain and pressure pain testing protocols. During their next session, participants completed the Profile of Mood States, rated the intensity of heat pulses, and indicated their pressure pain thresholds and ratings before and after three minutes of submaximal, isometric exercise. Situational catastrophizing was assessed at the end of the experimental session.

Results

Results indicated that experimental pain sensitivity was significantly reduced after exercise ( P  < 0.05). Men and women did not differ on any of the measured psychosocial variables ( P  > 0.05). Positive family environments predicted attenuated pain sensitivity and greater EIH, whereas negative and chronic pain-present family environments predicted worse pain and EIH outcomes. Situational catastrophizing and negative mood state also predicted worse pain and EIH outcomes and were additionally associated with increased ratings of perceived exertion and muscle pain during exercise.

Conclusions

This study provides preliminary evidence that psychosocial variables, such as the family environment and mood states, can affect both pain sensitivity and the ability to modulate pain through exercise-induced hypoalgesia.

[Pain in patients with paraplegia]

Chronic pain is one of the most reported health problems in patients suffering from spinal cord injuries and is described by the patients as one of the most burdensome sequelae of paraplegia. Various types of pain, such as nociceptive, neuropathic and other types of pain can occur. In addition, multiple pathophysiological mechanisms based on the biopsychosocial pain model play a role in the origins of the pain. These aspects necessitate a multimodal pain management approach in this patient group. This article presents an overview of the occurrence, importance and pathophysiology of chronic pain following spinal cord injury as well as diagnostic and therapeutic approaches.

Pain as a Risk Factor for Loneliness Among Older Adults

Objective: The objective of this is to examine whether pain is associated with the onset of loneliness in a sample of community-dwelling older adults. Methods: We used data from the 2008 and 2012 Health and Retirement Study. We limited the sample to community-dwelling persons aged 60 years and over who were not lonely in 2008 in order to predict the risk of onset of loneliness (incidence) in 2012. Our analytic sample included 1,563 observations. Results: Approximately 31.7% of participants reported loneliness at follow-up (2012). Logistic regression models showed that the odds of loneliness onset was 1.58 higher for those with pain at both time points, compared with those who had pain at neither time point, even after controlling for other covariates. Discussion: The results indicate that pain may increase the risk of loneliness in older adults. This suggests that appropriate pain interventions could prevent future loneliness, which in turn could prevent functional decline, disability, and premature mortality.

Posttraumatic stress following spinal cord injury: a systematic review of risk and vulnerability factors

OBJECTIVES

To summarise quantitatively the available evidence relating to pretraumatic, peritraumatic and posttraumatic characteristics that may increase or decrease the risk of developing posttraumatic stress disorder (PTSD) following spinal cord injury (SCI).

STUDY DESIGN

Systematic review.

METHODS

Seventeen studies were identified from the PubMed, PsycInfo, Embase, Scopus, CINAHL, Web of Science and PILOTS databases. Effect size estimates (r) with associated 95% confidence intervals (CIs), P-values and fail-safe Ns were calculated.

RESULTS

Individual studies reported medium-to-large associations between factors that occurred before (psychiatric history r=0.48 (95% CI, 0.23-0.79) P=0.01) or at the time of injury (tetraplegia r=-0.36 (95% CI, -0.50 to -0.19) P<0.01). Postinjury factors had the strongest pooled effects: depressed mood (r_w=0.64, (95% CI, 0.54-0.72)), negative appraisals (r_w=0.63 (95% CI, 0.52-0.72)), distress (r_w=0.57 (95% CI, 0.50-0.62)), anxiety (r_w=0.56 (95% CI, 0.49-0.61)) and pain severity (r_w=0.35 (95% CI, 0.27-0.43)) were consistently related to worsening PTSD symptoms (P<0.01). Level of injury significantly correlated with current PTSD severity for veteran populations (Q_B (1)=18.25, P<0.001), although this was based on limited data.

CONCLUSION

Combinations of peri- and post-injury factors appear to be influential in the development of PTSD among persons with SCI. Further studies are needed to extrapolate these findings to the broader spinal cord-injured population. More longitudinal research, driven by multicausal models of causation such as the diathesis-stress model, is also needed to determine the temporality of PTSD risk factors.

Evaluation of a specialized yoga program for persons with a spinal cord injury: a pilot randomized controlled trial

Objectives

The purpose of this randomized controlled trial was to evaluate the effects of a specialized yoga program for individuals with a spinal cord injury (SCI) on pain, psychological, and mindfulness variables.

Materials and methods

Participants with SCI (n=23) were outpatients or community members affiliated with a rehabilitation hospital. Participants were randomized to an Iyengar yoga (IY; n=11) group or to a 6-week wait-list control (WLC; n=12) group. The IY group participated in a twice-weekly 6-week seated IY program; the WLC group participated in the same yoga program, after the IY group’s yoga program had ended. Pain, psychological, and mindfulness measures were collected at two time points for both groups (within 1–2 weeks before and after program 1 and at a third time point for the WLC group (within 1 week after program 2).

Results

Linear mixed-effect growth models were conducted to evaluate the main effects of group at T2 (postintervention), controlling for T1 (preintervention) scores. T2 depression scores were lower (F_1,18=6.1, P<0.05) and T2 self-compassion scores higher (F_1,18=6.57, P< 0.05) in the IY group compared to the WLC group. To increase sample size and power, the two groups were combined and analyzed across time by comparing pre- and postintervention scores. Main effects of time were found for depression scores, (F_1,14.83=6.62, P<0.05), self-compassion, (F_1,16.6=4.49, P<0.05), mindfulness (F_1,16.79=5.42, P<0.05), mindful observing (F_1,19.82=5.06, P<0.05), and mindful nonreactivity, (F_1,16.53=4.92, P<0.05), all showing improvement after the intervention.

Discussion

The results indicated that a specialized 6-week yoga intervention reduced depressive symptoms and increased self-compassion in individuals with SCI, and may also have fostered greater mindfulness.

Perceived social support moderates the relationship between activities of daily living and depression after lower limb loss

OBJECTIVE

This study examined the moderating influence of perceived social support on the prospective relationship between baseline levels of activities of daily living (ADL) and depressive symptoms during the 1st year following amputation.

METHOD

Participants included 73 veterans with new/first unilateral lower extremity amputation due to vascular disease or diabetes. Baseline levels of perceived social support, ADL function, and mobility were assessed by retrospective recall 6 weeks after amputation. Depressive symptoms were measured at 6 weeks and 12 months following surgery.

RESULTS

Perceived social support moderated the relationship between baseline ADL functioning and depressive symptoms at 12 months (β = -0.27, p < .001) after controlling for 6-week depressive symptoms and sociodemographic and physical/functional variables. Lower levels of baseline ADL function were associated with depressive symptoms at 12 months among those who reported lower levels of perceived social support.

CONCLUSION

These data allowed us to identify those participants with both low ADL function at baseline and low social support as being at higher risk for depression symptoms postamputation. The findings support the stress buffering hypothesis and suggest that perceived social support may be an important modifiable target of intervention among individuals with lower levels of functioning. (PsycINFO Database Record

Examination of an Internet-Delivered Cognitive Behavioural Pain Management Course for Adults with Fibromyalgia: A Randomized Controlled Trial

Fibromyalgia (FM) is a common and often debilitating chronic pain condition. Research shows that symptoms of depression and anxiety are present in up to three quarters of individuals with FM. Of concern, most adults with FM cannot access traditional face-to-face cognitive behavioural pain management programs, which are known to be beneficial. Given known difficulties with treatment access, the present study sought to explore the efficacy and acceptability of a previously developed Internet-delivered cognitive behavioural pain management course, the Pain Course, for adults with FM. The five-lesson course was delivered over eight weeks and was provided with brief weekly contact, via telephone and secure email, with a guide throughout the course. Participants were randomized either to the Pain Course (n = 30) or to a waiting-list control group (n = 30). Symptoms were assessed at pre-treatment, post-treatment and 4-week follow-up. Completion rates (87%) and satisfaction ratings (86%) were high. Improvements were significantly greater in treatment group participants compared to waiting-list group participants on measures of FM (Cohen's d =.70; 18% reduction), depression (Cohen's d =.63-.72; 20-28% reduction), pain (Cohen's d =.87; 11% improvement) and fear of pain (Cohen's d =1.61; 12% improvement). Smaller effects were also observed on measures of generalized anxiety and physical health. The changes were maintained at four-week follow-up. The current findings add to existing literature and highlight the specific potential of Internet-delivered cognitive behavioural pain management programs for adults with FM, especially as a part of stepped-care models of care. Future research directions are described.

The Associations Between Pain-related Beliefs, Pain Intensity, and Patient Functioning: Hypnotizability as a Moderator

OBJECTIVES

On the basis of the idea that thoughts held about pain may represent "self-suggestions" and evidence indicating that people with higher levels of trait hypnotizability are more responsive to suggestions, the current study evaluated hypothesized moderating effects of hypnotizability on the associations between pain-related thoughts and both pain intensity and pain interference.

METHODS

Eighty-five individuals with chronic pain were given measures of hypnotizability, pain intensity, pain interference, and pain-related thoughts (control beliefs, catastrophizing).

RESULTS

Analyses supported a moderating role of hypnotizability on the association between control beliefs and pain interference. Specifically, the negative association between pain control beliefs and pain interference were stronger among those with higher trait hypnotizability than between those with lower trait hypnotizability.

DISCUSSION

The study findings, if replicated in additional samples of individuals with chronic pain, have important clinical and theoretical implications. For example, if trait hypnotizability is found to predict an individual's response to a particular technique of cognitive therapy-such as focusing on and repeating pain control belief self-statements-measures of hypnotizability could be used to identify individuals who might be most responsive to this technique. The current findings indicate that research to further examine this possibility is warranted.

Effectiveness of a physiotherapist delivered cognitive-behavioral patient education for patients who undergoes operation for total knee arthroplasty: a protocol of a randomized controlled trial

Background

Total Knee Arthroplasty (TKA) is a common and generally effective procedure performed mainly due to advanced osteoarthritis, pain, physical disability and reduced quality of life. However, approximately 20% of the patients respond poorly to the surgery and chronic pain and disability following TKA remains a major health burden for many patients. Among the most well documented and powerful psychological predictors of poor outcome following TKA is pain catastrophizing. Recent research has shown that patients with these thoughts are at higher risk of having persistent pain and lower physical function after the operation than patients with low levels of pain catastrophizing before TKA. There is high need of developing treatments aimed at improving self-management for this group of patients and the aim of this study is to investigate the effectiveness of a patient education in pain coping on physical function and pain among patients with high pain catastrophizing score before a TKA.

Methods

This study is a two-arm parallel group trial design including 56 patients with high levels of pain catastrophizing referred for total knee arthroplasty due to osteoarthritis. Patients eligible for participation will be randomized into the two arms, usual care or usual care and patient education. Usual care consists of operation and standard rehabilitation. The patient education consists of 7 individual sessions focusing on pain behavior and pain coping managed by a physiotherapist. Three before the operation and four after. Measurements will be taken at baseline before the operation and 3 and 12 months after the operation. Primary outcome will be pain after 12 months measured with VAS (Visual Analogue Scale). Secondary outcomes include physical function and activity, quality of life, pain management and psychological factors.

Discussion

Only few studies have evaluated the effectiveness of psychological interventions on patients with high levels of pain catastrophizing before the operation. This trial will provide evidence for the effectiveness of a cognitive-behavioral patient education delivered by physiotherapists and may provide better functional outcome and less pain for a vulnerable group of TKA patients. We expect that the results can provide important new knowledge to the current care recommendations.

Trial registration

Clinical Trials (NCT02587429). Registered 23 October 2015

Resilience and vulnerability in individuals with chronic pain and physical disability

OBJECTIVE

To examine the independent contributions of vulnerability and resilience factors to pain interference, self-efficacy for managing pain, global mental health, and global physical health.

RESEARCH METHOD/DESIGN

Secondary analysis of baseline data from individuals with a spinal cord injury (n = 73), amputation (n = 33), or multiple sclerosis (n = 82) and chronic pain who participated in a randomized controlled trial comparing 2 chronic pain interventions. Participants completed a comprehensive battery of pain-related outcomes that assessed for both psychosocial assets and maladaptive cognitions and behaviors.

RESULTS

Results suggested that vulnerability and resilience factors together account for a considerable amount of variance in the physical outcomes, but that neither set of factors was able to make a substantial contribution above and beyond the other. In contrast, for mental health related outcomes, results indicated that resilience factors did make a meaningful contribution above and beyond vulnerability factors, suggesting the important contribution of resilience factors to the psychological experience of chronic pain.

CONCLUSIONS

The present study suggested a valuable contribution of both resilience and vulnerability factors to pain outcomes, with the additional caveat that resilience factors uniquely impact specific outcomes-particularly those that are more psychosocially focused-above and beyond vulnerability factors. Taken together, this highlights the importance of considering resilience factors in addition to vulnerability factors for individuals with chronic pain. Additional research is needed to explore other factors that could be considered representative of the resilience construct and more attention should be focused on evaluating the effects of interventions that seek to build an individual's assets.

Pain extent and function in youth with physical disabilities

Background

The aim of this study was to increase our understanding of the role that spatial qualities of pain (location and extent) play in functioning, among youths with disabilities and chronic pain.

Methods

One-hundred and fifteen youths (mean age 14.4 years; SD ±3.3 years) with physical disabilities and chronic pain were interviewed and were asked to provide information about pain locations and their average pain intensity in the past week, and to complete measures of pain interference, psychological function and disability. Most of the participants in this sample were males (56%), Caucasian (68%), and had a cerebral palsy (34%) or muscular dystrophy (25%) problem. Most participants did not report high levels of disability ( X¯=12.7, SD ±9.5, range 0–60) or global pain intensity ( X¯=3.2, SD ±2.4, range 0–10).

Results

Pain at more than one body site was experienced by 91% of participants. There were positive associations between pain extent with pain interference (r = 0.30) and disability (r = 0.30), and a negative association with psychological function (r = –0.38), over and above average pain intensity. Additionally, pain intensity in the back (as opposed to other locations) was associated with more pain interference (r = 0.29), whereas pain intensity in the shoulders was associated with less psychological function (r = –0.18), and pain intensity in the bottom or hips was associated with more disability (r = 0.29).

Conclusion

The findings support the need to take into account pain extent in the assessment and treatment of youths with physical disabilities and chronic pain, call our attention about the need to identify potential risk factors of pain extent, and develop and evaluate the benefits of treatments that could reduce pain extent and target pain at specific sites.

The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain

The recently proposed Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)-American Pain Society (APS) Pain Taxonomy (AAPT) provides an evidence-based, multidimensional, chronic pain classification system. Psychosocial factors play a crucial role within several dimensions of the taxonomy. In this article, we discuss the evaluation of psychosocial factors that influence the diagnosis and trajectory of chronic pain disorders. We review studies in individuals with a variety of persistent pain conditions, and describe evidence that psychosocial variables play key roles in conferring risk for the development of pain, in shaping long-term pain-related adjustment, and in modulating pain treatment outcomes. We consider "general" psychosocial variables such as negative affect, childhood trauma, and social support, as well as "pain-specific" psychosocial variables that include pain-related catastrophizing, self-efficacy for managing pain, and pain-related coping. Collectively, the complexity and profound variability in chronic pain highlights the need to better understand the multidimensional array of interacting forces that determine the trajectory of chronic pain conditions.

PERSPECTIVE

The AAPT is an evidence-based chronic pain classification system in which psychosocial concepts and processes are essential in understanding the development of chronic pain and its effects. In this article we review psychosocial processes that influence the onset, exacerbation, and maintenance of chronic pain disorders.

Pain, Genes, and Function in the Post-Hip Fracture Period

Post-hip fracture generalized pain can lead to a progressive decline in function and greater disability. The purpose of this study was to explore the factors that influence pain among older adults post-hip fracture, including genetic variability, and evaluate whether pain directly or indirectly influenced upper and lower extremity function. This was a secondary data analysis using data from the first 200 participants in a Baltimore Hip Study (BHS), BHS-7. Assessments were done at 2 months post-hip fracture and included age, sex, marital status, education, cognitive status, comorbidities, body mass index (BMI), upper and lower extremity function, single nucleotide polymorphisms (SNPs) from 10 candidate genes, and total areas of pain and pain intensity. Model testing was done using the AMOS statistical program. The full sample included 172 participants with an average age of 81. Fifty percent were female and the majority was Caucasian (93%). Model testing was done on 144 individuals who completed 2 month surveys. Across all models, age, cognition, and BMI were significantly associated with total areas of pain. Thirty SNPs from five genes (BDNF, FKBP5, NTRK2, NTRK3, and OXTR) were associated with areas of pain and/or pain intensity. Together, age, cognition, BMI, and the SNP from one of the five genes explained 25% of total areas of pain and 15% of pain intensity. Only age and cognition were significantly associated with lower extremity function, and only cognition was significantly associated with upper extremity function. The full model was partially supported in this study. Our genetic findings related to pain expand prior reports related to BDNF and NTRK2.

Psychosocial aspects of spinal cord injury pain: a meta-analysis

STUDY DESIGN

Meta-analysis.

OBJECTIVES

Although the association between modifiable psychosocial factors and spinal cord injury (SCI) pain has been identified, the full range of psychological and social difficulties for those who experience acute and/or persistent pain remains unclear. This meta-analysis consolidates the available evidence, using the International Classification of Functioning, Disability and Health (ICF) as a reference framework.

METHODS

Nineteen studies that examined persistent neuropathic, nociceptive or mixed pain subtypes in adults with a SCI (newly acquired and chronic; Nparticipants=2934) were identified from electronic database searches. Standardised mean differences between SCI pain and no-pain groups on self-reported psychosocial outcomes were calculated, along with 95% confidence intervals, fail-safe Ns and heterogeneity statistics.

RESULTS

Twenty individual outcomes were grouped into nine ICF-related categories. Emotional functions were the most frequent (100%) psychosocial outcomes assessed, with pain contributing to heightened stress (d=-0.85), depression (d=-2.49) anxiety (d range=-0.85 to -1.45), poor self-efficacy (d=-0.77), lowered wellbeing (d range=-0.67 to -1.02) and decreased use of adaptive coping, such as illness acceptance (d=-0.85). Activity limitations and participation restriction were examined by seven studies (43%), although these findings were largely characterised by single studies.

CONCLUSIONS

Multicomponent treatments that target mood disturbance and foster community connections are important in SCI pain management. However, to improve the comparability of future studies, SCI pain research must adopt definitions of pain consistent with the International Spinal Cord Injury Pain Classification along with validated outcomes that map onto the ICF framework.

Psychological Considerations in the Assessment and Treatment of Pain in Neurorehabilitation and Psychological Factors Predictive of Therapeutic Response: Evidence and Recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation

Background: In order to provide effective care to patients suffering from chronic pain secondary to neurological diseases, health professionals must appraise the role of the psychosocial factors in the genesis and maintenance of this condition whilst considering how emotions and cognitions influence the course of treatment. Furthermore, it is important not only to recognize the psychological reactions to pain that are common to the various conditions, but also to evaluate how these syndromes differ with regards to the psychological factors that may be involved. As an extensive evaluation of these factors is still lacking, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN) aimed to collate the evidence available across these topics.

Objectives: To determine the psychological factors which are associated with or predictive of pain secondary to neurological conditions and to assess the influence of these aspects on the outcome of neurorehabilitation.

Methods: Two reviews were performed. In the first, a PUBMED search of the studies assessing the association between psychological factors and pain or the predictive value of these aspects with respect to chronic pain was conducted. The included papers were then rated with regards to their methodological quality and recommendations were made accordingly. In the second study, the same methodology was used to collect the available evidence on the predictive role of psychological factors on the therapeutic response to pain treatments in the setting of neurorehabilitation.

Results: The first literature search identified 1170 results and the final database included 189 articles. Factors such as depression, anxiety, pain catastrophizing, coping strategies, and cognitive functions were found to be associated with pain across the various conditions. However, there are differences between chronic musculoskeletal pain, migraine, neuropathy, and conditions associated with complex disability with regards to the psychological aspects that are involved. The second PUBMED search yielded 252 studies, which were all evaluated. Anxiety, depression, pain catastrophizing, coping strategies, and pain beliefs were found to be associated to different degrees with the outcomes of multidisciplinary programs, surgery, physical therapies, and psychological interventions. Finally, sense of presence was found to be related to the effectiveness of virtual reality as a distraction tool.

Conclusions: Several psychological factors are associated with pain secondary to neurological conditions and should be acknowledged and addressed in order to effectively treat this condition. These factors also predict the therapeutic response to the neurorehabilitative interventions.

Psychiatric and psychological perspectives on chronic pain

Chronic pain patients often have psychiatric disorders that negatively influence their responses to treatment. Also, many of them have dysfunctional beliefs and coping strategies, even if they do not meet DSM-5 criteria for a psychiatric disorder. Physiatrists should have a low threshold for referring both groups of patients for mental health services. This article describes psychiatric disorders that are highly prevalent among pain patients and also describes psychological processes that contribute to poor coping by the patients. Finally, it discusses factors that a physiatrist should consider in deciding whether to refer patients to psychiatrists versus psychologists.

The impact of health anxiety in patients with relapsing remitting multiple sclerosis: Misperception, misattribution and quality of life

OBJECTIVES

Multiple sclerosis (MS) is a progressive disease with an unpredictable prognosis. Previous studies have reported health anxiety within the MS population. This study examines the effect of health anxiety on MS patients' quality of life (QoL) and evaluates the potential contribution of cognitive factors in maintaining health anxiety.

METHODS

A total of 84 patients with relapsing remitting multiple sclerosis (RRMS) were screened for health anxiety. From this sample, a group with relatively high and another group with low anxiety (n = 21 in each group) were identified. A further 21 healthy controls were recruited for comparison. A measure of QoL was then completed. Cognitive biases were investigated by measuring perception and attribution of common bodily symptoms as well as appraisal of performance on neuropsychological and physical fatigue tests.

RESULTS

The high health anxiety group reported poorer QoL relative to the other groups, independent of level of disability. They were also more likely to misattribute common bodily changes to MS, and perceive their (objectively intact) performance on tests of cognition and fatigue as being impaired, attributing the cause of impairment to MS.

CONCLUSION

Health anxiety may be a factor in mediating the psychosocial impact of MS. Skilled psychological treatment which changes misperception and misattribution may significantly benefit patients with MS and elevated health anxiety.

PRACTITIONER POINTS

Clinical implications Health anxiety impacts on quality of life in patients with MS even when disability and other measures of psychological distress are taken into account. High levels of health anxiety distort perceptions of symptoms in patients with MS in line with the predictions made by the cognitive model of health anxiety. Limitations of study This study is limited to patients with RRMS within the relatively early stages of their disease and is based on a small sample size. Health anxiety is correlated with measures of generalized anxiety, depression, and worry, although it is found to have a unique impact on quality of life in patients with MS.

Cognitive behaviour therapy in women with fibromyalgia: A randomized clinical trial

Background and aims

Stress has been pointed out as an important influential factor in the development and maintaining of the fibromyalgia syndrome (FMS) . Since stress may worsen the pain experience, the development of individual strategies for coping with stress is essential to reduce the impact of FMS on daily life. The aim of the study was to investigate whether a group based stress management cognitive behaviour therapy (CBT) programme could influence self-reported stress, wellbeing and life control, as well as self-reported pain behaviour in female FMS patients.

Methods

48 female FMS patient were randomized into a cognitive behaviour therapy treatment group (n = 24) and a waitlist control group (n = 24) . When the 6 months waitlist period was over the control group received the same CBT programme. This allowed two analytical approaches, one based on the randomized controlled trial design and one based on a before-and-after design to improve the statistical power of the study. Four psychometric instruments were used: The West Haven-Yale Multidimensional Pain Inventory (three parts, MPI-1 to MPI-3), the Maastricht Questionnaire, the Everyday Life Stress, and the Montgomery-Åsberg Depression rating scale – self-reported. Primary outcome was the MPI-1 dimension ‘life control’, secondary outcomes were the MPI-1 dimensions ‘interference’, ‘affective distress’ and ‘support from spouses or significant others’, the various MPI-2 dimensions, the ‘general activity level’ in the MPI-3 dimension, and ‘vital exhaustion’, ‘stress behaviour’, and ‘depression’. The only tertiary outcome was the MPI-1 dimension ‘pain severity’.

Results

In the RCT design the West Haven-Yale Multidimensional Pain Inventory dimensions ‘life control’, ‘interference from pain’, ‘affective distress’, ‘support from spouses or significant others’, and ‘distracting responses’ and ratings for depression improved in the treatment group as compared with the control group. In the before-and after design these improvements were maintained and enhanced during 1-year follow-up, and so was the ‘vital exhaustion’ and ‘stress behaviour’. ‘Pain severity’ was rated higher after the intervention.

Conclusions

Cognitive behaviour therapy improved the life control in a female population with FMS. Coping behaviour in response to chronic pain was improved at the same time and in spite of higher subjective ratings of pain. Positive effects were seen on depression, vital exhaustion and stress behaviour. The effects of therapy were maintained and enhanced during the follow up period. It appears that women with FMS after the CBT treatment, according to this protocol obtained tools leading to better acceptance of their disorder.

Implications

FMS is a disorder with great therapeutic challenges. Total abolishment of pain symptoms is extremely difficult or impossible to achieve. Thus, the development of individual strategies for coping with pain is essential to reduce its impact on daily life. Since stress may worsen the pain experience, coping with stress might be a promising route to accomplishing that goal. In evaluations of interventions for pain it is important to monitor the effect on behaviour responses to pain and not only ratings of pain itself.

Beyond a physical symptom: the importance of psychosocial factors in multiple sclerosis pain

BACKGROUND AND PURPOSE

Pain affects around two-thirds of people with Multiple Sclerosis (pwMS). Biomedical treatments show limited efficacy. A recently developed cognitive-behavioural model of Multiple Sclerosis (MS) pain suggests several psychosocial factors may worsen pain and related disability. The current study investigated whether psychosocial factors drawn from this model explain significant amounts of the variance in pain severity and interference over and above measures of disease severity and pain subtype.

METHODS

Six hundred and twelve pwMS experiencing pain completed a U.K. wide cross-sectional survey including valid and reliable psychometric questionnaires. Hierarchical regressions determined the relative contribution of disease severity and psychosocial factors to predicting pain severity and interference.

RESULTS

All psychosocial factors including distress, negative beliefs about pain and its consequences, and avoidance of activity, were related to pain outcomes, explaining a further 24% and 30% of the variance in pain severity and interference after controlling for demographic and disease variables. Findings were similar for neuropathic and non-neuropathic pain subgroups.

CONCLUSIONS

All pwMS reported significant pain and associated disability even though over 90% were taking pain medication. Psychosocial factors identified as important in predicting pain severity and, to a greater extent, pain interference are potentially modifiable and may be important treatment targets for both pain subtypes.

Psychosocial experiences of chronic illness in individuals with an intellectual disability: A systematic review of the literature

BACKGROUND

Increased life expectancy has led to an increase in diagnoses of chronic illness in people with an intellectual disability; despite this increase, research about the psychological impact is rare. This review explored the psychosocial experiences of chronic illness in adults with an intellectual disability, revealing potential predictors and moderators of these experiences.

METHODS

Online databases were systematically searched to identify relevant literature, using predefined inclusion criteria. Of the 25,058 titles initially identified, 4 were included, that is, those collecting data on people with an intellectual disability and diagnosed with cancer (n = 2), chronic pain (n = 1) and diabetes (n = 1).

RESULTS

Narrative synthesis of the data identified six themes, namely, (1) delayed diagnosis, (2) information, communication and understanding, (3) negative psychological consequences, (4) negative physical consequences, (5) social perception and (6) social support.

CONCLUSIONS

There are unmet needs within this population, including a lack of assistance in understanding their illness. A substantial gap in the literature should be addressed through further empirical work.

Toward an evidence-based patient-provider communication in rehabilitation: linking communication elements to better rehabilitation outcomes

Background:

There is a growing interest in linking aspects of patient-provider communication to rehabilitation outcomes. However, the field lacks a conceptual understanding on: (a) ‘how’ rehabilitation outcomes can be improved by communication; and (b) through ‘which’ elements in particular. This article elaborates on the conceptual developments toward informing further practice and research.

Methods:

Existing models of communication in healthcare were adapted to rehabilitation, and its outcomes through a comprehensive literature review.

Results:

After depicting mediating mechanisms and variables (e.g. therapeutic engagement, adjustment toward disability), this article presents the ‘4 Rehab Communication Elements’ deemed likely to underpin rehabilitation outcomes. The four elements are: (a) knowing the person and building a supportive relationship; (b) effective information exchange and education; (c) shared goal-setting and action planning; and (d) fostering a more positive, yet realistic, cognitive and self-reframing.

Discussion:

This article describes an unprecedented, outcomes-oriented approach toward the design of rehabilitation communication, which has resulted in the development of a new intervention model: the ‘4 Rehab Communication Elements’. Further trials are needed to evaluate the impact of this whole intervention model on rehabilitation outcomes.

Prevalence of fatigue, pain, and affective disorders in adults with duchenne muscular dystrophy and their associations with quality of life

OBJECTIVES

To assess the prevalence of fatigue, pain, anxiety, and depression in adults with Duchenne muscular dystrophy (DMD), and to analyze their relationship with health-related quality of life.

DESIGN

Cross-sectional study.

SETTING

Home of participants.

PARTICIPANTS

Adults (N=80) with DMD.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Fatigue was assessed with the Fatigue Severity Scale; pain with 1 item of the Medical Outcomes Study 36-Item Short-Form Health Survey and by interview; and anxiety and depression by using the Hospital Anxiety and Depression Scale. Health-related quality of life was assessed using the World Health Organization Quality of Life Scale-Brief Version. Associations between these conditions and quality of life were assessed by means of univariate and multivariate logistic regression analyses.

RESULTS

Symptoms of fatigue (40.5%), pain (73.4%), anxiety (24%), and depression (19%) were frequently found. Individuals often had multiple conditions. Fatigue was related to overall quality of life and to the quality-of-life domains of physical health and environment; anxiety was related to the psychological domain.

CONCLUSIONS

Fatigue, pain, anxiety, and depression, potentially treatable symptoms, occur frequently in adults with DMD and significantly influence health-related quality of life.

Pain catastrophizing as a risk factor for chronic pain after total knee arthroplasty: a systematic review

BACKGROUND

Total knee arthroplasty (TKA) is a common and costly surgical procedure. Despite high success rates, many TKA patients develop chronic pain in the months and years following surgery, constituting a public health burden. Pain catastrophizing is a construct that reflects anxious preoccupation with pain, inability to inhibit pain-related fears, amplification of the significance of pain vis-à-vis health implications, and a sense of helplessness regarding pain. Recent research suggests that it may be an important risk factor for untoward TKA outcomes. To clarify this impact, we systematically reviewed the literature to date on pain catastrophizing as a prospective predictor of chronic pain following TKA.

METHODS

We searched MEDLINE, EMBASE, and PsycINFO databases to identify articles related to pain catastrophizing, TKA, risk models, and chronic pain. We reviewed titles and abstracts to identify original research articles that met our specified inclusion criteria. Included articles were then rated for methodological quality. including methodological quality. Due to heterogeneity in follow-up, analyses, and outcomes reported across studies, a quantitative meta-analysis could not be performed.

RESULTS

We identified six prospective longitudinal studies with small-to-mid-sized samples that met the inclusion criteria. Despite considerable variability in reported pain outcomes, pain catastrophizing was identified as a significant predictor of chronic pain persisting ≥3 months following TKA in five of the studies assessed. Limitations of studies included lack of large-scale data, absence of standardized pain measurements, inadequate multivariate adjustment, such as failure to control for analgesic use and other relevant covariates, and failure to report non-significant parameter estimates.

CONCLUSION

This study provides moderate-level evidence for pain catastrophizing as an independent predictor of chronic pain post-TKA. Directions for future research include larger, well-controlled studies with standard pain outcomes, identification of clinically-relevant catastrophizing cut-offs that predict pain outcomes, investigation of other psychosocial risk factors, and assessment of interventions aimed to reduce pain catastrophizing on chronic pain outcomes following TKA surgery.

Towards a better understanding of MS pain: a systematic review of potentially modifiable psychosocial factors

OBJECTIVE

Pain is a common symptom of Multiple Sclerosis (MS). Biomedical treatments achieve only modest reductions in pain severity suggesting that this approach may be too narrow. The aim of this systematic review was to assess evidence for associations between modifiable psychosocial factors and MS pain severity and pain interference and use this evidence to develop a preliminary biopsychosocial model of MS pain.

METHODS

Empirical studies of pain in MS utilising standardised pain severity and pain interference measures were included. Online databases (Cochrane, PsychInfo, EMBASE, CINAHL, Medline, Web of Science and World Cat) and reference sections of included articles were searched, and corresponding authors contacted to identify unpublished studies. Information about design, sample size, MS type, time since diagnosis, psychosocial and pain measures and key findings were extracted. Thirty-one studies were assessed for quality and a narrative synthesis was conducted.

RESULTS

Similar to primary chronic pain, most studies reported small to medium associations between several psychosocial factors and pain severity and interference. Pain catastrophizing showed consistently strong associations with pain interference. Preliminary findings revealed a strong correlation between pain acceptance and pain interference. However, fear-avoidance appeared less important in MS, and other forms of behavioural avoidance were not explored.

CONCLUSIONS

A preliminary model of MS pain outlining specific psychosocial factors is presented with a conceptual formulation from both traditional, and contextual, cognitive-behavioural perspectives. Pain catastrophizing, acceptance, and endurance, as opposed to fear avoidance, responses are highlighted as potentially important treatment targets in MS, and directions for future research are outlined.

Postacute rehabilitation quality of care: toward a shared conceptual framework

There is substantial interest in mechanisms for measuring, reporting, and improving the quality of health care, including postacute care (PAC) and rehabilitation. Unfortunately, current activities generally are either too narrow or too poorly specified to reflect PAC rehabilitation quality of care. In part, this is caused by a lack of a shared conceptual understanding of what construes quality of care in PAC rehabilitation. This article presents the PAC-rehab quality framework: an evidence-based conceptual framework articulating elements specifically pertaining to PAC rehabilitation quality of care. The widely recognized Donabedian structure, process, and outcomes (SPO) model furnished the underlying structure for the PAC-rehab quality framework, and the International Classification of Functioning, Disability and Health (ICF) framed the functional outcomes. A comprehensive literature review provided the evidence base to specify elements within the SPO model and ICF-derived framework. A set of macrolevel-outcomes (functional performance, quality of life of patient and caregivers, consumers' experience, place of discharge, health care utilization) were defined for PAC rehabilitation and then related to their (1) immediate and intermediate outcomes, (2) underpinning care processes, (3) supportive team functioning and improvement processes, and (4) underlying care structures. The role of environmental factors and centrality of patients in the framework are explicated as well. Finally, we discuss why outcomes may best measure and reflect the quality of PAC rehabilitation. The PAC-rehab quality framework provides a conceptually sound, evidence-based framework appropriate for quality of care activities across the PAC rehabilitation continuum.

Pain, motor function and health-related quality of life in children with cerebral palsy as reported by their physiotherapists

Background

Children and adolescents with cerebral palsy suffer from higher levels of pain than their peers without disability. The aim of this study was to explore the impact of pain on health-related quality of life and motor function in individuals with cerebral palsy as reported by health professionals.

Methods

Cross-sectional study carried out in Associations for Care of Individuals with Cerebral Palsy and Related Disabilities (ASPACE) in Balearic Islands and Castile Leon (Spain). Thirty-five physiotherapists rated pain, health-related quality of life and motor function in 91 children and adolescents with cerebral palsy [8-19y]. A semi-structured interview was used to collect demographic and clinical data according with the Study of Participation of Children with Cerebral Palsy Living in Europe (SPARCLE).

Results

Physiotherapists reported that 51% of individuals with cerebral palsy suffered from pain. Physiotherapists also perceived that pain in individuals with cerebral palsy was responsible for reductions of psychological but not physical domains of health-related quality of life. According with physiotherapists’ estimations, motor impairment scores were not correlated with pain scores in individuals with cerebral palsy, but they were significantly associated with physical and autonomy domains of health-related quality of life.

Conclusions

These findings highlighted the importance of assessing and providing interventions for pain relief in persons with cerebral palsy even at an early age.

Relaying support in disaster-affected areas: the social implications of a 'pay-it-forward' network

When a disaster strikes a country, a temporary so-called post-disaster utopia emerges in which local residents help each other and outsiders support survivors and victims. However, this utopia does not last. Survivors are likely to have no chance to pay people back for the help they have received and thus return to their daily lives with a sense of debt. After the Great East Japan Earthquake the author motivated survivors of other disasters to help survivors in the Tohoku region in eastern Japan in return for the support they had received in the past. Two findings are revealed: firstly, this pay-it-forward support among disaster-affected areas allows for intermittent rebuilding of the post-disaster utopia. Secondly, a theoretical examination of the network theory also suggests that the pay-it-forward network is likely to expand and cover the whole of society very quickly. The psychological and sociological implications of these findings are also discussed.

Liposarcoma of the great toe: a case report

Soft tissue sarcomas are rare malignancies, of which liposarcomas are the most common. Pleomorphic liposarcoma accounts for 5% of liposarcoma diagnoses and most commonly presents in the thigh. A 57-year-old female presented with a 5-year history of a persistent, painless swelling of the left great toe that had been previously diagnosed and treated as an in-grown toenail. After magnetic resonance imaging and core biopsy, a grade 2 pleomorphic liposarcoma was diagnosed. Treatment consisted of neoadjuvant radiotherapy and amputation of the great toe and proximal half of the first metatarsal with primary closure. The patient had no evidence of local recurrence or metastatic disease after 1 year of follow-up and, with the use of a prosthesis, had a good functional outcome. This is the first documented presentation of a high-grade pleomorphic liposarcoma of the great toe to our knowledge. Although soft tissue sarcomas are rare, a high index of suspicion is required by clinicians when presented with a soft tissue mass to promptly diagnose and treat these potentially fatal lesions.

Multidimensional clinical pain phenotypes after spinal cord injury

SUMMARY Persistent neuropathic pain after spinal cord injury (SCI) is a serious problem that significantly affects general health and wellbeing over and above what is caused by other medical consequences after SCI. The ideal approach to the management of the neuropathic pain conditions after SCI would be to identify the primary contributing mechanisms of pain in each person and tailor the treatment to these. However, despite significant basic and clinical research progress, this approach remains elusive. One strategy to further this effort is to define neuropathic pain phenotypes based on pain symptoms, sensory function/dysfunction and psychosocial factors, and determine the relationship between these and treatment outcomes and biomarkers including brain imaging. This approach will facilitate the interaction between basic and clinical science and translational research, further the understanding of the mechanisms that contribute to the development and maintenance of neuropathic pain after SCI, and thus the development of effective mechanisms-based pain treatment strategies.

Biopsychosocial factors associated with pain in veterans with the hepatitis C virus

Little research has examined etiological factors associated with pain in patients with the hepatitis C virus (HCV). The purpose of this study was to evaluate the relationship between biopsychosocial factors and pain among patients with HCV. Patients with HCV and pain (n = 119) completed self-report measures of pain, mental health functioning, pain-specific psychosocial variables (pain catastrophizing, self-efficacy for managing pain, social support), prescription opioid use, and demographic characteristics. In multivariate models, biopsychosocial factors accounted for 37% of the variance in pain severity and 56% of the variance in pain interference. In adjusted models, factors associated with pain severity include pain catastrophizing and social support, whereas variables associated with pain interference were age, pain intensity, prescription opioid use, and chronic pain self-efficacy (all p values <0.05). The results provide empirical support for incorporating the biopsychosocial model in evaluating and treating chronic pain in patients with HCV.

Future directions of multiple sclerosis rehabilitation research

Multiple sclerosis continues to present a host of rehabilitation challenges, specifically the impact of secondary "hidden" conditions on quality of life, participation, and employment. To discuss the current state of rehabilitation research and direct future research endeavors, a state of the science conference was held in November 2010 in Alexandria, Virginia. The conference was presented by the University of Washington's Multiple Sclerosis Rehabilitation Research and Training Center and focused on the current state of research into secondary conditions, outcomes measurement, employment, and the utility of psychotherapeutic interventions. This article discusses the details and recommendations of this conference.

Which pain coping strategies and cognitions are associated with outcomes of a cognitive behavioral intervention for neuropathic pain after spinal cord injury?

BACKGROUND

Chronic neuropathic pain is one of the most difficult problems to manage after spinal cord injury (SCI). Pain coping and pain cognitions are known to be associated with the patient's experience of neuropathic pain, but they have not been studied in the context of a cognitive behavioral treatment program for coping with neuropathic pain after SCI.

OBJECTIVE

To explore associations of pain coping strategies and cognitions with pain intensity and pain-related disability and changes in pain coping strategies and cognitions with changes in pain intensity and pain-related disability.

METHODS

Forty-seven persons who participated in the CONECSI (COping with NEuropathiC Spinal cord Injury pain) trial completed questionnaires before the intervention (baseline) and 3 months after of the intervention (follow-up).

RESULTS

Compared to baseline, participants showed more favorable scores on 2 pain coping scales (Pain Transformation and Worrying), the subtotal score Active Coping, and 3 pain cognitions scales (Catastrophizing, Optimism, and Reliance on Health Care) at follow-up. Baseline Reliance on Health Care was associated with change in pain intensity and pain-related disability. Change in Catastrophizing and change in Restriction cognitions were associated with change in pain-related disability.

CONCLUSIONS

Our findings suggest that modifying pain coping strategies and cognitions by a cognitive behavioral intervention for chronic neuropathic pain after SCI may have some beneficial effects on pain intensity and pain-related disability. Further research should show how dysfunctional pain coping strategies and cognitions can be most effectively modified.

How significant is the Significant Other in patient coping in chronic pain?

SUMMARY While healthcare is most commonly focused at the individual level, considerable research has demonstrated that the presence and nature of the relationship with a significant other can play an important role in both mortality and morbidity. In the case of chronic pain, studies have shown that patient disability, mood and overall adjustment can be strongly influenced by the partner. The partner’s responses to patient overt communications of pain have been examined in detail, with support for operant behavioral models of chronic pain generally found. However, more recent studies have extended the behavioral paradigm by exploring issues such as empathy, relationship intimacy and the cognitive patterns of patients and their partners, to better understand dyadic adjustment to chronic pain. Future work will broaden the investigation of the determinants of partner helping behaviors, by looking at pre-illness variables and their expression in a chronic pain relationship.