Chronic spinal pain and physical–mental comorbidity in the United States: results from the national comorbidity survey replication

Gender differences in blood pressure-related hypoalgesia in a general population: the Tromsø Study

An inverse association between resting blood pressure (BP) and acute pain sensitivity is well documented. Whether BP-related hypoalgesia differs by gender is unclear from prior work. Whether it increases proportionally with BP throughout the full BP range is also unknown. We examined BP-related hypoalgesia in a general population sample (n = 10,371, aged 30-87) of equal gender distribution reflecting the extremely low through hypertensive BP range. Resting BP was assessed and individuals participated in a standardized cold pressor test, providing pain ratings every 9 seconds. For systolic BP (SBP), a significant SBP × Gender interaction was observed on mean pain ratings (P < .001). Females displayed significant BP-related hypoalgesia (P < .001), with males showing a 38% smaller effect (P < .001). A similar DBP × Gender interaction was also observed (P < .05). Spline regression indicated a significant (P < .001) change in slope of the SBP-pain association at 140 mmHg. Among individuals with lower resting SBP (<140/90), increasing hypoalgesia with increasing SBP levels was observed (P < .001), with no further increases in those with higher BP (≥140/90; P > .10). This is the first large-scale study to confirm past results suggesting that BP-related hypoalgesia differs by gender; that is, females exhibited greater hypoalgesia. BP-related hypoalgesia appears subject to ceiling effects in the hypertensive BP range.

PERSPECTIVE

Females show greater BP-related hypoalgesia than males, highlighting gender differences in endogenous antinociceptive systems. Extent of BP-related hypoalgesia does not increase further once resting pressures reach the hypertensive range, suggesting persistent maximal demands on these antinociceptive systems among hypertensive individuals.

Health service and medication use among veterans with persistent postconcussive symptoms

Persistent postconcussive symptoms (PPCS) are noted when a series of cognitive, emotional, and somatosensory complaints persist for months after a concussion. Clinical management of PPCS can be challenging in the veteran population because of the nonspecific nature of symptoms and co-occurrence with affective disturbances such as posttraumatic stress disorder (PTSD) and chronic pain. In this study, we compared health service and medication use patterns in a sample of 421 veterans with PPCS with an age-matched cohort of case controls. The results suggest that the veterans with PPCS showed high rates of medical and mental health service utilization during a mean treatment period of 2 years. Although chronic pain commonly co-occurs with PPCS in veterans, service use and medication prescribing trends seem to have been influenced more by the presence of PTSD than chronic pain. Our findings reinforce the overlap among PPCS, PTSD, and chronic pain and demonstrate the complexity inherent in treating these conditions in veterans.

The missing 'P' in pain management: how the current opioid epidemic highlights the need for psychiatric services in chronic pain care

OBJECTIVE

The prevalence of opioid therapy for chronic noncancer pain has increased dramatically in recent years, with a parallel increase in opioid abuse, misuse and deaths from accidental overdose. We review epidemiological and clinical data that point to the important roles psychiatric disorders have in the use and abuse of opioids in patients with chronic pain.

METHOD

We conducted literature searches on the PubMed with the key phrases "chronic pain" and "opioid therapy" and selected those articles on the epidemiology of comorbidity between chronic pain and psychiatric disorders, the trends in long-term opioid therapy and the clinical trials that involved using opioid therapy for chronic pain or for mental health disorders. We then thoroughly reviewed the bibliography of all relevant articles to identify additional papers to be included in the present review.

RESULTS

Chronic pain is highly comorbid with common psychiatric disorders. Patients with mental health and substance abuse disorders are more likely to receive long-term opioid therapy for chronic pain and more likely to have adverse outcomes from this therapy. Although opioids may exert brief antidepressant and anxiolytic effects in some patients with depression or anxiety, there is scant evidence for long-term benefit from opioid treatment of psychiatric disorders.

CONCLUSIONS

Opioids may be used in current clinical practice as the de facto and only psychiatric treatment for patients with chronic pain, despite little evidence for sustained benefit. The opioid epidemic thus reflects a serious unmet need for better recognition and treatment of common mental health problems in patients with chronic pain. Psychiatry is the missing P in chronic pain care.

Involvement of genetic and environmental factors in the onset of depression

First, this article provides a brief overview of the previous hypotheses regarding depression and then focuses on involvement of genetic and environmental factors in development of depression. According to epidemiological research, 30~40% of occurrences of bipolar disorder involve a genetic factor. Therefore, environmental factors play a more important role in development of depression. Resilience and resistance to stress are common; therefore, although a certain extent of stress might be received during the embryonic or perinatal period, having a genetic predisposition to mental disorders does not imply that a mental disorder will develop. However, having a genetic predisposition to disorders does weaken resistance to stresses received during puberty, and without the ability to recover, a mental disorder is triggered. The importance of epigenetics in maintaining normal development and biology is reflected by the observation that development of many diseases occurs when the wrong type of epigenetic marks are introduced or are added at the wrong time or in the wrong place. Involvement of genetic and environmental factors in the onset of depression was investigated in relation to epigenetics. When mice with the disrupted in schizophrenia 1 (DISC1) abnormal gene received isolated rearing stress, depression-like abnormal behaviors and decreased gene expression of tyrosine hydroxylase in the frontal cortex by epigenetical suppression via DNA methylation were observed. Decrease of dopamine in the frontal cortex triggers behavioral disorders. Administration of a glucocorticoid receptor antagonist resulted in full recovery from neurological and behavioral disorders. These results suggest a new therapeutic approach to depression.

[Chronic pain among elderly residents in São Paulo, Brazil: prevalence, characteristics, and association with functional capacity and mobility (SABE Study)]

The objective was to identify the prevalence and characteristics of chronic pain and the association with functional capacity. This was a cross-sectional study with a population sample of community-dwelling elderly residents in the city of São Paulo, Brazil, using home interviews. Statistical analysis used the RaoScott test of association with p < 0.05. Prevalence of chronic pain was 29.7% (95%CI: 25.4-33.9), most frequent in the lower back (25.4%) and lower limbs (21.9%), and moderate in 45.8% and intense in 46% of the sample. Chronic pain was associated with increased dependence and decreased mobility (p < 0.001).

Alterations in endogenous opioid functional measures in chronic back pain

The absence of consistent end organ abnormalities in many chronic pain syndromes has led to a search for maladaptive CNS mechanisms that may explain their clinical presentations and course. Here, we addressed the role of brain regional μ-opioid receptor-mediated neurotransmission, one of the best recognized mechanisms of pain regulation, in chronic back pain in human subjects. We compared μ-opioid receptor availability in vivo at baseline, during pain expectation, and with moderate levels of sustained pain in 16 patients with chronic nonspecific back pain (CNBP) and in 16 age- and gender-matched healthy control subjects, using the μ-opioid receptor-selective radioligand [(11)C]carfentanil and positron emission tomography. We found that CNBP patients showed baseline increases in thalamic μ-opioid receptor availability, contrary to a previously studied sample of patients diagnosed with fibromyalgia. During both pain expectation and sustained pain challenges, CNBP patients showed regional reductions in the capacity to activate this neurotransmitter system compared with their control sample, further associated with clinical pain and affective state ratings. Our results demonstrate heterogeneity in endogenous opioid system functional measures across pain conditions, and alterations in both receptor availability and endogenous opioid function in CNBP that are relevant to the clinical presentation of these patients and the effects of opioid analgesics on μ-opioid receptors.

Ferulic acid increases pain threshold and ameliorates depression-like behaviors in reserpine-treated mice: behavioral and neurobiological analyses

Depression-pain dyad involves a series of pathological changes including the dysfunction of neuroendocrine and immune networks. Depression and pain influence each other, but the mechanisms are still obscure. The present study aimed to investigate the effect of ferulic acid (FA) on reserpine-induced pain and depression-like behaviors in mice. The results showed that reserpine (1 mg/kg for 3 days, i.p.) led to a significant decrease in nociceptive threshold in thermal hyperalgesia and mechanical allodynia, as well as a significant increase in the immobility time in mouse models of despair test. The neurochemical assays suggested the decreased neurotransmitters (dopamine, norepinephrine and serotonin) along with the increased oxidative stress, inflammatory cytokines, and apoptotic parameters in the frontal cortex and hippocampus of the reserpinised mice. Treatment with FA (40 or 80 mg/kg, p.o.) reversed the behavioral abnormalities and decreased norepinephrine, serotonin and dopamine levels in the hippocampus and frontal cortex induced by reserpine. The higher dose of FA effectively antagonized the oxidative and nitrosative stress and inflammation as evidenced by down-regulated nitrite, LPO, IL-1β, TNF-α, and up-regulated GSH and SOD. Furthermore, FA produced a dose dependent decrease in substance P, NF-κβ p65 and caspase-3 levels in the frontal cortex and hippocampus of reserpinised mice. The findings suggest that FA exerts the effects on reserpine-induced pain and depression-like behaviors through regulating monoaminergic system, oxidative/antioxidant defense, inflammatory and apoptotic signaling pathways. Understanding the mechanism by which FA ameliorates depression and pain as a multi-targeted compound could open new avenues for the development of innovative treatments for depression coupled with pain.

Chronic traumatic encephalopathy and risk of suicide in former athletes

BACKGROUND

In the initial autopsy case studies of chronic traumatic encephalopathy (CTE), some researchers have concluded that the proteinopathy associated with CTE is the underlying cause of suicidality and completed suicide in former athletes.

METHODS

A review of the literature on contact sports and risk of completed suicide revealed only one epidemiological study with direct relevant data.

RESULTS

There are no published cross-sectional, epidemiological or prospective studies showing a relation between contact sports and risk of suicide. One published epidemiological study suggests that retired National Football League players have lower rates of death by suicide than the general population. Outside of sports, there is a mature body of evidence suggesting that the causes of suicide are complex, multifactorial and difficult to predict in individual cases.

CONCLUSIONS

Future research might establish a clear causal connection between the proteinopathy of CTE and suicide. At present, however, there is insufficient scientific evidence to conclude that there is a strong causal relationship between the presence of these proteinopathies and suicide in former athletes. Additional research is needed to determine the extent to which the neuropathology of CTE is a possible mediator or moderator variable associated with suicide.

Psychological Care, Patient Education, Orthotics, Ergonomics and Prevention Strategies for Neck Pain: An Systematic Overview Update as Part of the ICON Project

OBJECTIVES

To conduct an overview on psychological interventions, orthoses, patient education, ergonomics, and 1⁰/2⁰ neck pain prevention for adults with acute-chronic neck pain.

SEARCH STRATEGY

Computerized databases and grey literature were searched (2006-2012).

SELECTION CRITERIA

Systematic reviews of randomized controlled trials (RCTs) on pain, function/disability, global perceived effect, quality-of-life and patient satisfaction were retrieved.

DATA COLLECTION & ANALYSIS

Two independent authors selected articles, assessed risk of bias using AMSTAR tool and extracted data. The GRADE tool was used to evaluate the body of evidence and an external panel to provide critical review.

MAIN RESULTS

We retrieved 30 reviews (5-9 AMSTAR score) reporting on 75 RCTs with the following moderate GRADE evidence. For acute whiplash associated disorder (WAD), an education video in emergency rooms (1RCT, 405participants] favoured pain reduction at long-term follow-up thus helping 1 in 23 people [Standard Mean Difference: -0.44(95%CI: -0.66 to -0.23)). Use of a soft collar (2RCTs, 1278participants) was not beneficial in the long-term. For chronic neck pain, a mind-body intervention (2RCTs, 1 meta-analysis, 191participants) improved short-term pain/function in 1 of 4 or 6 participants. In workers, 2-minutes of daily scapula-thoracic endurance training (1RCT, 127participants) over 10 weeks was beneficial in 1 of 4 participants. A number of psychosocial interventions, workplace interventions, collar use and self-management educational strategies were not beneficial.

REVIEWERS' CONCLUSIONS

Moderate evidence exists for quantifying beneficial and non-beneficial effects of a limited number of interventions for acute WAD and chronic neck pain. Larger trials with more rigorous controls need to target promising interventions.

Pain conditions among veterans with schizophrenia or bipolar disorder

OBJECTIVE

The purpose of this study was to assess the rates of chronic, noncancer pain conditions in patients with schizophrenia or bipolar disorder within the Veterans Health Administration (VHA) System.

METHOD

This cross-sectional study used administrative data extracted from VHA treatment records of all individuals receiving VHA services in fiscal year 2008 (N=5,195,551). The associations between severe psychiatric disorders (schizophrenia and bipolar disorder) and chronic pain (arthritis, back pain, chronic pain, migraine, headache, psychogenic and neuropathic) were evaluated using a series of logistic regression analyses.

RESULTS

Veterans with schizophrenia [odds ratio (OR)=1.21] and bipolar disorder (OR=2.17) were significantly more likely to have chronic pain overall relative to veterans without these psychiatric conditions. These associations were slightly lower than for the association between depression and pain in this sample (OR=2.61). The highest associations between specific psychiatric diagnosis and pain condition were found with chronic pain, headache and psychogenic pain.

CONCLUSIONS

Noncancer pain conditions occur in elevated rates among patients with schizophrenia and bipolar disorder. Future research could further examine possible barriers to adequate pain treatment among people with serious mental illness, as well as the extent to which chronic pain might impact mental health recovery.

Self-reported pain complaints among Afghanistan/Iraq era men and women veterans with comorbid posttraumatic stress disorder and major depressive disorder

OBJECTIVE

Research has shown significant rates of comorbidity among posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and pain in prior era veterans but less is known about these disorders in Iraq and Afghanistan war era veterans. This study seeks to extend previous work by evaluating the association among PTSD, MDD, and pain (back, muscle, and headache pain) in this cohort.

METHOD

A sample of 1,614 veterans, recruited from 2005 to 2010, completed a structured clinical interview and questionnaires assessing trauma experiences, PTSD symptoms, depressive symptoms, and pain endorsement.

RESULTS

Veterans with PTSD endorsed pain-related complaints at greater rates than veterans without PTSD. The highest rate of pain complaints was observed in veterans with comorbid PTSD/MDD. Women were more likely to endorse back pain and headaches but no gender by diagnosis interactions were significant.

CONCLUSIONS

Findings highlight the complex comorbid relationship between PTSD, MDD, and pain among Iraq and Afghanistan veterans. This observed association suggests that integrated, multidisciplinary treatments may be beneficial, particularly when multiple psychological and physical health comorbidities are present with pain. Further support may be indicated for ongoing education of mental health and primary care providers about these co-occurring disorders.

Days with pain and substance use disorders: is there an association?

OBJECTIVES

We investigated possible associations between pain frequency and the 5 most common substance use disorders: alcohol abuse/dependence, cocaine abuse/dependence, methamphetamine abuse/dependence, opioid abuse/dependence, and marijuana abuse/dependence.

METHODS

We used data from the Rural Stimulant Study, a longitudinal (7 waves), observational study of at-risk stimulant users (cocaine and methamphetamine) in Arkansas and Kentucky (n=462). In fixed-effects logistic regression models, we regressed our measures of substance use disorders on the number of days with pain in the past 30 days and depression severity.

RESULTS

Time periods when individuals had 1 to 15 days [odds ratio (OR)=1.85, P<0.001] or 16+ days (OR=2.18, P<0.001) with pain in the past 30 days were more likely to have a diagnosis of alcohol abuse/dependence, compared with time periods when individuals had no days with pain. Compared with time periods when individuals had no pain days in the past 30 days, time periods when individuals had 16+ pain days were more likely to have a diagnosis of opioid abuse/dependence (OR=3.32, P=0.02). Number of days with pain was not significantly associated with other substance use disorders.

DISCUSSION

Pain frequency seems to be associated with an increased risk for alcohol abuse/dependence and opioid abuse/dependence in this population, and the magnitude of the association is medium to large. Further research is needed to investigate this in more representative populations and to determine causal relationships.

The relation between pain-related fear and disability: a meta-analysis

Within a biopsychosocial framework, psychological factors are thought to play an important role in the onset and progression of chronic pain. The cognitive-behavioral fear-avoidance model of chronic pain suggests that pain-related fear contributes to the development and maintenance of pain-related disability. However, investigations of the relation between pain-related fear and disability have demonstrated considerable between-study variation. The main goal of the current meta-analysis was to synthesize findings of studies investigating cross-sectional associations between pain-related fear and disability in order to estimate the magnitude of this relation. We also tested potential moderators, including type of measure used, demographic characteristics, and relevant pain characteristics. Searches in PubMed and PsycINFO yielded a total of 46 independent samples (N = 9,579) that reported correlations between pain-related fear and disability among persons experiencing acute or chronic pain. Effect size estimates were generated using a random-effects model and artifact distribution method. The positive relation between pain-related fear and disability was observed to be moderate to large in magnitude, and stable across demographic and pain characteristics. Although some variability was observed across pain-related fear measures, results were largely consistent with the fear-avoidance model of chronic pain.

PERSPECTIVE

Results of this meta-analysis indicate a robust, positive association between pain-related fear and disability, which can be classified as moderate to large in magnitude. Consistent with the fear-avoidance model of chronic pain, these findings suggest that pain-related fear may be an important target for treatments intended to reduce pain-related disability.

Psychiatric morbidity in pain conditions: results from the Singapore Mental Health Study

BACKGROUND

Chronic pain is a common problem among the general population and has been found to be associated with psychiatric disorders in studies based on both clinical samples and epidemiological surveys.

OBJECTIVES

To establish the prevalence, correlates and comorbidities of chronic pain disorders among the adult population of Singapore.

METHODS

The data used in the present analysis were derived from the Singapore Mental Health Study, a cross-sectional epidemiological survey of a representative sample of the adult resident population of Singapore. Diagnoses of psychiatric disorders were established using the Composite International Diagnostic Interview version 3.0. A modified version of the Composite International Diagnostic Interview 3.0 checklist of chronic medical disorders was used, in which the chronic medical disorders were reclassified into eight types of physical disorders. Chronic pain disorders included arthritis or rheumatism, back problems including disk or spine problems, and migraine headaches.

RESULTS

The lifetime prevalence estimates for arthritis, back pain and migraine in the Singapore general population were 6.0% (n=282), 7.0% (n=436) and 5.6% (n=446), respectively. After adjusting for sociodemographic factors, comorbid pain disorders and the presence of other chronic physical conditions, migraine remained significantly associated with major depressive disorder (adjusted OR=2.4), generalized anxiety disorder (adjusted OR=3.0) and alcohol use disorders (adjusted OR=2.1), while back pain was significantly associated with major depressive disorder (adjusted OR=2.0).

CONCLUSIONS

The significant association between pain and psychiatric disorders emphasizes the need to screen individuals with chronic pain conditions for psychiatric disorders, particularly depression. There is a need to develop integrated pharmacological and psychological treatments for both conditions.

Hermansky-Pudlak syndrome: health care throughout life

Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessive disease that displays genetic heterogeneity; there are 9 known subtypes. HPS is characterized by oculocutaneous albinism, a platelet storage pool deficiency and resultant bleeding diathesis, and lysosomal accumulation of ceroid lipofuscin. Patients with HPS, specifically those with the genotypes HPS-1, HPS-2, or HPS-4, are predisposed to interstitial lung disease. In addition, some patients with HPS develop granulomatous colitis. Optimal health care requires a thorough knowledge of the unique health risks and functional limitations associated with this syndrome.

Pain and use of alcohol in later life: prospective evidence from the health and retirement study

OBJECTIVE

To determine whether (a) late-life pain predicts growth in older adults' use of alcohol, and elevated risk of drinking problems; and (b) sociodemographic characteristics moderate these relationships.

METHOD

Five times over an 8-year interval, N = 5,446 Health and Retirement Study (HRS) participants provided information about their pain and alcohol use. Two-part latent growth modeling and logistic regression were used to analyze these data.

RESULTS

Participants with more pain at baseline had lower initial levels and a faster rate of decline over the next 8 years in alcohol consumption, but they also were at elevated risk of having drinking problems. Income and African American background interacted with pain to predict 8-year change in alcohol consumption and presence of drinking problems.

DISCUSSION

Late-life pain does not predict growth in older adults' alcohol consumption, but is nonetheless linked to elevated risk of drinking problems, especially among African Americans.

Psychiatric co-morbidities in patients with chronic peripheral neuropathic pain: a multicentre cohort study

BACKGROUND

Psychiatric co-morbidities are common in patients with chronic pain, but no data are available about their prevalence in patients with neuropathic pain.

METHODS

A multicentre study involving neurology practices (n = 30) and pain departments (n = 8) was conducted to assess the prevalence of lifetime and current anxiety and mood disorders on the basis of DSM-IV criteria in patients with peripheral neuropathic pain. Factors independently associated with such co-morbidity were also studied. A total of 182 consecutive patients (age 59.5 ± 13.8 years, 48% men) were recruited. Assessments included lifetime and current anxiety and mood disorders (Mini International Neuropsychiatric Interview), sleep (Medical Outcome Study sleep scale), pain interference (Brief Pain Inventory) and catastrophizing (Pain Catastrophizing Scale).

RESULTS

Lifetime and current prevalence of psychiatric co-morbidity were 39% and 20.3%, respectively, for any anxiety disorder, and 47.2% and 29.7%, respectively, for any mood disorder. The two most common psychiatric disorders were generalized anxiety (current prevalence 12.1%) and major depressive episode (current prevalence: 16.5%). Logistic regression analyses showed that high catastrophizing was the most significant variable independently associated with both current anxiety (OR = 4.21[1.4-12.7]; p = 0.04) and mood disorders (OR = 6.9[2.2-21]; p < 0.001).

CONCLUSIONS

Lifetime and current anxiety and mood disorders are highly prevalent in patients with peripheral neuropathic pain, and are associated with high levels of catastrophizing. Early management of catastrophizing may contribute to reducing the risk of psychiatric co-morbidities in these patients.

Chronic pain treatment: the influence of tricyclic antidepressants on serotonin release and uptake in mast cells

The involvement of serotonin (5-HT) in chronic pain mechanisms is established. 5-HT inhibits central painful stimuli, but recent data suggests that 5-HT could also enhance pain stimulus from the periphery, where mast cells play an important role. We aimed in our study to clarify the influence of selected tricyclic antidepressants (TCAs) on mast cell function: secretion, uptake, and reuptake of 5-HT, that could interfere with 5-HT levels and in this way contribute to the generation of pain. As an experimental model, we used isolated rat peritoneal mast cells and incubated them with selected TCAs (clomipramine, amitriptyline, doxepin, and imipramine) under different experimental conditions. 5-HT release, uptake, and reuptake were determined spectrofluorometrically. We showed that TCAs were able to inhibit 5-HT secretion from mast cells, as well as uptake of exogenous 5-HT and reuptake of secreted 5-HT back into mast cells. The effects of TCAs were concentration dependent; higher concentrations of TCAs inhibited the secretion of 5-HT induced by compound 48/80, whereas lower concentrations of TCAs inhibited 5-HT uptake. The most effective TCA was halogenated clomipramine. As TCAs are well introduced in chronic pain treatment, the insight into mechanisms of action is important for an understanding of their effect in various pain conditions.

Anxiety and depression are associated with migraine and pain in general: an investigation of the interrelationships

There is a well-established comorbidity between migraine and anxiety and depression (A/D). Here, we investigate whether this relationship is specific for migraine and A/D or whether other types of pain are also consistently associated with A/D. In addition, we test whether there is a consistent association between migraine and other types of pain when comorbidity with A/D is controlled for. Data on A/D, migraine, and 6 nonheadache pain locations (back, neck, orofacial area, abdomen, joints, and chest) were analyzed in 2,981 participants from the Netherlands Study of Depression and Anxiety (NESDA). It was tested whether the prevalence of pain in each individual location, as well as the total number of pain locations, depended on A/D and migraine status. A/D was consistently associated with pain in all measured locations. Migraine was also associated with pain in all anatomical sites, but these associations weakened substantially after correction for A/D severity, suggesting that a considerable part of the comorbidity of migraine and other types of pain may be explained by A/D. These findings emphasize the importance of accounting for A/D in studies of pain comorbidity. This will contribute to a better understanding of the mechanisms underlying A/D and pain.

PERSPECTIVE

Anxiety and depression are consistently associated with pain, regardless of anatomical site. These disorders may be important factors in the co-occurrence of different pain disorders. Awareness of this comorbidity and a better understanding of the underlying mechanisms may facilitate adequate treatment of both types of conditions.

Factors associated with generalized anxiety in workers undergoing work rehabilitation for persistent musculoskeletal pain

PURPOSE

To document in workers having a work disability due to a musculoskeletal disorder (MSD), the presence and variation over time of their intolerance of uncertainty and its maintenance factors as defined in Dugas et al.'s generalized anxiety disorder (GAD) model, i.e. worries, negative problem orientation, beliefs about the usefulness of worrying, cognitive avoidance and their consequences on depressive symptoms.

METHODS

An observational, prospective repeated-measures design was retained. Thirty-nine workers with an MSD having caused a work absence of over three months and who were beginning a work rehabilitation program were recruited and evaluated at four moments (beginning of rehabilitation program, first hours of work exposure, 50% of regular working hours and end of rehabilitation program). Validated self-report questionnaires measuring intolerance of uncertainty and its maintenance factors were administered. Finally, the Worry and Anxiety Questionnaire measured the presence and intensity of GAD symptoms as defined in the DSM-IV-TR.

RESULTS

Fifty percent of the workers initially exhibited GAD symptoms. Concerning the variation over time, improvements were noted in all GAD-related factors during the program, particularly with the first hours of work exposure. At the end of rehabilitation, only 21% of the participants still met GAD diagnostic criteria.

CONCLUSION

Workers with an MSD causing a work disability averaging one year in length and enrolled in a work rehabilitation program exhibited a high level of anxiety at the beginning of the work rehabilitation program. Workers perceived a usefulness in worrying and presented some intolerance of uncertainty and some cognitive avoidance strategies. According to Dugas et al.'s GAD model, the intensity of the symptoms associated with GAD development and maintenance factors was, however, not typical of a GAD. IMPLICATION FOR REHABILITATION: A reconceptualization of the problem in terms of reducing the work disability rather than reducing pain may constitute a promising avenue to reduce anxiety symptoms. Future studies should look at the specific impact of work exposure, not only on pain symptoms but also on worries. The high level of anxiety and the reported worries by workers stresses the importance of studying the hypothesis of a workplace phobia in order to improve clinical practice guidelines.

Depression symptoms and chronic pain in the community population in Beijing, China

We explore the association of depressive symptoms and chronic pain (arthritis, back or neck pain, headache, or other pain) in a community population of Beijing, China. Two thousand four hundred and sixty nine residents aged 16 years and older were investigated in 2010. Data were collected from face-to-face interviews using the Composite International Diagnostic Interview-3rd version. The presence of chronic pain condition and depressive symptoms were analyzed using univariate and multivariate analysis methods. We found a 12-month prevalence of MDD (Major depressive disorder) at 3.28%. Nearly half (41.01%) of respondents with depressive symptoms also had at least one chronic pain condition, and 64.20% of subjects with MDD (Major depressive disorder) experienced at least one chronic pain. After adjusting for selected demographic variables, it was found by multivariate logistic regression analysis that depressive symptom without MDD was significantly associated with back-or neck pain (Adjusted odds ratio (AOR)=1.97, 95% CI, 1.34-2.90), headache (AOR=3.17, 95% CI, 1.81-5.58), and other chronic pain (AOR=2.21, 95% CI, 1.07-4.49). MDD was significantly associated with arthritis (AOR=2.23) back or neck pain (AOR=4.17), headache (AOR=3.16), and other chronic pain (AOR=3.51). Multiple types of chronic pain are associated with depressive symptoms and MDD. Future studies are needed to infer causality.

"Push" versus "Pull" for mobilizing pain evidence into practice across different health professions: a protocol for a randomized trial

BACKGROUND

Optimizing pain care requires ready access and use of best evidence within and across different disciplines and settings. The purpose of this randomized trial is to determine whether a technology-based "push" of new, high-quality pain research to physicians, nurses, and rehabilitation and psychology professionals results in better knowledge and clinical decision making around pain, when offered in addition to traditional "pull" evidence technology. A secondary objective is to identify disciplinary variations in response to evidence and differences in the patterns of accessing research evidence.

METHODS

Physicians, nurses, occupational/physical therapists, and psychologists (n = 670) will be randomly allocated in a crossover design to receive a pain evidence resource in one of two different ways. Evidence is extracted from medical, nursing, psychology, and rehabilitation journals; appraised for quality/relevance; and sent out (PUSHed) to clinicians by email alerts or available for searches of the accumulated database (PULL). Participants are allocated to either PULL or PUSH + PULL in a randomized crossover design. The PULL intervention has a similar interface but does not send alerts; clinicians can only go to the site and enter search terms to retrieve evidence from the cumulative and continuously updated online database. Upon entry to the trial, there is three months of access to PULL, then random allocation. After six months, crossover takes place. The study ends with a final three months of access to PUSH + PULL. The primary outcomes are uptake and application of evidence. Uptake will be determined by embedded tracking of what research is accessed during use of the intervention. A random subset of 30 participants/ discipline will undergo chart-stimulated recall to assess the nature and depth of evidence utilization in actual case management at baseline and 9 months. A different random subset of 30 participants/ discipline will be tested for their skills in accessing evidence using a standardized simulation test (final 3 months). Secondary outcomes include usage and self-reported evidence-based practice attitudes and behaviors measured at baseline, 3, 9, 15 and 18 months.

DISCUSSION

The trial will inform our understanding of information preferences and behaviors across disciplines/practice settings. If this intervention is effective, sustained support will be sought from professional/health system initiatives with an interest in optimizing pain management.

TRIAL REGISTRATION

Registered as NCT01348802 on clinicaltrials.gov.

Diagnoses of Patients with Severe Subjective Health Complaints in Scandinavia: A Cross Sectional Study

Background. A diagnosis is the basis of medical action, the key to various social privileges and national sick leave statistics. The objectives of this study were to investigate which diagnoses general practitioners in Scandinavia give patients with severe subjective health complaints, and what kind of treatments they suggested. Methods. One hundred and twenty-six self-selected general practitioners in Scandinavia diagnosed nine patients, presented as video vignettes, in a cross-sectional study. The main outcome measures were primary, secondary, and tertiary diagnoses. Results. The nine patients got between 13 and 31 different primary diagnoses and a large variety of secondary and tertiary diagnoses. Fifty-eight percent of the general practitioners chose different primary and secondary diagnoses, indicating that they judged the patients to have multimorbid complaints. The most commonly recommended treatment was referral to a psychologist, a mix of psychological and physical treatments, or treatment by the general practitioner. Conclusion. Scandinavian general practitioners give a large variety of symptom diagnoses, mainly psychological and general and unspecified, to patients with severe subjective health complaints. Referral to a psychologist or a mix of psychological or physical treatments was most commonly suggested to treat the patients.

Hypertension prevalence and diminished blood pressure-related hypoalgesia in individuals reporting chronic pain in a general population: the Tromsø study

Resting blood pressure (BP) is inversely related to pain sensitivity in individuals free of chronic pain, reflecting homeostatic interactions between cardiovascular and pain modulatory systems. Several laboratory studies indicate that BP-related hypoalgesia is diminished in chronic pain patients, suggesting dysfunction in these interacting systems. Separate epidemiological findings reveal elevated hypertension prevalence in the chronic pain population. This study for the first time simultaneously evaluated both hypertension prevalence and BP-related hypoalgesia as they relate to chronic pain in the same sample. Resting BP and pain sensitivity were evaluated in a large general population sample (n=10,135, aged 30-87years). Subjects participated in a standardized 106s cold pressor test, providing pain ratings at 9s intervals. Self-reported presence of chronic pain and history of hypertension and use of antihypertensive medication were assessed. Significant interactions between chronic pain status and resting systolic (P<.001) and diastolic BP (P<.001) on mean pain ratings were observed. These interactions were due to significant (P<.001) BP-related hypoalgesia in individuals free of chronic pain that was twice the magnitude of the hypoalgesia observed in the group reporting chronic pain. Presence of chronic pain was associated with significantly increased odds of comorbid hypertension (P<.001). Within the chronic pain group, higher chronic pain intensity was a significant predictor of positive hypertension status beyond the effects of traditional demographic risk factors (P<.05). Results are consistent with the hypothesis that increased hypertension risk in the chronic pain population might be linked in part to chronic pain-related dysfunction in interacting cardiovascular-pain modulatory systems.

Comparing the effects on work performance of mental and physical disorders

OBJECTIVE

To estimate work loss days due to absenteeism and presenteeism associated with commonly occurring mental and physical disorders.

METHODS

In a nationally representative face-to-face survey (Netherlands Mental Health Survey and Incidence Study-2) including 4,715 workers, the presence of 13 mental and 10 chronic physical disorders was assessed using the Composite International Diagnostic Interview 3.0 and a physical disorder checklist. Questions about absent days due to illness and days of reduced quantitative and qualitative functioning while at work were based on the WHO Disability Assessment Schedule. Total work loss days were defined as the sum of the days of these three types of loss, where days of reduced functioning were counted as half. Both individual and population-level effects of disorders on work loss were studied, taking comorbidity into account.

RESULTS

Any mental disorder was associated with 10.5 additional absent days, 8.0 days of reduced-qualitative functioning and 12.0 total work loss days. For any physical disorder, the number of days was 10.7, 3.5 and 11.3, respectively. Adjusted for comorbidity, drug abuse, bipolar disorder, major depression, digestive disorders and panic disorder were associated with the highest number of additional total work loss days. At population-level, major depression, chronic back pain, respiratory disorders, drug abuse and digestive disorders contributed the most. Annual total work loss costs per million workers were estimated at <euro>360 million for any mental disorder; and <euro>706 million for any physical disorder.

CONCLUSIONS

Policies designed to lessen the impact of commonly occurring disorders on workers will contribute to a reduction in absenteeism and presenteeism. As the indirect costs of (mental) disorders are much higher than their medical costs, prevention and treatment of these conditions may be cost-effective.

Patient age is related to the types of physical therapy interventions provided for chronic low back pain: an observational study

STUDY DESIGN

Retrospective analysis of a longitudinal cohort of patients treated for chronic low back pain (CLBP).

OBJECTIVES

To determine whether patient age is associated with types of physical therapy interventions received for CLBP.

BACKGROUND

Advancing age is associated with less positive treatment outcomes in patients with CLBP. If patient age influences a therapist's choice of interventions, it may partially explain the difference in treatment outcomes.

METHODS

Data were examined in a sample of 7392 patients (62% women, 38% men; mean ± SD age, 56.7 ± 16.5 years) with CLBP. We used a generalized estimating equation to examine the probability of each subject receiving each of the individual intervention categories in the presence of the other intervention categories.

RESULTS

A significant interaction between intervention category and age existed after controlling for gender, duration of symptoms, comorbidities, payer source, and functional status at initial intake (χ(2) = 130.27, df = 8, P<.0001). The changes in probability of receiving an intervention category averaged 10% as patient age increased. The probability of receiving exercise or task-specific training did not change with advancing age. The probability of receiving postural exercises, pain modalities, joint mobility techniques, ice, or McKenzie exercises decreased with advancing age. The probability of receiving augmented soft tissue mobilization and balance/mobility training increased as age increased.

CONCLUSION

The impact of age on physical therapist treatment choices varies depending on the type of intervention. Other variables in addition to age may have an impact on treatment choice. Further research is needed to determine how therapists incorporate age into their clinical decision making.

Personality traits and life dissatisfaction as risk factors for disability pension due to low back diagnoses: a 30-year longitudinal cohort study of Finnish twins

OBJECTIVE

Little is known about the association of mild symptoms and mental well-being with risk of disability pension (DP) due to somatic diagnoses, even less for DP due to low back diagnoses (LBD). Moderate genetic influences on personality traits, life dissatisfaction and DP exist suggesting that shared genetic influences may underlie these associations. One can control for familial confounding (genetics and family environment) by examining twins. This twin study aimed to investigate personality traits and life dissatisfaction as predictors for DP due to LBD accounting for familial confounding.

METHODS

Data on 24043 twins aged 18-65year in a baseline survey in 1975 was followed up from national DP register data until 2004. Personality traits were assessed using the short version of the Eysenck Personality Inventory and life dissatisfaction was measured with a four item scale on levels of interest, happiness, easiness, and loneliness of life. Cox proportional hazards regression was used to calculate hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

DP due to LBD was granted to 537 individuals during the follow-up. Each one unit increase in life dissatisfaction (HR 1.06; 95%CI 1.03, 1.10) and neuroticism (1.07; 1.03, 1.10) but not extroversion was significantly associated with an elevated risk for DP due to LBD. These associations with life dissatisfaction and neuroticism remained when socioeconomic status, education, and marital status were taken into account, and demonstrated an independence from familial confounding.

CONCLUSION

Life dissatisfaction and neuroticism seems to be early, perhaps causal risk factors for DP due to LBD.

Functional disability among chronic pain patients receiving long-term opioid treatment

This study of 2,163 adult chronic, non-cancer-pain, long-term opioid therapy patients examines the relationship of depression to functional disability by measuring average pain interference, activity limitation days, and employment status. Those with more depression symptoms compared to those with fewer were more likely to have worse disability on all 3 measures (average pain interference score >5, OR = 5.36, p < .0001; activity limitation days ≥ 30, OR = 4.05, p < .0001; unemployed due to health reasons, OR = 4.06, p < .0001). Depression might play a crucial role in the lives of these patients; identifying and treating depression symptoms in chronic pain patients should be a priority.

Alcohol dependence as a chronic pain disorder

Dysregulation of pain neurocircuitry and neurochemistry has been increasingly recognized as playing a critical role in a diverse spectrum of diseases including migraine, fibromyalgia, depression, and PTSD. Evidence presented here supports the hypothesis that alcohol dependence is among the pathologies arising from aberrant neurobiological substrates of pain. In this review, we explore the possible influence of alcohol analgesia and hyperalgesia in promoting alcohol misuse and dependence. We examine evidence that neuroanatomical sites involved in the negative emotional states of alcohol dependence also play an important role in pain transmission and may be functionally altered under chronic pain conditions. We also consider possible genetic links between pain transmission and alcohol dependence. We propose an allostatic load model in which episodes of alcohol intoxication and withdrawal, traumatic stressors, and injury are each capable of dysregulating an overlapping set of neural substrates to engender sensory and affective pain states that are integral to alcohol dependence and comorbid conditions such as anxiety, depression, and chronic pain.

Hybrid cognitive-behaviour therapy for individuals with insomnia and chronic pain: a pilot randomised controlled trial

OBJECTIVE

Insomnia is a debilitating comorbidity of chronic pain. This pilot trial tested the utility of a hybrid treatment that simultaneously targets insomnia and pain-related interference.

METHODS

Chronic pain patients with clinical insomnia were randomly allocated to receive 4 weekly 2-h sessions of hybrid treatment (Hybrid Group; n = 10) or to keep a pain and sleep diary for 4 weeks, before receiving the hybrid treatment (Monitoring Group; n = 10). Participants were assessed at the beginning and end of this 4-week period. Primary outcomes were insomnia severity and pain interference. Secondary outcomes were fatigue, anxiety, depression and pain intensity. Ancillary information about the hybrid treatment's effect on psychological processes and sleep (as measured with sleep diary and actigraphy) are also presented, alongside data demonstrating the treatment's clinical significance, acceptability and durability after one and six months. Data from all participants (n = 20) were combined for this purpose.

RESULTS

Compared to symptom monitoring, the hybrid intervention was associated with greater improvement in sleep (as measured with the Insomnia Severity Index and sleep diary) at post-treatment. Although pain intensity did not change, the Hybrid Group reported greater reductions in pain interference, fatigue and depression than the Monitoring Group. Overall, changes associated with the hybrid intervention were clinically significant and durable at 1- and 6-month follow-ups. Participants also rated highly on treatment acceptability.

CONCLUSION

The hybrid intervention appeared to be an effective treatment for chronic pain patients with insomnia. It may be a treatment approach more suited to tackle challenges presented in clinical practice, where problems seldom occur in isolation.

The effectiveness of physiotherapy functional restoration for post-acute low back pain: a systematic review

BACKGROUND

The effectiveness of multidisciplinary treatment for post-acute (>6 weeks) low back pain (LBP) has been established. Physiotherapists have sufficient training to conduct less intensive functional restoration. The effectiveness of physiotherapy functional restoration (PFR) has not been evaluated using current systematic review methodology.

OBJECTIVES

To determine the effects of PFR for post-acute LBP.

DATA SOURCES

Electronic databases searched include: MEDLINE, EMBASE, CINAHL, PsycINFO, PEDro and Cochrane CENTRAL. TRIAL ELIGIBILITY CRITERIA: Randomised controlled trials of physiotherapy treatment for post-acute LBP combining exercise and cognitive-behavioural intervention compared with other intervention, no intervention or placebo. TRIAL APPRAISAL AND SYNTHESIS METHODS: Two authors independently extracted data. Risk of bias was assessed using the PEDro scale and overall quality of the body of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Treatment effect sizes and 95% confidence intervals were calculated for pain, function and sick leave.

RESULTS

Sixteen trials were included. Heterogeneity prevented meta-analysis for most comparisons. Meta-analyses showed moderate to high quality evidence of significant but small effects favouring PFR compared with advice for intermediate term function and intermediate and long term pain. There was however low to moderate quality evidence that PFR was no more effective than a range of other treatment types. Heterogeneous trials frequently contributed to very low quality evidence.

CONCLUSIONS

Moderate to high quality evidence was found of small effects favouring PFR compared with advice. Preliminary evidence suggested PFR is not different to other treatment types. Further high quality research is required replicating existing trial protocols.

Predictors of change in pain and physical functioning among post-menopausal women with recurrent pain conditions in the women's health initiative observational cohort

Pain complaints are commonly reported symptoms among postmenopausal women and can have significant effects on health-related quality of life. We sought to identify medical and psychosocial factors that predict changes in pain and overall physical functioning over a 3-year period among postmenopausal women with recurrent pain conditions. We examined data from postmenopausal women age 50 to 79 with recurrent pain conditions (low back pain, neck pain, headache or migraines, or joint pain or stiffness) over a 3-year period using the Women's Health Initiative Observational Study Cohort (N = 67,963). Multinomial logistic regression models controlling for demographic and clinical characteristics were used to identify baseline predictors of change in the SF-36 subscales for pain and physical functioning between baseline and 3-year follow-up. Body mass index (BMI) was associated with worsening of pain (OR [95% CI] 1.54 [1.45-1.63] for BMI ≥30) and physical functioning (1.83 [1.71-1.95] for BMI ≥30). A higher reported number of nonpain symptoms, higher medical comorbidity, and a positive screen for depression (1.13 [1.05-1.22] for worsened pain) were also associated with worsening of pain and physical functioning. Baseline prescription opioid use was also associated with lack of improvement in pain (OR .42, 95% CI .36-.49) and with worsened physical functioning (1.25 [1.04-1.51]).

PERSPECTIVE

This study presents prospective data on change in pain and physical functioning in postmenopausal women over a 3-year period. Our results suggest depression, nonpain physical symptoms, obesity, and possibly opioid treatment are associated with worse long-term pain outcomes in this population.

What facilitates return to work? Patients' experiences 3 years after occupational rehabilitation

OBJECTIVE

We have limited knowledge about the specific elements in an occupational rehabilitation programme that facilitate the process leading to return to work (RTW) as perceived by the patients. The aim of the study was to explore individual experiences regarding contributing factors to a successful RTW, 3 years after a resident occupational rehabilitation programme.

METHODS

The study is based on interviews of 20 individuals who attended an occupational rehabilitation programme 3 years earlier. Ten informants had returned to work (RTW) and ten were receiving disability pension (DP). Data were analysed by systematic text condensation inspired by Giorgi's phenomenological analysis.

RESULTS

The core categories describing a successful RTW process included positive encounters, increased self-understanding and support from the surroundings. While the informants on DP emphasized being seen, heard and taken seriously by the professionals, the RTW group highlighted being challenged to increase self-understanding that promoted new acting in every-day life. Being challenged on self-understanding implied increased awareness of own identity, values and resources. Support from the surroundings included support from peer participants, employer and social welfare system.

CONCLUSION

Successful RTW processes seem to comprise positive encounters, opportunities for increased self-understanding and support from significant others. An explicit focus on topics like identity, own values and resources might improve the outcome of the rehabilitation process.