The role of perceived injustice in the experience of chronic pain and disability: scale development and validation

Understanding the association between perceived injustice, depression symptoms, and stigma in individuals with traumatic spinal cord injury

STUDY DESIGN

This is a secondary analysis of data from a cross-sectional, observational study.

OBJECTIVES

The study aimed to determine whether stigma mediates the relationship between preceived injustice and depression symptoms among individuals with spinal cord injuries.

SETTING

Secondary analysis of participants enrolled in the Spinal Cord Injury Model System at a specialty rehabilitation hospital in the Western United States.

METHODS

A sample of 225 participants completed the questionnaires; eight participants were removed due to incomplete data, resulting in a final sample size of 217 participants (79% male; 21% female). Participants were, on average, 53 years old and were predominantly male, white, and 20 years post-injury. A bootstrapping mediation analysis was conducted to evaluate the stigma-mediated relationship between injustice appraisals and depression symptoms. Injustice appraisals were assessed using the Injustice Experience Questionnaire, stigma with the Spinal Cord Injury Quality of Life Stigma-Short Form, and depression symptoms with the Patient Health Questionnaire-9.

RESULTS

Stigma was found to mediate the relationship between injustice appraisals and depression, with an estimated proportion mediated of 80.9% (p ≤ 0.0001).

CONCLUSIONS

This study provides a novel finding that the relationship between injustice appraisals and depression symptoms is mediated by stigma. Consistent with previous research, injustice appraisals were associated with greater severity of depression symptoms. Results provide further evidence for the role of injustice appraisals after spinal cord injury and a potential mechanism (i.e., stigma) by which it may exert its effect on depression symptoms.

The impact of perceived injustice on pain and psychological outcomes after traumatic injury: a longitudinal analysis

ABSTRACT

Individuals' appraisals regarding the injustice of their pain or physical injury have emerged as a significant risk factor for worse physical and psychological outcomes. Injustice appraisals are defined by perceptions of external blame for pain or injury and viewing pain or injury as a source of irreparable loss. To date, research on the impact of injustice appraisal has been primarily cross sectional, and existing longitudinal studies have examined injustice appraisals at only 2 time points in the context of rehabilitation treatment. This study examined the trajectory of injustice appraisals in 171 patients admitted for traumatic injury at admission, as well as 3, 6, and 12 months after discharge and examined injustice appraisals as a potential moderator of recovery after injury. Findings can be summarized as follows: First, injustice perception was largely stable in the 12 months after hospital discharge. Second, elevated injustice perception was associated with decreased recovery in pain intensity and depressive symptomatology over the study period but did not moderate changes in pain catastrophizing or posttraumatic stress symptomatology over time. This study is the first naturalistic prospective analysis of injustice appraisal following trauma admission within the American healthcare system. Findings indicate that injustice appraisals do not naturally decrease in the aftermath of traumatic injury and may be a risk factor for poorer physical and psychological recovery. Future research should examine additional sociodemographic and psychosocial factors that may contribute to elevated injustice appraisal, as well as ways of addressing the potential deleterious impact of injustice appraisals in treatment settings.

Associations between pain intensity, psychosocial factors, and pain-related disability in 4285 patients with chronic pain

Pain, a widespread challenge affecting daily life, is closely linked with psychological and social factors. While pain clearly influences daily function in those affected, the complete extent of its impact is not fully understood. Given the close connection between pain and psychosocial factors, a deeper exploration of these aspects is needed. In this study, we aim to examine the associations between psychosocial factors, pain intensity, and pain-related disability among patients with chronic pain. We used data on 4285 patients from the Oslo University Hospital Pain Registry, and investigated pain-related disability, pain intensity, pain catastrophizing, psychological distress, perceived injustice, insomnia, fatigue, and self-efficacy. We found significant associations between all psychosocial variables and pain-related disability, even after adjusting for demographic factors. In the multiple regression model, sleep problems and pain intensity were identified as primary contributors, alongside psychological distress, and fatigue. Combined, these factors accounted for 26.5% of the variability in pain-related disability, with insomnia and pain intensity exhibiting the strongest associations. While the direction of causation remains unclear, our findings emphasize the potential of interventions aimed at targeting psychosocial factors. Considering the strong link between psychosocial factors and pain-related disability, interventions targeting these factors-particularly insomnia-could reduce disability and enhance quality of life in those who suffer.

Perceived Injustice and Anger in Fibromyalgia With and Without Comorbid Mental Health Conditions: A Hebrew Validation of the Injustice Experience Questionnaire

OBJECTIVES

Perceived injustice (PI), assessed by the Injustice Experience Questionnaire (IEQ), is an important trigger of anger. Both PI and anger are associated with adverse chronic pain outcomes, and with comorbid mental health severity. We aimed examined the roles of PI and anger in mediating pain across Fibromyalgia patients, with and without comorbid anxiety/depression (FM+A/D, FM-A/D, respectively), as well as rheumatoid arthritis (RA), and pain-free controls (PFC). We hypothesized the highest levels of PI, anger, and pain in FM+A/D patients, followed by FM-A/D, RA, and PFC, thus also validating a Hebrew version of the IEQ.

METHODS

We translated the IEQ using the forward-backward method and collected data online. Based on self-reported anxiety/depression, the sample comprised 66 FM+A/D patients, 64 FM-A/D, 34 RA, and 32 PFCs. Assessments included the IEQ, state and trait anger, pain intensity, anxiety, depression, and pain catastrophizing. The structure and reliability of the Hebrew IEQ were examined using factor analysis and Cronbach alpha. Bootstrapped-based modeling was used to test the roles of state and trait anger in mediating and moderating the relationship between PI and pain intensity.

RESULTS

We confirmed a one-factor structure of the IEQ, with excellent reliability. FM+A/D patients demonstrated the highest scores in all measures. Within this group, trait anger moderated the mediating effect of state anger in the relationship between PI and pain intensity.

DISCUSSION

Our findings validate a Hebrew IEQ and highlight the importance of PI and state and trait anger in the differential manifestation of mental health comorbidity in FM.

Comparison Between Disability, Physical Performance, and Other Biopsychosocial Factors in Full-Duty Career Firefighters Working With and Without Current Low Back Pain

INTRODUCTION

Low back pain (LBP) is highly prevalent and a top cause of disability-related early retirement in firefighters. Those with a lifetime history of LBP have various deficiencies that are associated with increased injury risk and absenteeism. However, the influence of working with current LBP on disability, physical performance, and other biopsychosocial factors has not been fully characterized in this population. The purpose of this study was to compare anthropometric measures, exercise habits, physical fitness/performance, disability/work ability, and other biopsychosocial factors of firefighters working with and without current LBP.

METHODS

A cross-sectional study was conducted using baseline assessments from 419 full-duty career firefighters without documented work restrictions (age: 37.6 ± 8.8 y; 5 F, 414 M) who were enrolled in a regional wellness initiative in Southern California, USA. Current LBP status was determined by a questionnaire and confirmed by an interview. Anthropometric measures, patient-reported outcomes, and physical fitness tests were used to assess body mass index; body fat %; waist circumference; strengthening, cardiovascular, and flexibility exercise frequency; back and core muscular endurance; functional movement quality, perceived back-related disability, lift and carry ability, and firefighter task ability; sleep quality; and perceptions of fear and fatigue and catastrophic injustice experience. Scores for participants with and without current LBP were compared using analysis of variance and chi-square analysis.

RESULTS

The point prevalence of current LBP was 19.81% (83/419). For the entire cohort, those with current LBP had significantly worse scores than those without current LBP for all assessed variables, except core muscular endurance and functional movement quality. These trends held up when analyses were stratified by age and obesity categories, and approximately half of the comparisons retained statistical significance. A significantly greater percentage of participants with current LBP were working with some level of back-related disability and/or perceived physical demand characteristics of work level below the required very heavy job demands.

CONCLUSION

Nearly one-fifth of full-duty career firefighters without documented work restrictions reported having current LBP, and these individuals had deficits in several modifiable biopsychosocial factors across five health domains. These findings can help guide future research and implementation efforts in the fire service designed to improve performance, resiliency, work readiness, recovery, and quality of life, as well as to reduce impairment, disability, and absenteeism and increase presenteeism.

Incarcerated Men: Pain Experiences Shaped by Altered Independence and Loss of Autonomy

BACKGROUND

Individuals experiencing pain while incarcerated depend on nurses, security structures, processes, and regulations for relief.

PURPOSE

The intent of this research was to understand men's experience of pain during incarceration to inform correctional nursing practice.

METHOD

Interpretive description, co-positioned with relational ethics, guided this study. Twelve incarcerated men participated in a single 1-hour interview that was audio-recorded and transcribed. The resultant text was analyzed for themes.

FINDINGS

The two main themes were dependence on staff and institutional processes and dependence on oneself and others who were incarcerated. Participants reported a substantial loss in their ability to access pain-relieving medications, products, and services. Unresponsive or delayed pain-relieving interventions from nurses contributed to their sense of indignity, disrespect, and injustice. The participants employed whatever was available, mainly exercise equipment and social support, to manage their pain.

DISCUSSION

Nurses must engage with incarcerated patients meaningfully to understand and respond to contextual factors that influence their pain experiences. Participants identified loss of autonomy and dependence on nurses as barriers to their pain relief.

CONCLUSION

Nurse engagement and responsiveness are crucial to altering incarcerated men's perceptions of injustice or helplessness while improving their pain experiences. Nurses must also foster autonomous pain-management approaches that men can use without limitations within correctional settings.

Perceived injustice: a historical and clinical review of a useful concept for psychiatry

OBJECTIVE

Perceived injustice, a concept that arose in pain medicine, refers to an individual's experiences and perceptions of victimisation from injuries resulting in chronic pain. Here, we have undertaken a historical and clinical review on the role of perceived injustice medicine in psychiatry and a systematic review on psychotherapeutic interventions for perceived injustice.

METHOD

For the systematic review, two studies were identified from a search of six databases.

RESULTS

Though evidence is limited, psychotherapeutic interventions show promise in addressing perceived injustice and associated symptomatology.

CONCLUSION

Perceived injustice is a concept which may have great potential utility to psychiatry, particularly in occupational and medicolegal areas. Interventions addressing perceived injustice may help improve clinical outcomes.

Effect of perceived injustice-targeted pain neuroscience education compared with biomedically focused education in breast cancer survivors: a study protocol for a multicentre randomised controlled trial (BCS-PI trial)

INTRODUCTION

Current treatments for pain in breast cancer survivors (BCSs) are mostly biomedically focused rather than biopsychosocially driven. However, 22% of BCSs with pain are experiencing perceived injustice, which is a known predictor for adverse pain outcomes and opioid prescription due to increased maladaptive pain behaviour. Educational interventions such as pain neuroscience education (PNE) are suggested to target perceived injustice. In addition, motivational interviewing can be an effective behavioural change technique. This trial aims to examine whether perceived injustice-targeted PNE with the integration of motivational interviewing is superior to biomedically focused pain education in reducing pain after 12 months in BCS with perceived injustice and pain. In addition, improvements in quality of life, perceived injustice and opioid use are evaluated, and a cost-effectiveness analysis will finally result in a recommendation concerning the use of perceived injustice-targeted PNE in BCSs with perceived injustice and pain.

METHODS AND ANALYSIS

This two-arm multicentre randomised controlled trial will recruit female BCS (n=156) with pain and perceived injustice. Participants will be randomly assigned to perceived injustice-targeted PNE or biomedically focused pain education in each centre. Both interventions include an online session, an information leaflet and three one-to-one sessions. The primary outcome (pain), secondary outcomes (quality of life, perceived injustice and outcomes for cost-effectiveness analysis) and explanatory outcomes (pain phenotyping, sleep, fatigue and cognitive-emotional factors) will be assessed at baseline and at 0, 6, 12 and 24 months postintervention using self-reported questionnaires online. Treatment effects over time will be evaluated using linear mixed model analyses. Additionally, a cost-utility analysis will be done from a healthcare payer and societal perspective.

ETHICS AND DISSEMINATION

The ethical agreement was obtained from the Main Ethics Committee (B.U.N.1432020000068) at the University Hospital Brussels and all other participating hospitals. Study results will be disseminated through presentations, conferences, social media, press and journals.

TRIAL REGISTRATION NUMBER

NCT04730154.

Pain and the Non-Pharmacological Management of Pain in People with Parkinson's Disease

Pain is a distressing and universal experience, yet everyone's pain experience is influenced by a complex array of biological, psychological, and social factors. For people with Parkinson's disease (PwP), these biopsychosocial factors include neurodegeneration and the psychological and social factors that accompany living with a chronic, neurodegenerative condition in addition to the factors experienced by those in the general population (e.g., living with co-morbidities such as osteoarthritis). The way these factors influence each individual is likely to determine which pain management strategies are optimal for them. This review first describes pain and the biopsychosocial model of pain. It explores how pain is classified in Parkinson's disease (PD) and describes the three main types of pain: nociceptive, neuropathic, and nociplastic pain. This background provides context for a discussion of non-pharmacological pain management strategies that may aid in the management of pain in PwP; exercise, psychological strategies, acupuncture and massage. While there is little PD-specific research to inform the non-pharmacological management of pain, findings from current PD research are combined with that from chronic pain research to present recommendations for clinical practice. Recommendations include assessment that incorporates potential biopsychosocial contributors to pain that will then guide a holistic, multi-modal approach to management. As exercise provides overall benefits for PwP, those with chronic pain should be carefully monitored with exercise prescribed and adjusted accordingly. Research is needed to develop and evaluate multi-modal approaches to pain management that are delivered in a biopsychosocial framework.

Race, Ethnicity, and Belief in a Just World: Implications for Chronic Pain Acceptance Among Individuals with Chronic Low Back Pain

Chronic pain acceptance is a psychological process consistently linked with improved functional outcomes. However, existing research on this construct has not considered the role of racial or ethnic background, despite growing evidence of racialized disparities in pain experience and treatment. This study aimed to examine racial differences in chronic pain acceptance, as measured by the chronic pain acceptance questionnaires (CPAQ), in a multicultural sample of individuals with chronic low back pain (N = 137-37.2% White, 31.4% Hispanic, and 31.4% Black/African American). We further sought to examine moderating effects of discrimination, pain-related perceived injustice (PI), and just world belief (JWB). Analyses consisted of cross-sectional one-way analyses of variance with Bonferroni-corrected post hoc comparisons, followed by regression models with interaction terms, main effects, and relevant covariates. Results indicated higher scores on the CPAQ for White individuals compared to Black or Hispanic individuals. Significant interactions were noted between race/ethnicity and JWB in predicting pain acceptance, after controlling for demographic and pain-related variables, such that the positive association between JWB and pain acceptance was significant for White participants only. Race/ethnicity did not show significant interactions with PI or prior racial discrimination. Findings highlight racial differences in levels of chronic pain acceptance, an adaptive pain coping response, and a stronger JWB appears to have a positive impact on pain acceptance for White individuals only. Results further confirm that members of disadvantaged racial groups may be more susceptible to poorer pain adjustment, which is the result of complex, multi-level factors. PERSPECTIVE: This study identifies racial differences in levels of pain acceptance, an adaptive psychological response to chronic pain, such that White individuals with chronic low back pain demonstrate higher levels of pain acceptance. The article further explores the impacts of intrapersonal and sociocultural variables on racial differences in pain acceptance.

Recommended approaches to assessing and managing physiotherapy clients experiencing psychological distress: a systematic mapping review

BACKGROUND

Some physiotherapists find assessing and managing clients experiencing psychological distress challenging and are uncertain regarding the boundaries of the profession's scope.

OBJECTIVE

To map the approaches recommended for physiotherapists in scholarly literature, with respect to the assessment and management of clients experiencing psychological distress.

METHODS

A systematic mapping review was conducted. CINAHL, APA PsycINFO, Embase, and Medline ALL databases were systematically searched for secondary and tertiary literature relevant to the research objective. Recommended approaches were extracted from each article and analyzed descriptively and thematically.

RESULTS

3884 records were identified with 40 articles meeting the inclusion/exclusion criteria. Most recommendations related to identifying, assessing, and managing pain-related distress, with depression screening and referral also receiving some attention. Three approaches to detecting and assessing psychological distress were identified: 1) brief depression screen; 2) integrated suicide/nonsuicidal self-harm and depression screen; and 3) multidimensional screen and health-related distress assessment. Regarding the management of psychological distress the main approaches identified were: 1) education and reassurance; 2) cognitive-behavioral approaches; 3) mindfulness; and 4) case management.

CONCLUSION

While assessment and management of health-related distress by physiotherapists is commonly recommended, further guidance is needed to differentiate various forms of distress.

Qualitative Examination of the Experience of Perceived Injustice Following Disabling Occupational Injury

PURPOSE

The primary objective of this study was to explore individuals' perspectives on the factors, situations or events that contributed to their perceptions of injustice following occupational injury.

MATERIALS AND METHODS

The study sample consisted of 30 participants (18 women, 12 men) who had submitted a time-loss claim for a work-related musculoskeletal injury. Participants with elevated scores on a measure of perceived injustice were interviewed about the factors that contributed to their sense of injustice. A thematic analysis was conducted to identify the broad classes of situations or events that participants experienced as unjust in the weeks following occupational injury.

RESULTS

Three dominant themes emerged from the interviews: (1) Invalidation, (2) Undeserved suffering and (3) Blame. Inductively derived subthemes reflected specific dimensions of post-injury experiences that contributed to participants' sense of injustice.

CONCLUSIONS

Given that suffering and invalidating communication are potentially modifiable factors, there are grounds for optimism that intervention approaches can be developed to prevent or reduce perceptions of injustice in the aftermath of debilitating injury. The development of intervention approaches that are effective in preventing or reducing perceptions of injustice holds promise of contributing to more positive recovery outcomes in individuals who have sustained debilitating work injuries.

Hierarchical Cluster Analysis Based on Clinical and Neuropsychological Symptoms Reveals Distinct Subgroups in Fibromyalgia: A Population-Based Cohort Study

Fibromyalgia (FM) is a condition characterized by musculoskeletal pain and multiple comorbidities. Our study aimed to identify four clusters of FM patients according to their core clinical symptoms and neuropsychological comorbidities to identify possible therapeutic targets in the condition. We performed a population-based cohort study on 251 adult FM patients referred to primary care according to the 2010 ACR case criteria. Patients were aggregated in clusters by a K-medians hierarchical cluster analysis based on physical and emotional symptoms and neuropsychological variables. Four different clusters were identified in the FM population. Global cluster analysis reported a four-cluster profile (cluster 1: pain, fatigue, poorer sleep quality, stiffness, anxiety/depression and disability at work; cluster 2: injustice, catastrophizing, positive affect and negative affect; cluster 3: mindfulness and acceptance; and cluster 4: surrender). The second analysis on clinical symptoms revealed three distinct subgroups (cluster 1: fatigue, poorer sleep quality, stiffness and difficulties at work; cluster 2: pain; and cluster 3: anxiety and depression). The third analysis of neuropsychological variables provided two opposed subgroups (cluster 1: those with high scores in surrender, injustice, catastrophizing and negative affect, and cluster 2: those with high scores in acceptance, positive affect and mindfulness). These empirical results support models that assume an interaction between neurobiological, psychological and social factors beyond the classical biomedical model. A detailed assessment of such risk and protective factors is critical to differentiate FM subtypes, allowing for further identification of their specific needs and designing tailored personalized therapeutic interventions.

Cross-cultural translation and psychometric validation of the French version of the Fear-Avoidance Components Scale (FACS)

BACKGROUND

The Fear-Avoidance Components Scale (FACS) is a reliable and valid instrument widely used to assess fear-avoidance beliefs related to pain and disability. However, there is a scarcity of validated translations of the FACS in different cultural and linguistic contexts, including the French population. This study aimed to translate and validate the French version of the FACS (FACS-Fr/CF), examining its psychometric properties among French-speaking individuals.

METHODS

A cross-cultural translation process-including forward translation, backward translation, expert committee review, and pre-testing-was conducted to develop the FACS-Fr/CF. The translated version was administered to a sample of French-speaking adults (n = 55) with chronic musculoskeletal pain. Internal consistency (including confirmatory analyses of the 2 factors identified in the Serbian version), test-retest reliability and convergent validity were then assessed.

RESULTS

The FACS-Fr/CF demonstrated high global internal consistency (α = 0.94, 95% CI: 0.91-0.96) as well as high internal consistency of the 2 factors identified in the Serbian version (α = 0.90, 95% CI: 0.86-0.94 and α = 0.90, 95% CI: 0.85-0.94, respectively). Test-retest analysis revealed a moderate (close to high) reliability (ICC = 0.89; 95% CI: 0.82-0.94 and r = 0.89; p<0.005). Convergent validity was supported by significant correlations between the FACS-Fr/CF scores and the Tampa Scale for Kinesiophobia (r = 0.82; p < 0.005), the Pain Catastrophizing Scale (r = 0.72; p < 0.005) and the Hospital Anxiety and Depression Scale (r = 0.66; p < 0.005).

CONCLUSION

The present study provides evidence for the cross-cultural translation and psychometric validation of the FACS-Fr/CF. The FACS-Fr/CF exhibits a high internal consistency, a moderate (close to high) test-retest reliability, and good construct validity, suggesting its utility in assessing fear-avoidance beliefs in the French-speaking population. This validated tool can enhance the assessment and understanding of fear-avoidance behaviors and facilitate cross-cultural research in pain-related studies.

Perceived Injustice in Cancer Survivors: Population-Specific Cut-Off Score and Relations with Personal Factors, Symptoms and Quality of Life-A Cross-Sectional Study

Fatigue and pain are the most common side effects impacting quality of life (QoL) in cancer survivors. Recent insights have shown that perceived injustice (PI) can play a substantial role in these side effects, but research on cancer survivors is scarce. Furthermore, guidelines for recognizing clinically relevant levels of PI in cancer survivors are missing. The aims of this study are to provide a clinically relevant cut-off for PI and to explore relationships between personal characteristics, symptoms, and QoL with PI. This multicenter, cross-sectional study uses the Injustice Experience Questionnaire (IEQ), Numeric Pain Rating Scale (NPRS), Patient-Specific Complaints (PSC), Multidimensional Fatigue Index (MFI), and European Organization for Research and Treatment of Cancer QoL Questionnaire-C30 (EORTC-QLQ-C30). A clinical cut-off for PI was identified based on the 75th percentile of IEQ scores. Univariate and multivariate regressions explored the relationship between PI and personal characteristics (sex, age, cancer type, treatment type), symptoms (pain intensity, fatigue), and QoL (daily activity complaints, cancer-related QoL). Cancer survivors (n = 121) were included, and a cut-off of 20 was identified. Significant indirect associations were found between chemotherapy, NPRS, PSC, MFI, and EORTC-QLQ-C30 with PI. In the multivariate model, only MFI (B = 0.205; 95% CI: 0.125-0.018) and age (B = 0.086; 95% CI: -0.191-0.285) maintained a significant association with PI.

A self-guided Internet-based intervention for individuals with chronic pain and depressive symptoms: study protocol of a randomized controlled trial

BACKGROUND

Despite the existence of evidence-based therapy options for the treatment of chronic pain and comorbid depressive symptoms (e.g., CBT), many individuals remain untreated. Treatment gaps result from a lack of specialists, patient fear of stigmatization, or patient immobility. Internet-based self-help interventions could serve as an anonymous and flexible alternative treatment option. In a pilot study, chronic pain patients with comorbid depressive symptoms who used a generic Internet-based depression program showed a significant reduction in depressive symptoms (but not pain symptoms) compared to a waitlist control group. Based on these findings, we developed the low-threshold, anonymous, and cost-free Internet-based self-help intervention Lenio that is tailored to the specific needs of chronic pain patients with comorbid depressive symptoms. Lenio is accompanied by the smartphone application (app) COGITO designed to increase therapeutic success. With Lenio and COGITO addressing both chronic pain and depressive symptoms, the trial aims to increase treatment effects of online interventions for chronic pain patients by reducing both depressive symptoms and pain.

METHODS

The effectiveness of the Internet-based self-help intervention and accompanying smartphone app will be evaluated in a randomized controlled trial (RCT). A total of 300 participants will be randomized into an intervention group (Lenio/COGITO), an active control group (depression-focused smartphone app), or a waitlist control group. Assessments will be done at baseline, after an 8-week intervention period (post), and after 16 weeks (follow-up). The primary outcome is the post-assessment reduction in "pain impairment" (mean value of impairment in daily life, free time, and work) as assessed by the DSF (German pain questionnaire). Secondary outcomes will include the reduction in depressive symptoms as well as in the severity of pain.

DISCUSSION

Lenio is one of the first Internet-based interventions to reduce chronic pain and depression that will be empirically evaluated. Internet-based interventions could offer a promising alternative to conventional face-to-face psychotherapy in the treatment of chronic pain patients. The primary objective of the current study is to add essential insight into the feasibility, effectiveness, and acceptance of Internet-based interventions for people with chronic pain and depressive symptoms.

TRIAL REGISTRATION

DRKS-ID DRKS00026722, Registered on October 6th, 2021.

Perceived injustice and its impact on psychological distress in cancer patients and survivors

PURPOSE

Perceived injustice is a novel psychosocial construct that reflects negative cognitive appraisals of unfairness, externalized blame and the irreparability and severity of one's loss. Previous research has highlighted the negative impact of perceived injustice on recovery and mental health outcomes, particularly in pain-related samples. This study aimed to (i) explore the role of perceived injustice on psychological outcomes in a general cancer population and (ii) describe demographic and psychosocial characteristics associated with perceptions of injustice.

METHODS

The study employed a cross-sectional, observational design. Using a purposive convenience sampling technique, individuals that have or have had cancer completed an online survey assessing perceived injustice (IEQ), psychological distress (HADS), mental adjustment to cancer (Mini-MAC) and satisfaction with care (PSCC) (N = 121).

RESULTS

Levels of perceived injustice were high with 43.2% of the sample scoring in the clinical range. Hierarchical regression analyses showed that perceived injustice contributed unique variance to the prediction of anxiety and depression. Low satisfaction with care, being under the age of 40 and not having children were identified as significant predictors of perceived injustice. Satisfaction with care did not significantly moderate the association between perceived injustice and mental health outcomes but directly impacted anxiety levels.

CONCLUSION

Cancer patients reporting high levels of perceived injustice are at greater risk of feeling psychologically distressed. Prevention and management of injustice perceptions may require interventions targeting specific negative attributions, as well as cancer care in general. Further implications for healthcare practice are discussed.

A cross-sectional study of fear of surgery in female breast cancer patients: Prevalence, severity, and sources, as well as relevant differences among patients experiencing high, moderate, and low fear of surgery

BACKGROUND

Fear of surgery has been associated with more postoperative pain, disability, and a lower quality of life among patients undergoing various surgical procedures. While qualitative studies indicate breast cancer patients to be afraid of surgery, detailed quantitative analyses are lacking. The present research aimed at investigating the prevalence, severity, and sources of fear of surgery in this patient group and to compare patients reporting different degrees of such fear.

METHODS

This cross-sectional study included 204 breast cancer patients, 18-70 years old, and scheduled for surgery at Oslo University Hospital, Norway. Following their preoperative visit participants completed validated psychological questionnaires online. Among these, the primary outcome measure, the Surgical Fear Questionnaire (SFQ; scores: 0-10 per item, 0-80 overall). Patients were grouped based on SFQ-percentiles (<25th = little, 25th-75th = moderate and >75th percentile = high fear) and compared on psychological (anxiety, depression, experienced injustice, optimism and expected postsurgical pain), sociodemographic, and medical outcomes.

RESULTS

195 patients completed the SFQ. On average fear of surgery was low (M = 26.41, SD = 16.0, median = 26, min-max = 0-80), but omnipresent. Only 1.5% (n = 3) indicated no fear at all. Overall, patients feared surgery itself the most (M = 3.64, SD = 2.8). Groups differed significantly (p < .001) in their experience of anxiety, depression, and injustice, as well as their disposition to be optimistic, and expectance of postsurgical pain. Differences between groups concerning demographic and medical information were largely insignificant.

DISCUSSION

This study was the first to demonstrate fear of surgery to be prevalent and relevant among female breast cancer patients. The higher a patients' fear group, the poorer their preoperative psychological constitution. This, largely irrespective of their current diagnoses or treatments, medical history, and demographics. Fear of surgery might thus cater as a prognostic marker and treatment target in this patient group. However, given the cross-sectional character of the present data, prognostic studies are needed to evaluate such claims.

The development and measurement properties of the Dutch version of the fear-avoidance components scale (FACS-D) in persons with chronic musculoskeletal pain

OBJECTIVES

The Fear-Avoidance Components Scale (FACS) is a recently developed patient-reported instrument assessing different constructs related to the fear-avoidance model of pain. The aim was to translate the original English FACS into Dutch (FACS-D) and assess its measurement properties in persons with chronic musculoskeletal pain.

METHODS

The original English FACS (20 item-scale, range: 0-100) was translated in Dutch through standard forward-backward translation methodology. The FACS-D's measurement properties were evaluated in 224 persons with chronic musculoskeletal pain. Internal consistency, test-retest reliability and measurement error were assessed with the Cronbach's alpha coefficient (α), intraclass correlation coefficient (ICC), and standard error of measurement (SEM). Construct validity was assessed through inter-item correlation analyses, exploratory factor analysis, association with other fear-avoidance-related constructs, and hypothesis testing.

RESULTS

Internal consistency, test-retest reliability and hypotheses testing were good (α=0.92; ICC=0.92, CI 0.80-0.96; 7/8 hypotheses confirmed). Similar to the original FACS and other translated versions, a two-factor model best fit the data. However, the item distribution differed from other versions. One factor represented "pain-related cognitions and emotions" and a second factor represented "avoidance behaviour." In contrast to the original FACS, low inter-item correlations for item 12 were found. The FACS-D was more strongly associated with fear-avoidance-related constructs of pain severity, perceived disability, feelings of injustice, and depressive/anxiety symptoms than the other fear-avoidance-related scales studied here.

CONCLUSIONS

The FACS-D demonstrated good reliability and construct validity, suggesting that it may be a useful measure for Dutch-speaking healthcare providers. Two clinically relevant factors, with a different item distribution than the original FACS, were identified: one covering items on pain-related cognitions and emotions, and one covering items on avoidance behaviour. The stronger association between FACS-D and fear-avoidance related constructs suggests that the FACS-D may be more effective in evaluating the cognitive, emotional and behavioural constructs of pain-related fear-avoidance than other similar measures.

Preliminary Validation of the Injustice Experience Questionnaire in Patients With Advanced Cancer

CONTEXT

When diagnosed with advanced cancer, patients may perceive their situation as an injustice. The Injustice Experience Questionnaire (IEQ) is a 12-item measure of perceived unfairness originally developed for patients with chronic pain. The factor structure, reliability, and validity of the IEQ in patients with cancer have not been assessed.

OBJECTIVES

To examine the factor structure, internal consistency, and construct validity of the IEQ in patients with advanced cancer.

METHODS

Patients with advanced lung or prostate cancer (N = 201) were recruited from academic and public clinics in Indianapolis, IN. Patients completed the 12-item IEQ and other measures of psychological processes and distress. IEQ instructions were modified to focus on cancer-related perceived injustice. Confirmatory factor analysis (CFA) was used to examine the dimensionality of the measure. Internal consistency reliability and construct validity were examined.

RESULTS

CFA showed that the original IEQ's 2-factor structure had an adequate fit (RMSEA = 0.07, CFI = 0.96, SRMR = 0.05). The factors included Severity/irreparability and Blame/unfairness. Internal consistency was excellent (α = 0.92, ω = 0.94). The IEQ showed significant positive associations with physical and psychological symptoms (rs = 0.20 - 0.65, Ps < 0.05). The IEQ also showed significant negative associations with quality of life and acceptance of cancer (rs=-0.51 - -0.46, Ps < 0.05).

CONCLUSION

Findings provide preliminary support for using the IEQ in patients with advanced cancer. Future research should assess the sensitivity of the IEQ to change in an interventional context.

Altered social decision making in patients with chronic pain

BACKGROUND

Chronic pain affects up to 20% of the population, impairs quality of life and reduces social participation. Previous research reported that pain-related perceived injustice covaries with these negative consequences. The current study probed whether chronic pain patients responded more strongly to disadvantageous social inequity than healthy individuals.

METHODS

We administered the Ultimatum Game, a neuroeconomic social exchange game, where a sum of money is split between two players to a large sample of patients with chronic pain disorder with somatic and psychological factors (n = 102) and healthy controls (n = 101). Anonymised, and in truth experimentally controlled, co-players proposed a split, and our participants either accepted or rejected these offers.

RESULTS

Chronic pain patients were hypersensitive to disadvantageous inequity and punished their co-players for proposed unequal splits more often than healthy controls. Furthermore, this systematic shift in social decision making was independent of patients' performance on tests of executive functions and risk-sensitive (non-social) decision making .

CONCLUSIONS

Our findings indicate that chronic pain is associated with anomalies in social decision making (compared to healthy controls) and hypersensitivity to social inequity that is likely to negatively impact social partaking and thereby the quality of life.

Clinical phenotypes and prognostic factors in persons with hip osteoarthritis undergoing total hip arthroplasty: protocol for a longitudinal prospective cohort study (HIPPROCLIPS)

BACKGROUND

Large heterogeneity exists in the clinical manifestation of hip osteoarthritis (OA). It is therefore not surprising that pain and disability in individuals with hip OA and after total hip arthroplasty (THA) cannot be explained by biomedical variables alone. Indeed, also maladaptive pain-related cognitions and emotions can contribute to pain and disability, and can lead to poor treatment outcomes. Traumatic experiences, mental disorders, self-efficacy and social support can influence stress appraisal and strategies to cope with pain, but their influence on pain and disability has not yet been established in individuals with hip OA undergoing THA. This study aims (1) to determine the influence of traumatic experiences and mental disorders on pain processing before and shortly after THA (2) to identify preoperative clinical phenotypes in individuals with hip OA eligible for THA, (3) to identify pre- and early postoperative prognostic factors for outcomes in pain and disability after THA, and (4) to identify postoperative clinical phenotypes in individuals after THA.

METHODS

This prospective longitudinal cohort study will investigate 200 individuals undergoing THA for hip OA. Phenotyping variables and candidate prognostic factors include pain-related fear-avoidance behaviour, perceived injustice, mental disorders, traumatic experiences, self-efficacy, and social support. Peripheral and central pain mechanisms will be assessed with thermal quantitative sensory testing. The primary outcome measure is the hip disability and osteoarthritis outcome score. Other outcome measures include performance-based measures, hip muscle strength, the patient-specific functional scale, pain intensity, global perceived effect, and outcome satisfaction. All these measurements will be performed before surgery, as well as 6 weeks, 3 months, and 12 months after surgery. Pain-related cognitions and emotions will additionally be assessed in the early postoperative phase, on the first, third, fifth, and seventh day after THA. Main statistical methods that will be used to answer the respective research questions include: LASSO regression, decision tree learning, gradient boosting algorithms, and recurrent neural networks.

DISCUSSION

The identification of clinical phenotypes and prognostic factors for outcomes in pain and disability will be a first step towards pre- and postoperative precision medicine for individuals with hip OA undergoing THA.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05265858. Registered on 04/03/2022.

Perceived Injustice as a Determinant of the Severity of Post-traumatic Stress Symptoms Following Occupational Injury

BACKGROUND

The present study assessed the role of perceived injustice in the experience and persistence of post-traumatic stress symptoms (PTSS) following work-related musculoskeletal injury.

METHODS

The study sample consisted of 187 individuals who were absent from work as a result of a musculoskeletal injury. Participants completed measures of pain severity, perceived injustice, catastrophic thinking, post-traumatic stress symptoms, and disability on three occasions at three-week intervals.

RESULTS

Consistent with previous research, correlational analyses revealed significant cross-sectional relations between pain and PTSS, and between perceived injustice and PTSS. Regression analysis on baseline data revealed that perceived injustice contributed significant variance to the prediction of PTSS, beyond the variance accounted for by pain severity and catastrophic thinking. Sequential analyses provided support for a bi-directional relation between perceived injustice and PTSS. Cross-lagged regression analyses showed that early changes in perceived injustice predicted later changes in PTSS and early changes in PTSS predicted later changes in perceived injustice.

CONCLUSIONS

Possible linkages between perceived injustice and PTSS are discussed. The development of effective intervention techniques for targeting perceptions of injustice might be important for promoting recovery of PTSS consequent to musculoskeletal injury.

The role of perceived patient injustice on pain related and functional outcomes in orthopaedic patients; a systematic review

Introduction

Higher levels of perceived patient injustice has been associated with higher levels of pain and poor functional outcomes in patients with chronic musculoskeletal pain. We wanted to investigate if there was any evidence of this association in patients who underwent orthopaedic surgery.

Materials and methods

A systematic search of the literature was performed independently by two researchers on the electronic databases of MEDLINE, EMBASE, Google Scholar, Web of Science, and the Cochrane Database of Systematic Reviews and data extracted in accordance with PRISMA guidelines for systematic reviews. Outcomes of interest were pain, pain intensity, pain interference, opiate use, disability, physical function, return to work, quality of life, depression, anxiety, post-traumatic stress, social functioning and quality of life.

Results

Five studies were identified for qualitative analysis involving elective and trauma orthopaedic patients. All studies identified a positive correlation between higher levels of perceived injustice and depression, pain intensity and interference as well as reduced function and higher levels of disability.

Conclusions

Higher levels of perceived patient injustice is associated with worse pain and functional outcomes in patients who undergo orthopaedic surgery in the traumatic and elective setting. Further research is warranted to further elucidate this association and identify potential therapeutic interventions.

Cross-cultural adaptation and validation of the Hebrew version of the Injustice Experience Questionnaire - long and short versions

PURPOSE

To translate, validate, and culturally adapt the Injustice Experience Questionnaire (IEQ) and IEQ Short Form (IEQ-SF) into Hebrew, as measuring tools for examining feelings of injustice in cases of accidents and chronic pain.

METHODS

The translation was performed in several steps following the cross-cultural adaptation process. A sample of 150 patients suffering from traumatic injury fill out a battery of questionnaires: IEQ, IEQ-SF, Hospital Anxiety and Depression Scale (HADS), Numeric Pain Rating Scale (NPRS), and Pain Catastrophizing Scale (PCS), which were used for calculating construct validity. A test-retest was performed on 41 patients.

RESULTS

The IEQ and IEQ-SF found Cronbach's alpha of 0.92 and 0.84, respectively. Test-retest reliability for IEQ (ICC: 0.94) was found to be excellent. Spearman's correlation coefficient between IEQ and PCS was 0.68, NPRS (severe pain: 0.45, average pain: 0.51), HADS (anxiety: 0.62, depression: 0.60). The correlation between IEQ-SF and PCS was 0.67, with HADS (anxiety: 0.52, depression: 0.48). A weak correlation was found for NPRS (severe pain: 0.30, average pain: 0.34).

CONCLUSIONS

The Israeli translation and cross-cultural adaptation of the IEQ and IEQ-SF questionnaires were found to be valid and reliable.Implications for rehabilitationThe perception of injustice is a significant mental and psychological factor for recovery after accidents and injuries.This study translated, validated and culturally adapted the Injustice Experience Questionnaire (IEQ) and the short form into Hebrew.The questionnaires were found to be valid and reliable in Hebrew.

Post-Traumatic Trigeminal Neuropathic Pain after Dental Implant Surgery and the Injustice Experience Questionnaire

Painful post-traumatic trigeminal neuropathy (PTTN) is a known complication of dental implant therapy. Patients with PTTN develop sensory abnormalities in the orofacial region, which may be a psychosocial aspect, and dentists should assess somatosensory testing and psychosocial factors. The patients were assessed using quantitative sensory testing (QST). A 64-year-old female presented with allodynia of the left lower lip that occurred after a surgical implant procedure. Persistent pain started 4 months after the placement of two dental implants in the mandible. Sensory testing of these areas revealed warm hyposensitivity and mechanical hypersensitivity of the mandibular region. We also assessed PTTN-related perceived injustice using the Injustice Experience Questionnaire. The patient refused medication therapy such as pregabalin; therefore, autogenic training was adopted as an alternative management strategy. We conclude that for expensive dental procedures, such as implant placement, sufficient consensus should be obtained preoperatively before proceeding with surgery.

The Association Between Perceived Injustice and Opioid Craving in Patients With Chronic Pain: The Mediating Role of Daily Pain Intensity, Negative Affect, and Catastrophizing

OBJECTIVES

The first objective of this study was to examine the association between perceived injustice and opioid craving in patients with chronic pain who are prescribed opioids. We also examined whether pain intensity, negative affect, or catastrophizing mediated this association.

METHODS

In this longitudinal diary study, patients (n = 103) completed a questionnaire assessing perceived injustice and then completed daily measures of pain intensity, negative affect, catastrophizing, and opioid craving for 14 consecutive days.

RESULTS

A significant association was found between perceived injustice and opioid craving ( P < 0.01), with higher levels of perceived injustice being associated with heightened levels of opioid craving. A 2-1-1 multilevel mediation analysis indicated that the association between perceived injustice and craving was significantly mediated by catastrophizing ( P < 0.05).

CONCLUSIONS

The present study provides new insights into the factors that might contribute to opioid craving in patients with chronic pain. Our findings suggest that perceived injustice might lead to increased catastrophizing and, in turn, heightened daily levels of opioid craving. These findings could have implications for chronic pain management clinicians who prescribe opioids.

The Experience of BIPOC Living with Chronic Pain in the USA: Biopsychosocial Factors that Underlie Racial Disparities in Pain Outcomes, Comorbidities, Inequities, and Barriers to Treatment

PURPOSE OF REVIEW

This review synthesizes recent findings related to the biopsychosocial processes that underlie racial disparities in chronic pain, while highlighting opportunities for interventions to reduce disparities in pain treatment among BIPOC.

RECENT FINDINGS

Chronic pain is a prevalent and costly public health concern that disproportionately burdens Black, Indigenous, and people of color (BIPOC). This unequal burden arises from an interplay among biological, psychological, and social factors. Social determinants of health (e.g., income, education level, and lack of access or inability to utilize healthcare services) are known to affect overall health, including chronic pain, and disproportionately affect BIPOC communities. This burden is exacerbated by exposure to psychosocial stressors (i.e., perceived injustice, discrimination, and race-based traumatic stress) and can affect biological systems that modulate pain (i.e., inflammation and pain epigenetics). Further, there are racial/ethnic disparities in pain treatment, perpetuating the cycle of undermanaged chronic pain among BIPOC.

Youth baseline and state pain-related injustice appraisals are associated with emotional responses of anger and sadness: An experimental study

Background

Youth pain-related injustice appraisals are associated with adverse functioning; however, mechanisms by which injustice appraisals exert their impact have yet to be elucidated. Adult injustice literature suggests anger, sadness, and attention bias to anger (AB) as potential mechanisms. This study examined the effects of injustice appraisals in a healthy youth sample by applying a justice violation manipulation. We hypothesized the justice violation condition to lead to worse pain outcomes with effects mediated by anger, sadness, and AB as compared to the control condition. We further explored associations between both baseline and state injustice appraisals and anger, sadness, and AB across conditions.

Methods

A 2 × 2 time by condition design was used to test hypotheses. 133 healthy youth aged 9-16 years old completed two cold pressor tasks (CPTs). In the experimental (i.e., justice violation) group, participants were initially told to complete one CPT, but were told afterwards to perform it again due to experimenter negligence. In the control group, no justice violation occurred. Baseline injustice appraisals and pain catastrophizing were assessed with the Injustice Experience Questionnaire and Pain Catastrophizing Scale for Children; state outcomes (i.e., injustice, catastrophizing, anger, sadness) were assessed after CPTs. AB was indexed using a dot-probe task.

Results

Findings indicated no effects of the justice violation on pain outcomes or associated mechanisms, nor on injustice appraisals, suggesting manipulation failure. However, across conditions, baseline and state injustice appraisals were positively associated with anger and sadness, but not with AB.

Conclusions

Despite the experimental justice violation failing to elicit differential injustice appraisals across conditions, the current study supports both anger and sadness as key emotional responses associated with pain-related injustice appraisals in a healthy youth sample.

Associations between social integration, participation and productivity loss among persons with chronic pain: a registry based cross sectional study

Purpose

To examine associations between factors of social inclusion and participation and productivity loss in employed persons with chronic pain, assessed for an interprofessional pain rehabilitation programme. We hypothesized that factors of social inclusion and participation and work related social factors are significantly associated with productivity when experiencing chronic pain and we expected a moderate effect.

Methods

Cross-sectional study using data collected prospectively in an interprofessional patient registry for chronic pain. The primary end point was productivity loss, measured with the iMTA Productivity Costs Questionnaire. We included data from 161 individuals. To be included, persons had to be 18 years old or older, in paid work, and had to have a medical diagnosis of chronic pain syndrome with actual or potential tissue damage. In addition, participants had to have indicators of significant impairments in psychosocial functions.

Results

Linear regression analysis showed that a highly stressful professional situation, frequent problems regarding the compatibility of the family and job and not being Swiss were associated with a significantly higher total productivity loss. Similar results were found for productivity loss in paid work. However, problems concerning the compatibility of the family and job did not reach the significance level for productivity loss in paid work.

Conclusion

The results of this study underscore the importance of factors of social inclusion and participation for interprofessional rehabilitation programmes to manage chronic pain especially when focussing on productivity loss.

Defining pain-validation: The importance of validation in reducing the stresses of chronic pain

Purpose

To validate an individual's feelings or behaviour is to sanction their thoughts or actions as worthy of social acceptance and support. In contrast, rejection of the individual's communicated experience indicates a denial of social acceptance, representing a potential survival threat. Pain-invalidation, though ill-defined, appears to be a fundamental component of psychosocial stress for people with chronic pain. As such, the aim of this paper was to define pain-validation and outline its importance for those with chronic pain.

Methods

The pain-validation construct was defined using themes inherent in the narratives of those with chronic pain, as identified in a previously published systematic search and thematic analysis, together with examination of additional literature on pain-validation in the clinical context.

Results

We present a construct definition, proposing that pain-validation must necessarily include: (i) belief that the pain experience is true for the individual, (ii) acceptability of the individual's expressions of pain, and (iii) communication of belief and acceptability to the individual experiencing pain. Further, we outline the importance of pain-validation as a protective factor and means of reducing many of the psychosocial stresses of chronic pain; for example, by indicating social support for pain-coping, buffering negative emotions, and re-enforcing unity and shared identity.

Implications

The role of pain-validation in the current era of pain management intervention is discussed. Adhering to interventions that involve cognitive and behavioural change is often difficult. Acknowledging and validating the acceptability of the patient's pain experience in the early stages of pain management may, therefore, be a key component of intervention that encourages compliance to the treatment plan and achieving therapeutic goals.

Biopsychosocial sequelae of chronically painful injuries sustained in motor vehicle accidents contributing to non-recovery: A retrospective cohort study

BACKGROUND

Claimants with chronically painful injuries sustained in motor vehicle accidents (MVAs) undergo assessment and management influenced by insurance and medico-legal processes defined by a biomedical paradigm which is discordant with best evidence. We aim to demonstrate the impact of biopsychosocial factors on post-MVA sequelae which contribute to non-recovery.

METHODS

This was a retrospective cohort study of medico-legal documents and reports on 300 consecutive claimants referred to a pain medicine physician over 7 years (2012-2018) for assessment of painful musculoskeletal injuries post-MVA. One hundred data items were extracted from the medico-legal documents and reports for each claimant and entered into an electronic database. Post-MVA sequelae were analysed using chi-square analysis (OR >2) for significant associations with demographic, pre-MVA and post-MVA variables. Factors with significant associations were entered into a logistic regression model to determine significant statistical predictors of post-MVA sequelae contributing to non-recovery.

RESULTS

The claimants were aged 17 to 80 years (mean age 42 years), and approximately half (53%, n=159) were female. The time from MVA to interview averaged 2.5 years. Widespread pain was present in 18% (n=54), and widespread somatosensory signs implying central sensitisation (OR=9.85, p<.001) was the most significant multivariate association. Long-term opiate use post-MVA (32%) was predicted by pre-MVA sleep disturbance (OR=5.08, p=.001), post-MVA major depressive disorder (MDD) (OR=3.02, p=.003) and long-term unemployment (OR=2.22. p=.007). Approximately half (47%, n=142) required post-MVA support from a psychologist or psychiatrist. Post-traumatic stress disorder (PTSD) was diagnosed by a psychiatrist or psychologist in 20% (n=59), yet early identification of risk of PTSD was rare. Pre-MVA, 89.4% (n=268) were studying or employed. Permanent unemployability post-MVA occurred in 35% (n=104) and was predicted by MDD (OR=3.59, p=.001) and antidepressant use (OR=2.17, p=.005). Major social change post-MVA (70%) was predicted by older age (OR=.966, p=.003), depressive symptoms (OR=3.71, p<.001) and opiate use (OR=2.00, p=.039).

CONCLUSIONS

Biomedical factors, including older age, impaired sleep and indicators of widespread central sensitisation, and psychological factors, including stress, anxiety and depression, were the most prominent multivariate associations as statistical predictors of major adverse sequelae contributing to non-recovery for claimants with chronic pain post-MVA.

Psychosocial Predictors of Chronic Musculoskeletal Pain Outcomes and their Contextual Determinants Among Black Individuals: A Narrative Review

Black communities are disproportionally affected by Chronic Musculoskeletal Pain (CMP), but little is known about the psychological predictors of CMP outcomes and their contextual determinants among Black individuals. To address this gap, we conducted a narrative review of extant literature to (1) report the major conceptual models mentioned in prior work explaining the link between contextual determinants and psychological responses to pain among Black individuals with CMP; and (2) describe psychological factors related to CMP outcomes in this population that are highlighted in the literature. We searched 4 databases (APA PsycNet, PubMed/MEDLINE, Scopus, and Google Scholar) using the following search terms: musculoskeletal pain, chronic pain, mental health, psychological, coping, health disparities, contextual factors, conceptual models, psychosocial, Black, African American, pain, disability, and outcomes. We illustrate 3 relevant conceptual models - socioecological, cumulative stress, and biopsychosocial - related to contextual determinants and several psychological factors that influence CMP outcomes among Black individuals: (1) disproportionate burden of mental health and psychiatric diagnoses, (2) distinct coping strategies, (3) pain-related perceived injustice and perceived racial/ethnic discrimination, and (4) preferences and expectations related to seeking and receiving pain care. The detailed clinical and research implications could serve as a blueprint for the providers and clinical researchers to address health disparities and improve care for Black individuals with CMP. PERSPECTIVE: This narrative review illustrates conceptual models explaining the link between contextual determinants and psychological responses to pain among Black individuals with chronic musculoskeletal pain. We discuss 3 relevant conceptual models - socioecological, cumulative stress, biopsychosocial -, and 4 psychological factors: disproportionate burden of mental health, distinct coping strategies, perceived injustice/discrimination, preferences/expectations.

The effect of the Progressive Goal Attainment Program on cognitions, perceptions, and work participation of workers with chronic health problems: study protocol for a randomized controlled trial

Background

Cognitions and perceptions of workers with chronic health problems, such as catastrophizing thoughts and fear-avoidance beliefs, can negatively influence work participation. The Progressive Goal Attainment Program (PGAP) is an intervention developed in Canada with the aim of decreasing limiting cognitions and perceptions and increasing work participation. The objective of this protocol article is to describe the design of a randomized controlled superiority trial to study whether PGAP is effective in decreasing limiting cognitions and perceptions and increasing workability and work participation of workers with chronic health problems in the Netherlands.

Methods

This study is a randomized controlled superiority trial with two (parallel) groups, in which workers on sick leave are randomly assigned to an intervention group (PGAP intervention) or to a waiting-list control group (care as usual). The PGAP intervention consists of a maximum of 10 weekly individual sessions provided by a trained PGAP professional in which the worker learns about staying active, planning activities, and setting goals. Participants in this risk-targeted behavioral activation intervention also learn to be more aware of their cognitions and perceptions and learn about solution-focused problem-solving skills in challenging situations. The primary outcome is the degree of catastrophizing. Secondary outcomes are other personal cognitions and perceptions (e.g., expectations regarding return to work, self-efficacy), health symptoms (e.g., fatigue, depression), work participation (e.g., sick leave status, work hours), and other work-related outcomes (e.g., workability, quality of working life).

Discussion

Although PGAP shows positive effects in Canada, we do not know whether this intervention is effective in the Netherlands. This study is the first randomized controlled trial to test the effect of PGAP on limiting cognitions and perceptions and on work participation of workers with chronic health problems in the Netherlands. If PGAP is effective it could be implemented in the Netherlands in order to stimulate workability and work participation of workers.

Trial registration

The protocol of this study is registered in the Netherlands Trial Register (NL9832) in October 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06698-8.

Enhancing COVID Rehabilitation with Technology (ECORT): protocol for an open-label, single-site randomized controlled trial evaluating the effectiveness of electronic case management for individuals with persistent COVID-19 symptoms

BACKGROUND

As of May 2022, Ontario has seen more than 1.3 million cases of COVID-19. While the majority of individuals will recover from infection within 4 weeks, a significant subset experience persistent and often debilitating symptoms, known as "post-COVID syndrome" or "Long COVID." Those with Long COVID experience a wide array of symptoms, with variable severity, including fatigue, cognitive impairment, and shortness of breath. Further, the prevalence and duration of Long COVID is not clear, nor is there evidence on the best course of rehabilitation for individuals to return to their desired level of function. Previous work with chronic conditions has suggested that the addition of electronic case management (ECM) may help to improve outcomes. These platforms provide enhanced connection with care providers, detailed symptom tracking and goal setting, and access to relevant resources. In this study, our primary aim is to determine if the addition of ECM with health coaching improves Long COVID outcomes at 3 months compared to health coaching alone.

METHODS

The trial is an open-label, single-site, randomized controlled trial of ECM with health coaching (ECM+) compared to health coaching alone (HC). Both groups will continue to receive usual care. Participants will be randomized equally to receive health coaching (± ECM) for a period of 8 weeks and a 12-week follow-up. Our primary outcome is the WHO Disability Assessment Scale (WHODAS), 36-item self-report total score. Participants will also complete measures of cognition, fatigue, breathlessness, and mental health. Participants and care providers will be asked to complete a brief qualitative interview at the end of the study to evaluate acceptability and implementation of the intervention.

DISCUSSION

There is currently little evidence about the optimal treatment of Long COVID patients or the use of digital health platforms in this population. The results of this trial could result in rapid, scalable, and personalized care for people with Long COVID which will decrease morbidity after an acute infection. Results from this study will also inform decision making in Long COVID and treatment guidelines at provincial and national levels.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05019963. Registered on 25 August 2021.

An integrated mindfulness meditation and acceptance and commitment therapy intervention for chronic pain: Rationale, design, and methodology of a pilot randomized controlled trial of Acting with Mindfulness for Pain (AMP)

Acceptance and commitment therapy (ACT) is an evidence-based psychosocial intervention for chronic pain; however, in its present form ACT produces modest improvements in function and is no more effective than cognitive behavioral therapy (CBT), the current gold standard. This protocol paper describes the Acting with Mindfulness for Pain (AMP) protocol, which emphasizes and integrates formal mindfulness meditation practice within an ACT-based approach. This paper presents the rationale, design and methodology of an ongoing pilot randomized controlled trial (RCT) comparing AMP to CBT among Veterans with chronic pain (N = 86). Specifically, we argue that formal meditation practice is a necessary treatment component that directly targets key ACT processes which will help facilitate large treatment effects on function (e.g., general activity, social relationships, life enjoyment) among individuals with chronic pain. This study will be the first to consider formal mindfulness meditation practice as a principal treatment ingredient in the context of ACT for chronic pain. The purpose of this trial is to evaluate the feasibility of recruitment and collection of measures, and to examine preliminary treatment effects to determine the appropriateness of a subsequent full-scale RCT. This study will also explore within and between group change on primary and secondary outcomes including pain interference, pain acceptance, trait mindfulness, pain catastrophizing, values-based living, quality of life, practice adherence, and objective measures of physical activity. This study will help delineate the role of formal mindfulness practice within an ACT-based approach for chronic pain and provide preliminary data for a future fully powered RCT.

Pre- and post-operative psychological interventions to prevent pain and fatigue after breast cancer surgery (PREVENT): Protocol for a randomized controlled trial

Background

Breast cancer is the most common cancer type among women worldwide with over a million new cases each year. More than 40% of these women will struggle with chronic pain and fatigue after surgery, regardless of surgical procedure. These consequences are detrimental and result in distress and disability, including work disability. Few attempts have been made to prevent chronic pain and fatigue after surgery by applying a psychological approach, despite psychological risk factors being crucial in the development of both chronic pain and fatigue. In this study, we aim to develop and test an easily implementable strategy of preventing chronic pain and fatigue after breast cancer surgery. The intervention strategy involves a pre-operative hypnosis session and a web-based post-operative Acceptance and Commitment Therapy (ACT). The hypnosis has previously been found effective in alleviating acute post-operative pain and fatigue in breast cancer patients, while ACT is well suited to cancer populations as it offers a model of healthy adaptation to difficult circumstances. Together they form an intervention strategy with both a preventive and a rehabilitative focus.

Methods/Design

This randomized controlled trial aims to estimate the effects of the pre- and post- operative interventions compared to attentional control and treatment as usual (TAU) and will also include a qualitative process evaluation. Participants will be randomized to receive either a pre-operative brief hypnosis session and a post-operative web-based psychological intervention (iACT) or a pre-operative one-session mindfulness through an audio file and post-operative TAU. Self-reported questionnaire data and biomarker data will be assessed pre-surgery, post-surgery and 3 and 12 months after surgery. In addition, we will assess registry data on sick leave and prescriptions until 2-year follow-up. In the qualitative process evaluation, data will be collected from participants from both study arms (through interviews and a diary) and two different analyses performed (socio-narrative and Grounded Theory) with the objective to describe the development of chronic post-surgical pain and fatigue and the potential influence of the interventions on these processes. The study is set-up to demonstrate a minimum difference in pain of 1 point on NRS (0–10) and 3 points on FACIT-F (0–52) between the groups at 3-months follow-up by including 200 breast cancer patients in total.

Discussion

This trial will be the first study to estimate the effect of a combined pre-operative hypnosis with a post-operative iACT to prevent pain and fatigue after breast cancer surgery. The results from our study might i) help the large group of women affected by chronic pain and fatigue after breast cancer surgery, ii) shed light on the mechanisms involved in chronic pain and fatigue development, and iii) serve as a model for other surgical procedures.

Trial registration

Clinicaltrials.gov, registration number NCT04518085. Registered on January 29th, 2020. https://clinicaltrials.gov/ct2/show/NCT04518085.

Perceived Injustice in Patients With Chronic Pain: Prevalence, Relevance, and Associations With Long-Term Recovery and Deterioration

The Injustice Experience Questionnaire (IEQ) assesses the degree to which chronic pain sufferers perceive injustice in relation to their pain. The aim of the current study was to assess the prevalence and relevance of the IEQ and its association to perceived recovery and deterioration in a naturalistic pain clinic population. Data was obtained from the Oslo University Hospital's Pain Registry. Among 2,950 patients, the prevalence of low (<19), medium (19-29) and high (30+) IEQ was 39%, 32% and 29% respectively. High levels of injustice were positively associated with a wide range of adverse health outcomes. Differences between those with high vs low levels of IEQ were clinically significant for most health outcomes. A Venn diagram analysis showed considerable, but not complete, overlap between IEQ, pain catastrophizing, psychological distress and severe pain intensity. High IEQ was associated with reduced clinical recovery (OR 0.6, 95% CI 0.4-0.9) and deterioration (OR 3.6, 95% CI 2.1-6.2) at 12-months follow-up, however, not when controlling for pain-related disability and pain intensity. We conclude that perceived injustice is a prevalent and clinically relevant phenomenon in a chronic pain clinic population, and that more knowledge is needed regarding its role as indicator of poor prognosis and target for tailored treatment. PERSPECTIVE: This article shows that pain-related injustice is both prevalent and relevant in a large naturalistic pain clinic population. Higher levels of injustice were consistently associated with adverse pain outcomes. Injustice could as such be a viable target for treatment of chronic pain, with potential indirect effects on pain and disability.

The impact of maternal child- and self-oriented pain-related injustice appraisals upon maternal attention to child pain, attention to anger, and pain-attending behavior

Objectives

The current study investigated the role of maternal child- and self-oriented injustice appraisals about child pain in understanding maternal attention for child pain and adult anger cues and pain-attending behavior.

Methods

Forty-four children underwent a painful cold pressor task (CPT) while their mother observed. Eye tracking was used to measure maternal attention to child pain and adult anger cues. Initial attention allocation and attentional maintenance were indexed by probability of first fixation and gaze duration, respectively. Maternal pain-attending behaviors toward the child were videotaped and coded after CPT completion. Mothers also rated the intensity of pain and anger cues used in the free-viewing tasks. All analyses controlled for maternal catastrophizing about child pain.

Results

Neither child-oriented nor self-oriented injustice was associated with maternal attentional bias toward child pain. Regarding attention toward self-relevant anger cues, differential associations were observed for self- and child-oriented injustice appraisals, with maternal self-oriented injustice being associated with a greater probability of first fixating on anger and with higher anger ratings, whereas maternal child-oriented injustice was associated with enhanced attentional maintenance toward anger. Neither type of maternal injustice appraisals was associated with maternal pain-attending behavior, which was only associated with maternal catastrophizing.

Conclusions

The current study sheds light on potential differential mechanisms through which maternal self- vs. child-oriented injustice appraisals may exert their impact on parent and child pain-related outcomes. Theoretical implications and future directions are discussed.

Health screening questionnaires used in the management of mental distress acquired during an injured worker’s return to work: A scoping review

BACKGROUND: Mental distress is often endured by injured workers participating in the rehabilitation or return to work process following a physical injury. Delays in detecting the onset and treating mental distress can lead to a diverse range of cognitive and behavioural changes that may precipitate psychological distress such as anxiety, depression, and posttraumatic stress. OBJECTIVE: The objective of this scoping review was to provide an overview of existing health questionnaires utilised by health care providers and affiliated researchers. It reviewed their effectiveness and suitability to detect mental distress endured by injured workers engaged in the return to work process. METHODS: A scoping review methodology was conducted using the Arksey and O’Malley framework which examined peer-reviewed articles published between 2000 and March 2020 comprising health questionnaires. Database searches included Medline, CINAHL, EMBASE and PsycINFO combining specific MeSH terms and key words. RESULTS: The full search identified 3168 articles. Following full screening a total of 164 articles reviewed the use of health questionnaires and specific criteria to determine their suitability. Most of the health questionnaires reviewed were used as screening measures for identifying both work and non-work-related psychological hazards. However, they were found to be limited in their application when considering all potential predictors of delayed return to work such as poor or stressful interactions with stakeholders, financial stress and the injured workers experience of the RTW process. CONCLUSION: Earlier identification of mental distress using an optimal MHSQ followed by appropriate intervention will reduce the risk of psychological injury becoming cumulative on a physical workplace injury. Without such complications, early return to work can be achieved with significant cost saving to the economy.

Perceived Injustice After Mild Traumatic Brain Injury

OBJECTIVE

To examine perceived injustice and its associations with self-reported symptoms and return to work at 3 months after injury in a prospectively recruited sample of patients with mild traumatic brain injury (mTBI).

DESIGN

Observational study.

SETTING

TBI outpatient unit.

PARTICIPANTS

Adult patients aged 18 to 68 years with mTBI (n = 100) or orthopedic injury ([OI]; n = 34).

MAIN MEASURES

The Injustice Experience Questionnaire (IEQ) and its associations with the Rivermead Post Concussion Questionnaire (RPQ), Beck Depression Inventory-Second Edition (BDI-II), PTSD Checklist-Civilian Version (PCL-C), and Pain Visual Analog Scale (PVAS). Information on injury-related characteristics, compensation seeking and litigation, and return-to-work status was also collected.

RESULTS

Median IEQ total score was 3 (range, 0-23) in the mTBI group and 2.5 (range, 0-25) in the OI group. In the mTBI group, IEQ was significantly correlated with RPQ (rs = 0.638, P < .01), BDI-II (rs = 0.612, P < .01), PCL-C (rs = 0.679, P < .01), and PVAS (rs = 0.232, P < .05). The association between IEQ and PCL-C (rs =0.797, P < .01) and BDI-II (rs = 0.395, P < .05) was also found in the OI group. In both groups, patients who were still on sick leave at 3 months after injury tended to report higher perceived injustice (IEQ total score) than patients who had returned to work or studies. However, this difference did not reach statistical significance.

CONCLUSIONS

Perceived injustice is associated with self-reported symptoms in patients with mTBI. Our results suggest that perceived injustice could be a relevant construct to consider in clinical management of patients with mTBI. Also, perceived injustice could be a potential target for psychological interventions promoting recovery after mTBI.

Risk-targeted behavioral activation for the management of work disability associated with comorbid pain and depression: a feasibility study

Purpose

The purpose of the present study was to conduct a preliminary evaluation of the feasibility and impact of a risk-targeted behavioral activation intervention for work-disabled individuals with comorbid pain and depression.

Methods

The design of the study was a single-arm non-randomized trial. The sample consisted of 66 work-disabled individuals with comorbid pain and depression. The treatment program consisted of a 10-week standardized behavioral activation intervention supplemented by techniques to target two psychosocial risk factors for delayed recovery, namely, catastrophic thinking and perceptions of injustice. Measures of pain severity, depression, catastrophic thinking, perceived injustice, and self-reported disability were completed pre-, mid-, and post-treatment. Satisfaction with treatment was assessed at post-treatment. Return to work was assessed at 6-month follow-up.

Results

The drop-out rate was 18%. At treatment termination, 91% of participants indicated that they were “very” or “completely” satisfied with their involvement in the treatment program. Significant reductions in pain (Cohen’s d = 0.71), depression (d = 0.86), catastrophic thinking (d = 1.1), and perceived injustice (d = 1.0) were observed through the course of treatment. In multivariate analyses, treatment-related reductions in depression, catastrophic thinking, and perceived injustice, but not pain, contributed significant unique variance to the prediction of return-to-work outcomes.

Conclusions

Risk-targeted behavioral activation was found to be an acceptable and effective intervention for work-disabled individuals with comorbid pain and depression. The findings suggest that interventions targeting psychosocial risk factors for pain and depression might contribute to more positive recovery outcomes in work-disabled individuals with comorbid pain and depression.

Trial registration

ClinicalTrials.gov: NCT0517442. Retrospectively registered.

Evaluating the role of perceived injustice in mental health outcomes in cervical cancer care

Purpose

Perceived injustice is a novel psychosocial construct which reflects negative cognitive appraisals of blame, unfairness, and the severity and irreparability of one’s loss. Experiences of injustice are increasingly recognised as a key determinant of recovery outcomes in healthcare. The aim of this study was to explore the impact of perceived injustice on psychological outcomes amongst a group of cancer patients and survivors who received false-negative smear results under a National Cervical Cancer Screening Programme (CervicalCheck).

Methods

Women who received false-negative smear results who were involved in the CervicalCheck controversy in Ireland completed online measures of perceived injustice (IEQ), psychological distress (depression and anxiety as measured by the HADS), and satisfaction with care (PSCC) (n = 144).

Results

Rates of psychological distress in this sample were high, with 76% scoring in the clinical range for anxiety, 51% in the clinical range for depression, and 88% in the clinical range for perceived injustice. Hierarchical regression analyses revealed that perceived injustice contributed unique variance to the prediction of depression and anxiety. Satisfaction with care significantly moderated the association between perceived injustice and depression.

Conclusions

Cancer patients who report high levels of perceived injustice are at greater risk for experiencing psychological distress. The relationship between perceived injustice and depression may vary as a function of satisfaction with care. Addressing issues of perceived injustice in the psychosocial and rehabilitative care of cancer patients may support the early identification of those at risk of significant psychological distress and enhance intervention success. Implications for policy and practice in healthcare are discussed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-07060-z.

eDOL mHealth App and Web Platform for Self-monitoring and Medical Follow-up of Patients With Chronic Pain: Observational Feasibility Study

BACKGROUND

Chronic pain affects approximately 30% of the general population, severely degrades quality of life (especially in older adults) and professional life (inability or reduction in the ability to work and loss of employment), and leads to billions in additional health care costs. Moreover, available painkillers are old, with limited efficacy and can cause significant adverse effects. Thus, there is a need for innovation in the management of chronic pain. Better characterization of patients could help to identify the predictors of successful treatments, and thus, guide physicians in the initial choice of treatment and in the follow-up of their patients. Nevertheless, current assessments of patients with chronic pain provide only fragmentary data on painful daily experiences. Real-life monitoring of subjective and objective markers of chronic pain using mobile health (mHealth) programs can address this issue.

OBJECTIVE

We hypothesized that regular patient self-monitoring using an mHealth app would lead physicians to obtain deeper understanding and new insight into patients with chronic pain and that, for patients, regular self-monitoring using an mHealth app would play a positive therapeutic role and improve adherence to treatment. We aimed to evaluate the feasibility and acceptability of a new mHealth app called eDOL.

METHODS

We conducted an observational study to assess the feasibility and acceptability of the eDOL tool. Patients completed several questionnaires using the tool over a period of 2 weeks and repeated assessments weekly over a period of 3 months. Physicians saw their patients at a follow-up visit that took place at least 3 months after the inclusion visit. A composite criterion of the acceptability and feasibility of the eDOL tool was calculated after the completion of study using satisfaction surveys from both patients and physicians.

RESULTS

Data from 105 patients (of 133 who were included) were analyzed. The rate of adherence was 61.9% (65/105) after 3 months. The median acceptability score was 7 (out of 10) for both patients and physicians. There was a high rate of completion of the baseline questionnaires and assessments (mean 89.3%), and a low rate of completion of the follow-up questionnaires and assessments (63.8% (67/105) and 61.9% (65/105) respectively). We were also able to characterize subgroups of patients and determine a profile of those who adhered to eDOL. We obtained 4 clusters that differ from each other in their biopsychosocial characteristics. Cluster 4 corresponds to patients with more disabling chronic pain (daily impact and comorbidities) and vice versa for cluster 1.

CONCLUSIONS

This work demonstrates that eDOL is highly feasible and acceptable for both patients with chronic pain and their physicians. It also shows that such a tool can integrate many parameters to ensure the detailed characterization of patients for future research works and pain management.

TRIAL REGISTRATION

ClinicalTrial.gov NCT03931694; http://clinicaltrials.gov/ct2/show/NCT03931694.

Concussion in Women's Flat-Track Roller Derby

Concussions are common among flat-track roller derby players, a unique and under-studied sport, but little has been done to assess how common they are or what players can do to manage injury risk. The purpose of this study is to provide an epidemiological investigation of concussion incidence and experience in a large international sampling of roller derby players. Six hundred sixty-five roller derby players from 25 countries responded to a comprehensive online survey about injury and sport participation. Participants also responded to a battery of psychometric assessment tools targeting risk-factors for poor injury recovery (negative bias, social support, mental toughness) and players' thoughts and feelings in response to injury. Per 1,000 athletes, 790.98 concussions were reported. Current players reported an average of 2.2 concussions, while former players reported 3.1 concussions. However, groups were matched when these figures were corrected for differences in years of play (approximately one concussion every 2 years). Other frequent injuries included fractures in extremities and upper limbs, torn knee ligaments, and sprained ankles. We found no evidence that players' position, full-contact scrimmages, or flooring impacted number of concussions. However, neurological history and uncorrected vision were more influential predictors of an individual's number of concussions during roller derby than years of participation or age, though all four contributed significantly. These findings should assist athletes in making informed decisions about participation in roller derby, though more work is needed to understand the nature of risk.