Psychological Factors Influencing Chronic Pain and the Impact of Litigation

The Postconcussion Syndrome and Posttraumatic Headaches in Civilians, Soldiers, and Athletes

Posttraumatic headaches are one of the most common and controversial secondary headache types. After a mild traumatic brain, an estimated 11% to 82% of people develop a postconcussion syndrome, which has been controversial for more than 160 years. Headache is estimated as present in 30% to 90% of patients after a mild head injury. Most headaches are tension-type-like or migraine-like. Headaches in civilians, soldiers, athletes, and postcraniotomy are reviewed. The treatments are the same as for the primary headaches. Persistent posttraumatic headaches can continue for many years.

The efficacy of acceptance and commitment therapy for chronic pain: A three-level meta-analysis and a trial sequential analysis of randomized controlled trials

The current study included randomized controlled trials (RCTs) to assess the benefits of Acceptance and commitment therapy (ACT) for chronic pain. Searches were conducted in Web of Science, PsycINFO, PubMed, Scopus, Cochrane Library, and Embase from inception until September 30, 2022. Thirty-three RCTs, including 2293 participants, were included. Small to medium effect sizes for pain intensity/physical function favoring ACT were found both at post-treatment (pain intensity: g = 0.44; physical function: g = 0.59) and follow-up (pain intensity: g = 0.34; physical function: g = 0.56). The effect sizes on psychological outcomes were significant at post-treatment (depression: g = 0.43; anxiety: g = 0.43; quality of life: g = 0.45) and follow-up (depression: g = 0.43; anxiety: g = 0.35; quality of life: g = 0.43). The results of the trial sequential analyses indicated that pooled estimates were unlikely to be incidental findings, as effects of multiple testing were controlled and power was adequate. Face-to-face ACT yielded significantly larger effects on physical outcomes than internet-delivered ACT. Participants with chronic headache and fibromyalgia showed greater benefit from ACT compared to those with non-specific pain or mixed pain. In addition, the longer the follow-up duration, the smaller the effect sizes for pain intensity/physical function at follow-up. The present meta-analysis suggests sufficient evidence for the significant benefits of ACT for people with chronic pain.

The Litigation Complexity of Posttraumatic Headaches

PURPOSE OF REVIEW

This review explores the workings of the legal process in posttraumatic headache (PTH) claims by discussing representative court cases, the approaches taken by both plaintiff and defense attorneys in evaluating a client with PTH, and the role of the expert witness. This discussion also examines the question of whether or not litigation prolongs the symptoms of PTH and concussion, looking at the issues of malingering and the psychological effect of litigation.

RECENT FINDINGS

Litigation prolongs recovery of PTH, primarily not from malingering but rather due to the psychological mindset of the plaintiff as created by the litigation process. Just as the medical community struggles with PTH diagnosis, mechanism, and treatment, the legal system grapples with identifying valid claims for PTH. Psychological support is an important component for PTH recovery to more effectively deal with the psychological impact of litigation and the concept of perceived injustice.

Pain Across the Menstrual Cycle: Considerations of Hydration

Chronic pain – pain that persists for more than 3 months – is a global health problem and is associated with tremendous social and economic cost. Yet, current pain treatments are often ineffective, as pain is complex and influenced by numerous factors. Hypohydration was recently shown to increase ratings of pain in men, but studies in this area are limited (n = 3). Moreover, whether hypohydration also affects pain in women has not been examined. In women, changes in the concentrations of reproductive hormones across menstrual phases may affect pain, as well as the regulation of body water. This indicates potential interactions between the menstrual phase and hypohydration on pain, but this hypothesis has yet to be tested. This review examined the literature concerning the effects of the menstrual phase and hypohydration on pain, to explore how these factors may interact to influence pain. Future research investigating the combined effects of hypohydration and menstrual phase on pain is warranted, as the findings could have important implications for the treatment of pain in women, interpretation of previous research and the design of future studies.

Negative Life Events (NLEs) Contributing to Psychological Distress, Pain, and Disability in a U.S. Military Sample

Introduction

The objective was to explore how negative life events (NLEs, e.g., litigation related to pain and disability, failing most recent physical fitness test, and financial difficulties) are related to pain coping and psychological adjustment to pain in active duty military personnel.

Materials and Methods

Data were gathered as part of the Evaluation of Suicidality, Cognitions, and Pain Experience study, a DoD-funded cross-sectional assessment of chronic pain and emotional coping among a cohort of military members. The investigators examined data from 147 respondents with complete survey and pain assessment data.

Results

The sample was active duty, male (62.6%), in a relationship or married (83.0%), and had children (68.7%). The majority of the sample endorsed zero NLEs (72.0%); 23.8% endorsed one NLE, 4.2% endorsed two NLEs, and no one endorsed all three NLEs. A significantly higher proportion of participants endorsing one or more NLEs reported suicidal ideation compared to those who reported no NLEs (χ2(2) = 8.61, p = 0.014). A higher number of endorsed NLEs coincided with higher symptom severity related to psychosocial distress (depression, thwarted belongingness, perceived burdensomeness, PTSD, and suicide cognitions) and poor pain coping (rumination, helplessness, and less acceptance of chronic pain).

Conclusions

Findings revealed that NLEs may impart a significant burden on military pain sufferers. Greater numbers of endorsed NLEs are associated with increased psychosocial distress and poor pain coping. Future longitudinal studies examining long-term psychosocial distress/poor pain coping as related to NLEs would help to elaborate the long-term consequences of NLEs on pain coping and psychosocial distress.

Physical and psychological predictors on pain intensity in conscripts with plantar fasciitis

BACKGROUND

Plantar fasciitis is commonly found among the physically active population, including conscripts. Some studies have reported that being overweight and having psychological symptoms contribute to pain from plantar fasciitis. However, there is a lack of information regarding the physical predictors, and more research is needed to determine the relationship between such predictors and pain intensity from plantar fasciitis in conscripts.

OBJECTIVE

To determine which physical and psychological variables act as predictors of pain intensity among Thai novice conscripts with plantar fasciitis.

METHODS

Two hundred and seventy Thai novice conscripts without musculoskeletal pain completed the Depression, Anxiety and Stress Scale short version and then received baseline assessment of ankle dorsiflexion angle, ankle plantarflexor strength, and quality of lower extremity movement from a physical therapist. After 10 weeks of military training, 71 of these Thai conscripts developed pain from plantar fasciitis. Multiple linear regression analysis with the forward stepwise method was used to explore the predictors of pain intensity due to plantar fasciitis.

RESULTS

Using a forward regression analysis, anxiety (B=0.13; 95% CI, 0.06-0.20; p<0.01) and quality of movement score (B=0.87; 95% CI, 0.28-1.47; p=0.01) were significant predictors of pain intensity. The regression model with these predictors explained 25% of the variability in pain intensity from plantar fasciitis.

CONCLUSION

Higher scores of anxiety and movement quality on the lateral step-down task were associated with pain intensity from plantar fasciitis after the completion of a 10-week military program. However, lower ankle dorsiflexion angle and ankle plantarflexor strength did not predict pain intensity.

The context of litigation in evaluating physical and psychological outcomes from pain management programmes

Objectives

There has been extensive research in evaluating chronic pain in the context of litigation while considering the implications that it can have on healthcare outcomes and rehabilitation progress. The aim of this article is to present retrospective observational data about the levels of disability and distress reported by patients with ongoing litigation at the start and following a UK-based multi-disciplinary pain management programme (PMP) when compared with those without litigation.

Method

Between June 2014 and September 2017, 859 patients attended and completed a 16-day PMP at a tertiary-level National Health Service (UK) pain clinic. Patients were split into two groups: (1) litigation (n = 110) and (2) non-litigation (n = 749). As a part of the assessment procedure, the patients were given a battery of psychological and physical measures to complete over two time points.

Results

Patients with litigation are statistically significantly more distressed at assessment but make comparable clinically meaningful change in PMP intervention when compared with a non-litigation sample. A very small proportion of the variance in depression scores post-treatment is accounted for by the context of litigation (0.5%), which may be accounted for by employment status. There was no effect of litigation on physical outcome post-intervention.

Discussion

This article concludes that it is not appropriate to merely assume that the context of litigation results in limited positive psychological and physical outcomes post-PMP. There are some limitations to the clinical sample presented in respect to the conclusions.

Addressing Opioid-Related Chemical Coping in Long-Term Opioid Therapy for Chronic Noncancer Pain: A Multicenter, Observational, Cross-Sectional Study

Opioid consumption has increased worldwide, which carries the risk of opioid use disorder (OUD). However, the literature on OUD and opioid-related chemical coping (OrCC) in chronic noncancer pain (CNCP) is heterogeneous, with most studies conducted in the United States. We performed a multicenter, observational, cross-sectional study to address OrCC in long-term opioid therapy (LtOT) for CNCP in South Korea. The objectives were to determine the frequency and predictors of OrCC. We included 258 patients. Among them, fifty-five (21%) patients showed OrCC. The sample had high pain catastrophizing (≥30 points; 66%), moderate-severe insomnia (≥15 points; 63%), low resilience (68 points), and high suicidal ideation (67%). OrCC patients had greater pain interference (85.18% vs. 58.28%, p = 0.017) and lower satisfaction with the LtOT (56.4% vs. 78.3%, p = 0.002). In multivariable analysis, alcohol abuse (OR = 6.84, p = 0.001), prescription drugs abuse (OR = 19.32, p = 0.016), functional pain (OR = 12.96, p < 0.001), head and neck pain (OR = 2.48, p = 0.039), MEDD (morphine equivalent daily dose) ≥ 200 mg/day (OR = 3.48, p = 0.006), and ongoing litigation (OR = 2.33, p = 0.047) were significant predictors of OrCC. In conclusion, the break-out of OrCC in CNCP in South Korea was comparable to those in countries with high opioid consumption, such as the United States, regardless of the country's opioid consumption rate.

The Polyanalgesic Consensus Conference (PACC): Recommendations for Trialing of Intrathecal Drug Delivery Infusion Therapy

INTRODUCTION

Intrathecal (IT) drug infusion is an appropriate and necessary tool in the algorithm to treat refractory cancer and noncancer pain. The decision-making steps/methodology for selecting appropriate patients for implanted targeted drug delivery systems is controversial and complicated. Therefore, a consensus on best practices for determining appropriate use of IT drug infusion may involve testing/trialing this therapy before implantation.

METHODS

This current Polyanalgesic Consensus Conference (PACC) update was designed to address the deficiencies and emerging innovations since the previous PACC convened in 2012. A literature search identified publications available since the previous PACC publications in 2014, and relevant sources were contributed by the PACC members. After reviewing the literature, the panel determined the evidence levels and degrees of recommendations. The developed consensus was ranked as strong (>80%), moderate (50-79%), or weak (<49%).

RESULTS

The trialing for IT drug delivery systems (IDDS) remains an area of continued controversy. The PACC recommendations for trialing are presented in 34 consensus points and cover trialing for morphine, ziconotide, and medication admixtures; starting doses and titration practices; measurements of success; trial settings and monitoring; management of systemic opioids during trialing; and the role of psychological evaluation. Finally, the PACC describes clinical scenarios in which IT trialing is required or not required.

CONCLUSION

The PACC provides consensus guidance on best practices of trialing for IDDS implants. In addition, the PACC recommends that no trial may be required in certain patient populations.