A new episode of low back pain: who relies on bed rest?

A decision tree algorithm to identify predictors of post-stroke complex regional pain syndrome

This prospective cohort study aimed to identify the risk factors for post-stroke complex regional pain syndrome (CRPS) using a decision tree algorithm while comprehensively assessing upper limb and lower limb disuse and physical inactivity. Upper limb disuse (Fugl-Meyer assessment of upper extremity [FMA-UE], Action Research Arm Test, Motor Activity Log), lower limb disuse (Fugl-Meyer Assessment of lower extremity [FMA-LE]), balance performance (Berg balance scale), and physical inactivity time (International Physical Activity Questionnaire-Short Form [IPAQ-SF]) of 195 stroke patients who visited the Kishiwada Rehabilitation Hospital were assessed at admission. The incidence of post-stroke CRPS was 15.4% in all stroke patients 3 months after admission. The IPAQ, FMA-UE, and FMA-LE were extracted as risk factors for post-stroke CRPS. According to the decision tree algorithm, the incidence of post-stroke CRPS was 1.5% in patients with a short physical inactivity time (IPAQ-SF < 635), while it increased to 84.6% in patients with a long inactivity time (IPAQ-SF ≥ 635) and severe disuse of upper and lower limbs (FMA-UE score < 19.5; FMA-LE score < 16.5). The incidence of post-stroke CRPS may increase with lower-limb disuse and physical inactivity, in addition to upper-limb disuse. Increasing physical activity and addressing lower- and upper-limb motor paralysis may reduce post-stroke CRPS.

Pain Catastrophizing: Controversies, Misconceptions and Future Directions

Recent reports have pointed to problems with the term "pain catastrophizing." Critiques of the term pain catastrophizing have come from several sources including individuals with chronic pain, advocates for individuals with chronic pain, and pain scholars. Reports indicate that the term has been used to dismiss the medical basis of pain complaints, to question the authenticity of pain complaints, and to blame individuals with pain for their pain condition. In this paper, we advance the position that the problems prompting calls to rename the construct of pain catastrophizing have little to do with the term, and as such, changing the term will do little to solve these problems. We argue that continued calls for changing or deleting the term pain catastrophizing will only divert attention away from some fundamental flaws in how individuals with pain conditions are assessed and treated. Some of these fundamental flaws have their roots in the inadequate training of health and allied health professionals in evidence-based models of pain, in the use of psychological assessment and intervention tools for the clinical management of pain, and in gender equity and antiracism. Critiques that pain scholars have leveled against the defining, operational, and conceptual bases of pain catastrophizing are also addressed. Arguments for reconceptualizing pain catastrophizing as a worry-related construct are discussed. Recommendations are made for remediation of the problems that have contributed to calls to rename the term pain catastrophizing. PERSPECTIVE: The issues prompting calls to rename the construct of pain catastrophizing have their roots in fundamental flaws in how individuals with pain are assessed and treated. Efforts to address these problems will require more than a simple change in terminology.

Presurgical sleep and pain behaviors predict insomnia symptoms and pain after total knee arthroplasty: a 12-month longitudinal, observational study

OBJECTIVE

Up to 40% of individuals who undergo total knee arthroplasty (TKA) experience some degree of pain following surgery. Presurgical insomnia has been identified as a predictor of postsurgical pain; however, modifiable presurgical behaviors related to insomnia have received minimal attention. The objective of the present study was to develop a 2-item sleep and pain behavior scale (SP2) to investigate a maladaptive sleep and pain behavior and is a secondary analysis of a larger, parent study.

METHODS

Patients (N = 109) completed SP2 at baseline and 12 months and questionnaires assessing sleep and pain at baseline (pre-TKA), 6 weeks, 3, 6, and 12 months post-TKA. SP2 demonstrated adequate preliminary psychometric properties.

RESULTS

As hypothesized, even after controlling for baseline insomnia, pain, anxiety and other covariates, baseline SP2 predicted insomnia symptom severity at 6 weeks (β = 2.828), 3 (β = 2.140), 6 (β = 2.962), and 12 months (β = 1.835) and pain at 6 weeks (β = 6.722), 3 (β = 5.536), and 6 months (β = 7.677) post-TKA (P < .05). Insomnia symptoms at 6-weeks post-TKA mediated the effect of presurgical SP2 on pain at 3 (95% CI: 0.024-7.054), 6 (95%CI: 0.495-5.243), and 12 months (95% CI: 0.077-2.684).

CONCLUSIONS

This provides preliminary evidence that patients who cope with pain by retiring to their bed and bedroom have higher rates of post-surgical insomnia and pain and supports efforts to target this maladaptive sleep and pain behavior to reduce postsurgical pain.

Post-Stroke Complex Regional Pain Syndrome and Upper Limb Inactivity in Hemiplegic Patients: A Cross-Sectional Study

Purpose

The purpose of this study was to investigate the prevalence of post-stroke complex regional pain syndrome (CRPS) and to examine the characteristics of inactivity status of the upper limb in post-stroke CRPS patients. In addition, as a sub-analysis, the association between the upper limb inactivity status and pain intensity was investigated in post-stroke CRPS patients.

Patients and Methods

This cross-sectional study included 102 patients with first-ever stroke between April 2019 and February 2020. Each patient was allocated into one of two groups based on the presence or absence of CRPS. Demographic data (age, sex, stroke etiology, lesion side, and number of days since stroke onset) were collected. The following evaluations were performed in all patients: Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), and Motor Activity Log (MAL). The numerical rating scale (NRS) to determine pain intensity was assessed only in patients with post-stroke CRPS.

Results

Nineteen and 83 patients were assigned to the post-stroke CRPS and control group, respectively. The prevalence of post-stroke CRPS was 18.6% (19/102). FMA, ARAT, and MAL scores were significantly lower in patients with post-stroke CRPS than those without it. FMA and ARAT scores were significantly correlated with NRS scores, but MAL was almost zero-scored in patients with post-stroke CRPS.

Conclusion

The study results indicated that activity status of the affected upper limb was severely deteriorated, and more inactivity of the upper limb was associated with higher pain intensity in patients with post-stroke CRPS. Thus, our results suggest that post-stroke CRPS may be influenced by the degree of upper limb inactivity after stroke.

The Influence of Expectancies on Pain and Function Over Time After Total Knee Arthroplasty

OBJECTIVE

Expectancies have a well-documented influence on the experience of pain, responses to treatment, and postsurgical outcomes. In individuals with osteoarthritis, several studies have shown that expectations predict increased pain and disability after total knee replacement surgery. Despite the growing recognition of the importance of expectancies in clinical settings, few studies have examined the influence of expectancies throughout postsurgical recovery trajectories. The objective of the present study was to examine the role of presurgical expectancies on pain and function at 6-week, 6-month, and 1-year follow-ups after total knee arthroplasty.

DESIGN AND PARTICIPANTS

Data were collected from patients scheduled for total knee arthroplasty 1 week before surgery and then at 6 weeks, 6 months, and 1 year after surgery. Correlational and multivariable regression analyses examined the influence of expectancies on patients' perceptions of pain reduction and functional improvement at each time point. Analyses controlled for age, sex, body mass index, presurgical pain intensity and function, pain catastrophizing, anxiety, and depression.

RESULTS

Results revealed that expectancies significantly predicted pain reduction and functional improvement at 1-year follow-up. However, expectancies did not predict outcomes at the 6-week and 6-month follow-ups. Catastrophizing and depressive symptoms emerged as short-term predictors of postsurgical functional limitations at 6-week and 6-month follow-ups, respectively.

CONCLUSIONS

The results suggest that targeting high levels of catastrophizing and depressive symptoms could optimize short-term recovery after total knee arthroplasty. However, the results demonstrate that targeting presurgical negative expectancies could prevent prolonged recovery trajectories, characterized by pain and loss of function up to 1 year after total knee arthroplasty.

Pain in Spinal Muscular Atrophy: A Questionnaire Study

OBJECTIVE

This study aimed to reveal the chronic pain prevalence in spinal muscular atrophy (SMA) patients and identify the clinical characteristics of these patients with chronic pain. The pain status was also investigated in SMA patients with chronic pain.

METHODS

This cross-sectional study was conducted between July 2018 and December 2018. SMA type II and type III patients in Japan were mailed a survey questionnaire. The survey items were chronic pain prevalence, clinical characteristics, and motor function. Patients with chronic pain also answered questions on various pain status parameters: pain intensity, frequency, duration, location using body map, and factors that exacerbated and relieved pain.

RESULTS

The questionnaire recovery rate was 61.1%. Sixty-four type II (mean age 17.3 ± 11.7 years) and 22 type III (mean age 44.9 ± 21.6 years) patients were eligible for inclusion. The prevalence of chronic pain in type II and III patients was 40.6% and 40.9%, respectively. Type II patients with chronic pain were more likely to report the inability to sit without manual support than those without pain (p = 0.03). Pain intensity in SMA patients was mild, but pain usually occurred daily, for prolonged durations, most often in the neck, back, and lower extremities. Sitting and high physical activity exacerbated pain the most.

CONCLUSION

The percentage of patients with SMA with chronic pain was high, at above 40%. Moreover, the pain experienced by patients with SMA was low in intensity but frequent and most common in the lower extremities.

Interventions to facilitate return to work in adults with chronic non-malignant pain: a protocol for a systematic review and network meta-analysis

INTRODUCTION

Work absenteeism due to chronic non-malignant pain (CNMP) is a major societal and individual cause of concern that requires effective treatments.

OBJECTIVE

We present a protocol for a systematic review and network meta-analysis (NMA) aiming to compare available interventions for return to work (RTW) in adults with CNMP.

METHODS AND ANALYSIS

PubMed, Embase, PsycINFO, Web of Knowledge and Cochrane Central Register of Controlled Trials databases will be searched till 31 August 2020 for randomised controlled trials (RCTs) examining interventions for RTW outcomes among patients with CNMP. Two independent investigators will search the databases, perform data extraction and assess the methodological quality of the selected RCTs. The primary outcome will be RTW, if possible, full-time or part-time after work absence due to chronic pain from baseline to the last available follow-up. Secondary outcomes will include self-reported workability or work capacity, or self-reported physical functioning and quality of life as measured by any validated scale. Pairwise meta-analysis and NMA will be conducted for each outcome using a random-effects model. For the primary outcomes, we will also obtain the ranking of all competing interventions within each NMA using surface under the cumulative ranking curve. The assumption of coherence (ie, that direct and indirect evidence are in statistical agreement) will be examined using both a local and a global approach. We will also conduct subgroup and meta-regression analyses, whenever feasible, to investigate the unexplained variation in effect size. The comparison-adjusted funnel plot will be used to evaluate small-study effects. The overall quality of evidence will be rated with the Confidence in Network Meta-Analysis tool. Data analysis will be conducted using Stata V.16.0.

ETHICS AND DISSEMINATION

This systematic review does not require ethical approval since it will not disseminate any private patient data. The results of this study will be disseminated through peer-reviewed publication.

PROSPERO REGISTRATION NUMBER

CRD42020171429.

Negative health consequences of pain catastrophizing among retired National Football League athletes

OBJECTIVE

This study examined the association between pain catastrophizing with pain interference, depressive symptoms, and health-related quality of life (HRQoL) among National Football League (NFL) retirees.

METHOD

Former NFL athletes from the Retired NFL Players Association (N = 90) were recruited from 2018 to 2019 via telephone and were administered measures of pain, substance use, depressive symptoms, and HRQoL. Multiple linear and binomial regression analyses examined the association of pain catastrophizing with pain interference, depressive symptoms, and HRQoL while controlling for covariates (i.e., pain intensity, concussions, opioid use, binge alcohol use, years since NFL retirement, and marital status).

RESULTS

Many retired NFL athletes reported moderate-severe depressive symptoms as well as poorer perceived physical health compared with general medical patients. Greater pain catastrophizing was associated with more severe pain interference, greater odds of reporting moderate-severe depressive symptoms, and lower odds of reporting average and above physical and mental HRQoL after adjusting for relevant covariates. Concussions were not associated with any of the study outcomes.

CONCLUSIONS

Given the findings from this study, health care professionals should monitor symptoms of catastrophizing among current and retired NFL athletes. Assessment and requisite treatment of pain catastrophizing may assist these elite athletes in reducing depressive symptoms, while improving pain interference and HRQoL in this population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Association Between Daily Physical Activity and Pain Among Patients with Knee Osteoarthritis: The Moderating Role of Pain Catastrophizing

OBJECTIVE

The primary objective of this study was to examine the day-to-day association between physical activity and pain intensity among a sample of patients with knee osteoarthritis (KOA) and the potential moderation of this association by negative cognitive processes.

METHODS

In this micro-longitudinal daily diary study, KOA patients (N = 121) completed questionnaires assessing pain (Brief Pain Inventory) and psychosocial functioning (pain catrophizing scale, WOMAC McMaster Universities Osteoarthritis Index function, Patient-Reported Outcomes Measurement Information System [PROMIS; anxiety and depression], the Godin-Shephard Leisure-Time Physical Activity questionnaire, the six-minute walking test) and were then asked to report their levels of physical activity and pain intensity once per day for a period of seven days using an electronic diary.

RESULTS

Multilevel modeling analyses indicated that day-to-day increases in physical activity were associated with heightened levels of pain intensity (B = 0.13 SE = 0.03, P < 0.001). In addition, it was revealed that the association between physical activity and pain intensity was moderated by catastrophizing (B = -0.01 SE = 0.002, P < 0.05), with patients scoring higher in catastrophizing showing a relatively stronger link between day-to-day physical activity and increased knee pain. This effect was specific to catastrophizing, as depression and anxiety did not moderate the activity-pain relationship (P > 0.05).

CONCLUSIONS

Our findings suggest that increases in daily physical activity are associated with concurrent increases in KOA patients' levels of knee pain, particularly among patients reporting higher levels of pain catastrophizing. These results may have clinical implications for the design and testing of interventions targeted at reducing catastrophizing and increasing physical activity among patients with chronic osteoarthritis pain.

The Relation Between Catastrophizing and Occupational Disability in Individuals with Major Depression: Concurrent and Prospective Associations

Background Catastrophic thinking has been associated with occupational disability in individuals with debilitating pain conditions. The relation between catastrophic thinking and occupational disability has not been previously examined in individuals with debilitating mental health conditions. The present study examined the relation between catastrophic thinking and occupational disability in individuals with major depression. Methods The study sample consisted of 80 work-disabled individuals with major depressive disorder (MDD) who were referred to an occupational rehabilitation service. Participants completed measures of depressive symptom severity, catastrophic thinking and occupational disability at admission and termination of a rehabilitation intervention. Return-to-work outcomes were assessed 1 month following the termination of the rehabilitation intervention. Results Cross-sectional analyses of admission data revealed that catastrophic thinking contributed significant variance to the prediction of self-reported occupational disability, beyond the variance accounted for by depressive symptom severity. Prospective analyses revealed that reductions in catastrophic thinking predicted successful return to work following the rehabilitation intervention, beyond the variance accounted for by reductions in depressive symptom severity. Conclusions The findings suggest that catastrophic thinking is a determinant of occupational disability in individuals with major depressive disorder. The findings further suggest that interventions designed to reduce catastrophic thinking might promote occupational re-integration in individuals with debilitating mental health conditions.

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

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

PERSPECTIVE

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

Catastrophizing-a prognostic factor for outcome in patients with low back pain: a systematic review

BACKGROUND CONTEXT

Psychological factors including catastrophizing thoughts are believed to influence the development of chronic low back pain (LBP).

PURPOSE

To assess the prognostic importance of catastrophizing as a coping strategy in patients with LBP.

STUDY DESIGN

This is a systematic review.

PATIENT SAMPLE

This study included patients with LBP.

OUTCOME MEASURES

Work-related outcomes and perceived measures including return to work, pain, and disability.

METHODS

In September 2012, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, Medline, Scopus, and Web of Science. To ensure completeness of the search, a hand search and a search of bibliographies were conducted and all relevant references included. All observational studies investigating the prognostic value of catastrophizing in patients with LBP were eligible. Included were studies with 100 and more patients and follow-up of at least 3 months. Excluded were studies with poor methodological quality, short follow-up duration, and small sample size.

RESULTS

A total of 1,473 references were retrieved, and 706 references remained after the removal of duplicates. For 77 references, the full text was assessed and 19 publications based on 16 studies were included. Of four studies that investigated work-related outcomes, two found catastrophizing to be associated with work status. Most studies that investigated self-reported outcome measures (n=8, 66%) found catastrophizing to be associated with pain and disability at follow-up in acute, subacute, and chronic LBP patients. In most studies that applied cutoff values, patients identified as high catastrophizers experienced a worse outcome compared with low catastrophizers (n=5, 83%).

CONCLUSIONS

There is some evidence that catastrophizing as a coping strategy might lead to delayed recovery. The influence of catastrophizing in patients with LBP is not fully established and should be further investigated. Of particular importance is the establishment of cutoff levels for identifying patients at risk.

Changes in pain catastrophizing predict later changes in fibromyalgia clinical and experimental pain report: cross-lagged panel analyses of dispositional and situational catastrophizing

Introduction

Fibromyalgia (FM), characterized by wide-spread diffuse pain and sensory abnormalities, is associated with elevated indices of distress and pain-related catastrophizing compared to both pain-free samples and those with chronic pain conditions. Catastrophizing is a pervasive negative mental set, and is a strong predictor of negative pain-related outcomes such as clinical pain intensity, and physical disability. Situational catastrophizing, measured in the context of experimentally-induced pain, is strongly related to enhanced pain sensitivity, a core aspect of the pathophysiology of fibromyalgia. However, little is known regarding the temporal course of the association between catastrophizing and pain-related "outcomes". Most studies involve only static assessments of pain and catastrophizing at a single time point, which provides little insight into the direction of the observed associations. We sought to investigate the temporal relationships between catastrophizing and indices of both clinical pain (substudy 1) and experimentally-induced pain (substudy 2) in a larger randomized controlled longitudinal trial.

Methods

Fifty-seven patients with FM completed catastrophizing, depression, and pain questionnaires as well as laboratory cold pressor pain testing at baseline, post-intervention and three month follow-up during a lifestyle physical activity study. Cross-lagged panel analyses were used to address these temporal relationships.

Results

In substudy 1, analyses revealed that pre-to-post changes in dispositional catastrophizing ratings prospectively accounted for unique variance in subsequent post-to-follow-up changes in clinical pain ratings (p = 0.005), while pre-to-post changes in pain ratings did not account for unique variance in post-to-follow-up changes in catastrophizing ratings. An identical pattern was observed experimentally in substudy 2, with pre-to-post changes in situational catastrophizing ratings prospectively accounting for unique variance in subsequent post-to-follow-up changes in experimental pain ratings (p = 0.014), while pre-to-post changes in pain ratings did not account for unique variance in post-to-follow-up changes in catastrophizing ratings. Specifically, initial alterations in catastrophizing were associated with subsequent alterations in clinical and experimentally induced pain. Controlling for levels of depression did not affect the results.

Conclusions

These findings provide empirical evidence that catastrophizing processes might precede and contribute to subsequent alterations in the pain experience for FM patients.

Trial Registration

clinicaltrials.gov: NCT00383084.

The role of presurgical expectancies in predicting pain and function one year following total knee arthroplasty

The present study examined the prospective value of response expectancies (ie, pain, sleep) and behavioral outcome expectancies (ie, return to function) in the prediction of pain severity and functional limitations 12 months after total knee arthroplasty (TKA). The study sample consisted of 120 individuals (73 women, 47 men) with osteoarthritis of the knee who were scheduled for TKA. Measures of expectancies, pain severity, pain catastrophizing, pain-related fears of movement, and depression were completed prior to surgery. Participants also completed measures of pain severity and functional limitations 12 months following surgery. Analyses revealed that behavioral outcome expectancies were stronger predictors of follow-up pain and functional limitations than response expectancies. Consistent with previous research, analyses also revealed that pain catastrophizing, pain-related fear of movement, and depression predicted follow-up pain and function. In a multivariate analysis, only pain catastrophizing contributed significant unique variance to the prediction of follow-up pain and function. Behavioral outcome expectancies partially mediated the relation between catastrophizing and follow-up pain and function. The relation between catastrophizing and follow-up pain severity and functional limitations remained significant even when controlling for behavioral outcome expectancies. The results suggest that interventions designed to specifically target behavioral outcome expectancies and catastrophizing might improve post-surgical outcomes.

Comparison of physician's advice for non-specific acute low back pain in Japanese workers: advice to rest versus advice to stay active

To assess the effects of physician's advice on non-specific acute low back pain (ALBP) in Japanese workers, existing data from a prospective, epidemiological study of Japanese workers were analyzed. Among workers who had had low back strain during the past year at baseline and responded to the 1-yr follow-up survey (n=475), those who obtained medical care (n=255) and received advice either to rest (n=68 for the rest group) or to stay active (n=32 for the active group) were examined. The rest group seemed to have a higher risk of ALBP than the active group after adjusting for age, gender, history of low back strain, type of physical activity at work, and severity of LBP during the past month at baseline (adjusted OR for the rest group vs. the active group: 3.65, 95%CI: 0.96-13.8). Compared to the active group, low back strain was more likely to occur repeatedly and to become chronic in the rest group. These findings suggest that advice to rest may not be better than advice to stay active for preventing future episodes of ALBP in Japanese workers, which is consistent with previous studies or guidelines for the management of ALBP in Western countries.

Patients at risk for long-term sick leave because of low back pain

BACKGROUND CONTEXT

Ten percent of patients with low back pain (LBP) are not able to resume work within 3 months of sick leave, accounting for 90% of all medical and indemnity costs.

PURPOSE

To quantify the relative contribution of sociodemographic, clinical, occupational, and psychological risk factors in determining the non-return to work after 3 months of compensated LBP and to develop a screening tool to identify patients who require further guidance and rehabilitation.

STUDY DESIGN/SETTING

A 6-month prospective cohort study of disabled workers applying for compensation benefit because of LBP during a 6-month period in the Belgian compulsory health insurance system.

PATIENT SAMPLE

Three hundred and forty-six patients.

OUTCOME MEASURES

Patients unable to resume work within 3 months of sick leave were classified as bad outcomes.

METHODS

Consecutively, injured workers applying for income replacement benefits between October 2003 and March 2004 because of LBP were followed 6 months after the start of the sick leave period. All subjects underwent a standardized physical examination and completed a battery of 12 self-report questionnaires.

RESULTS

Forty-seven percent of the population had not resumed work 3 months after the start of the sick leave period. The risk factors for sickness absence more than 3 months were Oswestry disability index (odds ratio for each point increase: 1.04; 95% confidence interval: 1.02-1.06), fear of avoidance severity score (odds ratio for each point increase: 1.05; confidence interval: 1.02-1.09), blue collar worker (odds ratio: 2.18; confidence interval: 1.21-3.92), LBP for less than 12 weeks before sick leave (odds ratio: 0.32; confidence interval: 0.17-0.64), and pain behavior (odds ratio for each point increase: 1.72; confidence interval: 1.25-2.39). A multivariate screening test based on five questions identified 80% of the patients unable to resume work after 3 months of sick leave (specificity: 56.6; cut off: 0.4).

CONCLUSIONS

A questionnaire comprising a limited set of items allows a practical screening of LBP patients unlikely to resume work.