A Principal Components Analysis of Negative Affect-Related Constructs Relevant to Pain: Evidence for a Three Component Structure

Social network and related factors in older people with sensory impairment in the community: Using principal component analysis

AIM

Older people with sensory impairment are more likely to have smaller and weaker social network due to their reduced ability, which lowers their quality of life. However, there is little research on the social network in older people with sensory impairment, especially the related factors. The aim of the study was to explore the related factors of social network and to provide evidence for the improvement of social network to promote successful aging in older people with sensory impairment.

METHODS

A cross-sectional study was conducted among 374 participants for hearing and vision assessment and questionnaire survey in a community, Beijing. Data were collected and analyzed by principal component analysis (PCA) and multiple logistic regression using IBM SPSS 25.0 software.

RESULTS

PCA showed that there were six risk factors whose eigenvalues >1 were extracted, with a total variance of 56.555%. Multiple logistic regression analysis of principal component indicated that five factors including physical health factor, social interaction factor, psychological status factor, lifestyle factor, and family condition factor, were statistically significant (p < 0.05).

CONCLUSIONS

The social network of older people with sensory impairment is relatively poor. Physical health factor, social interaction factor, psychological status factor, lifestyle factor, and family condition factor may be related factors. Medical staff should pay attention to physical, psychological and social characteristics of older people, especially with sensory impairment, to carry out necessary measures to improve social network and avoid social isolation.

Which Psychological and Psychosocial Constructs Are Important to Measure in Future Tendinopathy Clinical Trials? A Modified International Delphi Study With Expert Clinician/Researchers and People With Tendinopathy

OBJECTIVE: To identify which psychological and psychosocial constructs to include in a core outcome set to guide future clinical trials in the tendinopathy field. DESIGN: Modified International Delphi study. METHODS: In 3 online Delphi rounds, we presented 35 psychological and psychosocial constructs to an international panel of 38 clinician/researchers and people with tendinopathy. Using a 9-point Likert scale (1 = not important to include, 9 = critical to include), consensus for construct inclusion required ≥70% of respondents rating "extremely critical to include" (score ≥7) and ≤15% rating "not important to include" (score ≤3). Consensus for exclusion required ≥70% of respondents rating "not important to include" (score ≤3) and ≤15% of rating "critical to include" (score ≥7). RESULTS: Thirty-six participants (95% of 38) completed round 1, 90% (n = 34) completed round 2, and 87% (n = 33) completed round 3. Four constructs were deemed important to include as part of a core outcome set: kinesiophobia (82%, median: 8, interquartile range [IQR]: 1.0), pain beliefs (76%, median: -7, IQR: 1.0), pain-related self-efficacy (71%, median: 7, IQR: 2.0), and fear-avoidance beliefs (73%, median: -7, IQR: 1.0). Six constructs were deemed not important to include: perceived injustice (82%), individual attitudes of family members (74%), social isolation and loneliness (73%), job satisfaction (73%), coping (70%), and educational attainment (70%). Clinician/researchers and people with tendinopathy reached consensus that kinesiophobia, pain beliefs, pain self-efficacy, and fear-avoidance beliefs were important psychological constructs to measure in tendinopathy clinical trials. J Orthop Sports Phys Ther 2024;54(1):1-12. Epub 20 September 2023. doi:10.2519/jospt.2023.11903.

Principal component analysis of the biopsychosocial features relevant to temporomandibular disorders

OBJECTIVES

This study aimed to explore the dimensionality of three biopsychosocial constructs with multiple subdimensions, including the Symptom Checklist-90-Revised (SCL-90R), pain catastrophizing scale (PCS) and Pittsburgh Sleep Quality Index (PSQI), and to identify the latent dimensions of five biopsychosocial constructs (SCL-90R, PCS, PSQI, pain severity, and pain interference) using the principal component analysis (PCA) in patients with temporomandibular disorder (TMD).

SUBJECTS AND METHODS

A secondary analysis of a previous cross-sectional study comprising 1488 patients with painful TMD was conducted using multiple questionnaires.

RESULTS

PCA of the SCL-90R and PCS identified one factor, which explained 60.8% and 80.2% of the total variance, respectively. For the PSQI, three factors explained 61.3% of the variance. PCA resulted in two main orthogonal components: factor 1, which comprised a combination of scores for pain severity, pain interference and global scores of PCS, and PSQI; and factor 2, which comprised one measure of the SCL-90R. Factors 1 (46.5%) and 2 (20.0%) explained 66.5% of the total variance.

CONCLUSION

The findings of this study revealed that five measures can be primarily categorised into two latent constructs of the psychological (affective) and pain-related (sensory-cognitive) dimensions. These core components could be applied in clinical settings and for research purposes.

Vulnerable Dispositional Traits and Chronic Pain: Predisposing but not Predetermining

Dispositional traits can be protective or contribute to increased vulnerability in individuals with chronic pain. This study aims to evaluate the association between two dispositional trait measures, affect balance style and multi-domain trait groups, with psychosocial measures, clinical pain, functional pain, and experimental pain at two years in individuals with chronic knee pain. The study is a prospective analysis of 168 community dwelling individuals aged 45 to 85 years old with knee pain with or at risk for knee osteoarthritis. At baseline, affect balance style and multi-domain trait groups were associated with psychosocial measures, clinical pain, and functional status. At the two-year time point, the multi-domain trait groups were associated with the clinical pain measures. Interestingly, individuals with previously demonstrated vulnerable traits showed more variability in dispositional trait status at the two-year time point compared to those with dispositional traits previously demonstrated as more protective. Findings reiterate that dispositional traits are predisposing but are not predetermining regarding pain-related experiences. PERSPECTIVE: Vulnerable and protective dispositional traits are positively and negatively associated with clinical pain and functional limitations respectively. Although considered relatively stable, a 30-50% shift in dispositional traits was indicated over a two-year period. Findings highlight that dispositional trait are modifiable and thus, predisposing but not predetermining for persisting chronic pain.

Use of healthcare resources in patients with low back pain and comorbid depression or anxiety

BACKGROUND CONTEXT

Psychological comorbidities are important prognostic factors for low back pain (LBP). To develop improved treatment paradigms, it is first necessary to characterize and determine current patterns of treatment in this population.

PURPOSE

Identify how comorbid depression or anxiety in patients with LBP is related to use of healthcare resources.

STUDY DESIGN/SETTING

Retrospective cohort study using electronic health records from outpatient offices at a large multisite academic medical center.

PATIENT SAMPLE

Data from 513,088 unique patients seen between January 2010 and July 2020 (58.0% female, 52.6±19.5 years) with a diagnosis of LBP, indicated by predetermined ICD-9 and ICD-10 codes.

OUTCOME MEASURES

Average self-reported pain scores, absolute differences and unadjusted risk ratios to compare opioid use, emergency department visits, hospitalizations, advanced imaging orders, spinal injections, and back surgeries between cohorts.

METHODS

Clinical characteristics and data regarding use of healthcare resources were extracted from the electronic health record. Clinical features and patterns in healthcare utilization were determined for patients with depression or anxiety compared to those without.

RESULTS

Depression or anxiety was coded for 21.4% of patients at first LBP visit. Those with depression or anxiety were more likely to be on opioids (unadjusted risk ratio: 1.22, CI: [1.22,1.23]), go to the emergency department (1.31 [1.30-1.33]), be hospitalized (1.15 [1.13, 1.17]), receive advanced imaging (1.09 [1.08, 1.11]), receive an epidural steroid injection (1.16 [1.15, 1.18]), and less likely to have back surgery (0.74 [0.72, 0.77]). Differences in pain scores for those with depression/anxiety compared to those without were not clinically significant.

CONCLUSIONS

Depression/anxiety is associated with increased use of healthcare resources, and is not associated with clinically meaningful elevated pain scores. Limitations come from use of an aggregate data set and reliance on administrative coding.

Attentional Biases Towards Body Expressions of Pain in Men and Women

This study investigated whether there are gender differences in attention to bodily expressions of pain and core emotions. Three experiments are reported using the attentional dot probe task. Images of men and women displaying bodily expressions, including pain, were presented. The task was used to determine whether participants' attention was drawn towards or away from target expressions. Inconsistent evidence was found for an attentional bias towards body expressions, including pain. While biases were affected by gender, patterns varied across the Experiments. Experiment 1, which had a presentation duration of 500 ms, found a relative bias towards the location of male body expressions compared to female expressions. Experiments 2 and 3 varied stimulus exposure times by including both shorter and longer duration conditions (e.g., 100 vs. 500 vs. 1250 ms). In these experiments, a bias towards pain was confirmed. Gender differences were also found, especially in the longer presentation conditions. Expressive body postures captured the attention of women for longer compared to men. These results are discussed in light of their implications for why there are gender differences in attention to pain, and what impact this has on pain behaviour. PERSPECTIVE: We show that men and women might differ in how they direct their attention towards bodily expressions, including pain. These results have relevance to understanding how carers might attend to the pain of others, as well as highlighting the wider role that social-contextual factors have in pain.

Does Pain Acceptance Buffer the Negative Effects of Catastrophizing on Function in Individuals With Chronic Pain?

OBJECTIVES

Pain catastrophizing and pain acceptance are psychological factors that have been shown to be associated with pain-related outcomes and predict multidisciplinary pain treatment outcomes. However, they are rarely examined in the same study. This study aimed to: (1) assess the independent roles of pain catastrophizingand pain acceptance as predictors of pain intensity, pain interference, and depression; and (2) evaluate the potential moderating role of pain acceptance on the association between pain catastrophizing and both pain and function.

MATERIALS AND METHODS

A sample of 467 adults with chronic pain completed an online survey including measures of pain intensity, pain interference, depression, pain catastrophizing, and pain acceptance.

RESULTS

Pain catastrophizing and pain acceptance were independent predictors of pain interference. Only pain catastrophizing and the activity engagement domain of pain acceptance were independent predictors of pain intensity and depression. Activity engagement moderated the association between pain catastrophizing and depression, indicating a buffering effect on the negative effects of catastrophizing on depression. Pain willingness moderated the association between pain catastrophizing and pain interference, such that endorsing low pain willingness may override any negative effects of pain catastrophizing.

DISCUSSION

The findings suggest that pain catastrophizing and pain acceptance are independently important to adjustment to chronic pain. Research is needed to determine if treatments that target both for change are more effective than treatments that target only one.

Characterization of acute pain-induced behavioral passivity in mice: Insights from statistical modeling

Affective-motivational disturbances are highly inconsistent in animal pain models. The reproducibility of the open-field test in assessing anxiety, malaise or disability remains controversial despite its popularity. While traumatic, persistent or multiregional pain models are commonly considered more effective in inducing negative affect or functional impairment, the early psychobehavioral changes before pain chronification are often underexplored. Here, we aimed to clarify the fundamental relationship between hypernociception and passive distress-like behavior using a model of transient inflammatory pain. To minimize latent confounders and increase data consistency, male C57BL/6N mice were habituated to the open-field arena 6 times before receiving the unilateral intraplantar injection of prostaglandin E2 (PGE2) or vehicle. Open-field (40-min exploration) and nociceptive behavior were evaluated repeatedly along the course of hypernociception in both wild-type and transgenic mice with a known pronociceptive phenotype. To reduce subjectivity, multivariate open-field behavioral outcomes were analyzed by statistical modeling based on exploratory factor analyses, which yielded a 2-factor solution. Within 3 hr after PGE2 injection, mice developed significantly reduced center exploration (factor 1) and a marginally significant increase in their habituation tendency (factor 2), which were not apparent in vehicle-injected mice. The behavioral passivity generally improved as hypernociception subsided. Therefore, transient inflammatory irritation is sufficient to suppress mouse open-field exploratory activity. The apparent absence of late affective-motivational changes in some rodents with prolonged hypernociception may not imply a lack of preceding or underlying neuropsychological alterations. Procedural pain after invasive animal experiments, however small, should be assessed and adequately controlled as a potential research confounder.

Obstetric pain correlates with postpartum depression symptoms: a pilot prospective observational study

BACKGROUND

Data linking labor pain and postpartum depression are emerging. Robust, prospective evaluations of this relationship while factoring other important variables are lacking. We assessed perinatal pain and other factors predicting postpartum depression (PPD) symptoms.

METHODS

Third trimester women, stratified by a priori plan to receive or avoid labor epidural analgesia, were longitudinally followed from the prenatal period through labor and delivery, until 6 weeks and 3 months postpartum. Electronic pain data was collected hourly during labor in real time, capturing pain unpleasantness, intensity, pain management satisfaction, and expectations. Prenatal and postpartum data included anxiety, depression, the Brief Pain Inventory (BPI), pain catastrophizing, resiliency, and perceived social support and stress. The primary outcome was Edinburgh Postnatal Depression Score (EPDS) as a marker of PPD symptoms. The primary pain variable of interest was labor pain emotional valence (unpleasantness burden, area under the curve for entire labor duration). Single and multivariable linear regressions examined perinatal pain variables in relation to EPDS.

RESULTS

Of 72 subjects included, 55 planned/received labor epidural analgesia and 17 planned avoidance/avoided it. In the planned epidural group, the emotional valence of labor pain independently predicted six-week EPDS (labor pain unpleasantness burden, R² = 0.42, P = 0.002). In addition to labor pain, prenatal and postpartum pain variables from the BPI independently predicted six-week EPDS. Three-month depression scores were linked to labor and acute pain (6 weeks postpartum), but not to chronic (3 months postpartum) pain variables. Intrapartum pain management satisfaction and expectations were largely met or exceeded and did not differ between analgesia groups.

CONCLUSION

For susceptible women, pain at all perinatal time points-prenatal, labor, and postpartum-appear to be independently linked to depression scores at 6 weeks postpartum. The relationships are true, even though satisfaction and expectations regarding labor pain management were met or exceeded. These data support the concept that labor and acute postpartum pain influences both acute and long-term PPD symptoms, although additional data are needed to assess how analgesia preference interacts with these relationships.

Missed targets, reaction times, and arousal are related to trait anxiety and attention to pain during an experimental vigilance task with a painful target

Although hypervigilance may play a role in some clinical pain syndromes, experimental vigilance toward painful stimuli has been studied infrequently. We evaluated vigilance toward pain by using a continuous performance task (CPT), in which subjects responded to moderately intense painful target stimuli, occurring in a train of mildly painful nontargets. We assessed nondetected targets (misses), reaction times (RTs), and psychological activation (tense arousal). During time on task in CPTs of other sensory modalities, there is an increase in misses and RTs (vigilance decrement). We hypothesized that our CPT would influence vigilance performance related to pain, anxiety, and limitation of attentional resources. The results showed a decrement in vigilance over time as misses increased, although RTs were unchanged. While mind-wandering did not influence vigilance performance, intrinsic attention to pain drove both hit RTs and number of misses. This resulted in pain-focused subjects performing worse on the CPT pain task with slower RTs and more misses per block. During the CPT, the change in stimulus salience was related to the change in pain intensity, while pain unpleasantness correlated with tense arousal. CPT performance during experimental vigilance to pain and psychological activation were related to trait anxiety, as measured by the Spielberger State-Trait Anxiety Inventory and neuroticism, as measured by the NEO five factor inventory. Trait anxiety and neuroticism may play important roles in an individual's predisposition to dwell on pain and interpret pain as threatening.NEW & NOTEWORTHY Subjects detected moderately painful target stimuli in a train of mildly painful nontarget stimuli, which resulted in vigilance performance metrics including missed targets, reaction times, and psychological activation. These performance metrics were related to intrinsic attention to pain and trait anxiety. Subjects with high trait anxiety and neuroticism scores, with a predisposition to attend to pain, had greater tense arousal and poorer vigilance performance, which may be important psychological aspects of vigilance to pain.

Association Between Catastrophizing and Dizziness-Related Disability Assessed With the Dizziness Catastrophizing Scale

Importance

Catastrophizing is a maladaptive thought process that involves irrational fear and worry about anticipated or actual symptoms. Although clinically relevant, the role of catastrophizing in patients with chronic dizziness or imbalance has not yet been explored to our knowledge.

Objectives

To validate a measure of dizziness catastrophizing and to assess its association with dizziness-related disability compared with other negative affect constructs (eg, anxiety and depression).

Design, Setting, and Participants

For this retrospective medical record review, the Dizziness Catastrophizing Scale (DCS), a dizziness-specific catastrophizing assessment tool, was adapted from the previously validated Pain Catastrophizing Scale. Psychometric evaluation of the DCS was performed. In addition, the associations of dizziness catastrophizing and positive and negative affectivity with dizziness-related disability were assessed using structural equation modeling and regression analyses. Data were collected using a retrospective medical record review from April 27, 2010, to June 25, 2014. The dates of analysis were June 3 to August 15, 2017. The setting was the Multidisciplinary Neurotology Clinic at the Toronto General Hospital (Toronto, Ontario, Canada). Participants were 457 adult outpatients with dizziness or imbalance who were referred to the clinic.

Main Outcomes and Measures

Psychometric properties of the DCS and its association with dizziness-related disability, as measured with the Dizziness Handicap Inventory.

Results

Among 457 patients (mean [SD] age, 53.4 [15.4] years; 154 [33.7%] male), the DCS demonstrated good convergent (r = 0.78, P < .001) and discriminant validity (r = -0.40, P < .001) with the negative and positive affectivity, respectively; internal consistency (α = .95); and test-retest reliability (intraclass correlation coefficient, 0.92; P < .001 at the 95% CI). An exploratory dimension reduction analysis revealed a single latent component of the DCS. The results of the structural equation modeling and regression analyses revealed that dizziness catastrophizing, although associated with negative affectivity (eg, symptoms of anxiety and depression), was independently associated with dizziness-related disability (standardized β = 0.378; P < .001). Furthermore, a strong association was found between catastrophizing and dizziness-related disability across different dizziness-related diagnoses (r ≥ 0.6; P < .001).

Conclusions and Relevance

In this study, the DCS was a valid and reliable measure for evaluating catastrophic thinking in patients with dizziness, which was independently associated with dizziness-related disability. Future studies should investigate the influence of alleviating symptoms of catastrophizing on functional outcomes in patients with dizziness or imbalance, the results of which will help guide novel approaches to the clinical care of patients with chronic dizziness.

Pain self-efficacy moderates the association between pain and somatization in a community sample

Background and aims Pain is a common condition. However, only a minority of people experiencing pain develop a chronic pain problem. Factors such as somatization, pain self-efficacy and lack of psychological well-being affect the risk of pain chronicity and pain-related disability. However, research on protective pain-related psychological factors in populations without chronic pain is scarce. We aim to examine if pain self-efficacy attenuates the associations between pain and both anxiety and somatization in a community sample. Methods In a cross-sectional study, 211 participants from a community sample responded to measures of average pain over the last 3 months, anxiety, somatization, and pain self-efficacy. The possibility of moderation effects were tested with a series of regression analyses. Results The association between pain and anxiety was not moderated by pain self-efficacy. In contrast, pain self-efficacy moderated the relation of pain and somatization. The interaction explained 3% of the variance in somatization, in addition to the independent effects of pain and self-efficacy (F(1,207)=5.65, p<0.025). Among those in the bottom quartile of pain self-efficacy, the association between pain and somatization was moderate or strong (r=0.62, p<0.01), whereas for those in the top quartile the association was modest (r=0.11, p>0.05). Conclusions The results are partly consistent with the hypothesis that pain self-efficacy attenuates the associations between pain and pain chronification risk factors in a relatively healthy community sample. Should further preferably longitudinal studies replicate the findings, the role pain self-efficacy as a protective factor needs to be explicated in theoretical models of pain chronification. Implications The findings are consistent with the notion that clinicians should promote patient's pain self-efficacy in acute and sub-acute pain conditions especially when the individual is prone to somatization. However, more prominent clinical implications require studies with longitudinal designs.

Latent variable analysis of negative affect and its contributions to neural responses during shock anticipation

Negative affect is considered an important factor in the etiology of depression and anxiety, and is highly related to pain. However, negative affect is not a unitary construct. To identify specific targets for treatment development, we aimed to derive latent variables of negative affect and test their unique contributions to affective processing during anticipation of unpredictable, painful shock. Eighty-three subjects (43 with depression and anxiety spectrum disorders and 40 healthy controls) completed self-report measures of negative valence and underwent neuroimaging while exploring computer-simulated contexts with and without the threat of a painful, but tolerable, shock. Principal component analysis (PCA) extracted distinct components of general negative affect (GNA) and pain-related negative affect (PNA). While elevated GNA and PNA were both indicative of depression and anxiety disorders, greater PNA was more strongly related to task-specific anxious reactivity during shock anticipation. GNA was associated with increased precuneus and middle frontal gyrus activity, whereas PNA was related to increased bilateral anterior insula activity. Anterior insula activity mediated the relationship between PNA and task-specific anxious reactivity. In conclusion, GNA and PNA have distinct neural signatures and uniquely contribute to anxious anticipation. PNA, via insula activity, may relate to arousal in ways that could contribute to affective dysregulation, and thus may be an important treatment target.

Delineation between different components of chronic pain using dimension reduction - an ASL fMRI study in hand osteoarthritis

Background

Traditional psychometric measures aimed at characterizing the pain experience often show considerable overlap, due to interlinked affective and modulatory processes under central nervous system control. Neuroimaging studies have been employed to investigate this complexity of pain processing, in an attempt to provide a quantifiable, adjunctive description of pain perception. In this exploratory study, we examine psychometric and neuroimaging data from 38 patients with painful osteoarthritis of the carpometacarpal joint. We had two aims: first, to utilize principal component analysis (PCA) as a dimension reduction strategy across multiple self‐reported endpoints of pain, cognitive and affective functioning; second, to investigate the relationship between identified dimensions and regional cerebral blood flow (rCBF) as an indirect measure of brain activity underpinning their ongoing pain experiences.

Methods

Psychometric data were collected using validated questionnaires. Quantitative estimates of rCBF were acquired using pseudo‐continuous arterial spin‐labelled functional magnetic resonance imaging.

Results

Two principal components were identified that accounted for 73% of data variance; one related to pain scores and a second to psychological traits. Voxel‐wise multiple regression analysis revealed a significant negative association between the ‘pain score’ component and rCBF to a right temporal lobe cluster, including the amygdala and the parahippocampal cortex.

Conclusion

We suggest this association may represent a coping mechanism that aims to reduce fear‐related pain‐anxiety. Further investigation of central brain processing mechanisms in osteoarthritis‐related pain may offer insights into more effective therapeutic strategies.

Significance

This study demonstrates that dimension reduction using PCA allows insight into pain perception and its affective components in relation to brain activation patterns in patients with painful hand osteoarthritis.

Is Use of a Psychological Workbook Associated With Improved Disabilities of the Arm, Shoulder and Hand Scores in Patients With Distal Radius Fracture?

BACKGROUND

Symptom intensity and magnitude of limitations correlate with stress, distress, and less effective coping strategies. It is unclear if interventions to target these factors can be used to improve outcomes after distal radius fracture in either the short- or longer term.

QUESTIONS/PURPOSES

(1) Are there any factors (including the use of a workbook aimed at optimizing psychological response to injury, demographic, radiographic, medical, or psychosocial) associated with improved Disabilities of the Arm, Shoulder and Hand (DASH) and Numerical Rating Scale pain (NRS pain) scores at 6 weeks after management of distal radius fracture? (2) Are any of these factors associated with improved DASH and NRS pain scores at 6 months after management of distal radius fracture?

METHODS

We conducted a double-blind randomized controlled trial comparing a workbook designed to optimize rehabilitation by improving psychological response to injury using recognized psychological techniques (the LEARN technique and goal setting) versus a workbook containing details of stretching exercises in the otherwise routine management of distal radius fracture. Patients older than 18 years of age with an isolated distal radius fracture were recruited within 3 weeks of injury from a single academic teaching hospital between March and August 2016. During recruitment, 191 patients who met the inclusion criteria were approached; 52 (27%) declined participation and 139 were enrolled. Eight patients (6%) were lost to followup by 6 weeks. The remaining cohort of 129 patients was included in the analysis. DASH scores and NRS pain scores were recorded at 6 weeks and 6 months after injury. Multivariable regression analysis was used to identify factors associated with outcome scores.

RESULTS

At 6 weeks after distal radius fracture, when compared with an information-only workbook, use of a psychologic workbook was not associated with improved DASH (workbook DASH: 38 [range, 21-48]; control DASH: 35 [range, 21-53]; difference of medians: 3; p = 0.949) nor NRS pain scores (workbook NRS: 3 [range, 1-5]; control NRS: 2 [range, 1-4]; difference of medians: 1; p = 0.128). Improved DASH scores were associated with less radial shortening (β = 0.2, p = 0.009), less dorsal tilt (β = 0.2, p = 0.035), and nonoperative treatment (β = 0.2, p = 0.027). Improved NRS pain scores were associated with nonoperative treatment (β = 0.2, p = 0.021) and no posttraumatic stress disorder (PTSD) (β = 0.2, p = 0.046). At 6 months, use of a psychologic workbook was not associated with improved DASH (workbook DASH: 11 [range, 5-28]; control DASH: 11 [range, 3-20]; difference of medians: 0; p = 0.367) nor NRS pain scores (workbook NRS: 1 [range, 0-2]; control NRS: 1 [range, 0-2]; difference of medians: 0; p = 0.704). Improved DASH score at 6 months was associated with having fewer medical comorbidities (β = 0.3, p < 0.001) and lower enrollment PTSD (β = 0.3, p < 0.011). Lower NRS pain scores at 6 months were associated with having fewer medical comorbidities (β = 0.2, p = 0.045), lower enrollment PTSD (β = 0.3, p = 0.008), and lower enrollment Tampa Scale for Kinesiophobia (β = 0.2, p = 0.042).

CONCLUSIONS

Our study demonstrates that there is no benefit from the untargeted use of a psychological workbook based on the LEARN approach and goal-setting strategies in patients with distal radius fracture. Future research should investigate if there is a subgroup of patients with a negative psychological response to injury that benefits from psychological intervention and, if so, how best to identify these patients and intervene.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Constructs of health belief and disabling distal upper limb pain

BACKGROUND

Musculoskeletal pain in the distal upper limb is common and is a cause of disability and healthcare consultation. At the time of presentation individuals reporting similar pain severities may report different levels of related disability. The biopsychosocial model proposes that health beliefs may help explain this difference. The aim of this cross-sectional study was to identify underlying constructs of health belief in those referred to physiotherapy with pain in the distal upper limb and investigate whether these constructs moderated the relationship between pain severity and extent of disability.

METHOD

Health beliefs were assessed using an instrument included in a questionnaire completed before randomisation to the Arm Pain Trial (ISRCTN79085082). Ordinal responses to statements about health beliefs were used to generate a polychoric correlation matrix. The output from this matrix was then used for Exploratory Factor Analysis to determine underlying constructs. The moderating influence of the identified health belief constructs was then tested using interaction terms in linear regression models.

RESULTS

476 trial participants contributed data, age range 18-85 (mean 48.8, SD 13.7), 54% female. Five health belief constructs were identified: beliefs about hereditary factors, beliefs about movement and pain, beliefs about locus of control, beliefs about the role of lifecourse/lifestyle factors, and beliefs about prognosis. The only health belief construct found to moderate the pain-disability relationship was beliefs about prognosis, with greater pessimism resulting in higher levels of disability at mild-to-moderate levels of pain severity (B -0.17, 95% CI -0.30, -0.036).

CONCLUSION

This exploratory cross-sectional study identified five constructs of health belief from responses to a previously used set of statements investigating fear avoidance and illness beliefs in a clinical population with pain in the distal upper limb. Of these constructs, beliefs about prognosis were found to moderate the relationship between pain and disability.

IMPLICATIONS

At the time of referral to physiotherapy it may be beneficial to assess patients' perception of prognosis. For those with higher than expected disability for the presenting level of pain, and pessimism about prognosis, focused reassurance may play an important part in initial consultation. Longitudinal study is required to support the findings from this study and investigate whether a causal relationship exists. Future investigations should confirm the health belief constructs proposed.

The disruptive effects of pain on multitasking in a virtual errands task

Background and aims

Pain is known to have a disruptive effect on cognitive performance, but prior studies have used highly constrained laboratory tasks that lack ecological validity. In everyday life people are required to complete more complex sets of tasks, prioritising task completion and recalling lists of tasks which need to be completed, and these tasks continue to be attempted during episodes or states of pain. The present study therefore examined the impact of thermal induced pain on a simulated errand task.

Methods

Fifty-five healthy adults (36 female) performed the Edinburgh Virtual Errands Task (EVET) either during a painful thermal sensation or with no concurrent pain. Participants also completed the Experience of Cognitive Intrusion of Pain (ECIP) questionnaire to measure their self-reported cognitive impact of pain in general life.

Results

Participants who completed the EVET task in pain and who self-reported high intrusion of pain made significantly more errors than those who reported lower intrusion on the ECIP.

Conclusions

Findings here support the growing literature that suggests that pain has a significant impact on cognitive performance. Furthermore, these findings support the developing literature suggesting that this relationship is complex when considering real world cognition, and that self-report on the ECIP relates well to performance on a task designed to reflect the complexities of everyday living.

Implications

If extrapolated to chronic pain populations, these data suggest that pain during complex multitasking performance may have a significant impact on the number of errors made. For people highly vulnerable to cognitive intrusion by pain, this may result in errors such as selecting the wrong location or item to perform tasks, or forgetting to perform these tasks at the correct time. If these findings are shown to extend to chronic pain populations then occupational support to manage complex task performance, using for example diaries/electronic reminders, may help to improve everyday abilities.

The reliability and validity of the Spanish version of the Fear of Pain Questionnaire

The purpose of this study was to evaluate the psychometric properties of the Spanish version of the Fear of Pain Questionnaire-III. The original three-factor structure of the Fear of Pain Questionnaire-III was confirmed and indicated a good to excellent level of internal consistency. Criterion validity was supported by positive significant correlations between the Fear of Pain Questionnaire-III scores and measures of pain catastrophizing and anxiety sensitivity; discriminant validity was supported by non-significant correlations between the Fear of Pain Questionnaire-III scores and measures of pain intensity and depressive symptomatology. The findings support the reliability and validity of the scores obtained by the Spanish version of the Fear of Pain Questionnaire-III.

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.

The Experience of Cognitive Intrusion of Pain: scale development and validation

Patients with chronic pain often report their cognition to be impaired by pain, and this observation has been supported by numerous studies measuring the effects of pain on cognitive task performance. Furthermore, cognitive intrusion by pain has been identified as one of 3 components of pain anxiety, alongside general distress and fear of pain. Although cognitive intrusion is a critical characteristic of pain, no specific measure designed to capture its effects exists. In 3 studies, we describe the initial development and validation of a new measure of pain interruption: the Experience of Cognitive Intrusion of Pain (ECIP) scale. In study 1, the ECIP scale was administered to a general population sample to assess its structure and construct validity. In study 2, the factor structure of the ECIP scale was confirmed in a large general population sample experiencing no pain, acute pain, or chronic pain. In study 3, we examined the predictive value of the ECIP scale in pain-related disability in fibromyalgia patients. The ECIP scale scores followed a normal distribution with good variance in a general population sample. The scale had high internal reliability and a clear 1-component structure. It differentiated between chronic pain and control groups, and it was a significant predictor of pain-related disability over and above pain intensity. Repairing attentional interruption from pain may become a novel target for pain management interventions, both pharmacologic and nonpharmacologic.

Into the unknown: A review and synthesis of contemporary models involving uncertainty

The current review and synthesis serves to define and contextualize fear of the unknown relative to related constructs, such as intolerance of uncertainty, and contemporary models of emotion, attachment, and neuroticism. The contemporary models appear to share a common core in underscoring the importance of responses to unknowns. A recent surge in published research has explored the transdiagnostic impact of not knowing on anxiety and related pathologies; as such, there appears to be mounting evidence for fear of the unknown as an important core transdiagnostic construct. The result is a robust foundation for transdiagnostic theoretical and empirical explorations into fearing the unknown and intolerance of uncertainty.

Psychiatric Comorbidity Is Associated Prospectively with Diminished Opioid Analgesia and Increased Opioid Misuse in Patients with Chronic Low Back Pain

BACKGROUND

Opioids are frequently prescribed for chronic low back pain (CLBP), but there are little prospective data on which patient subgroups may benefit. Psychiatric comorbidity, such as high levels of depression and anxiety symptoms (termed comorbid negative affect [NA]), is a common presentation and may predict diminished opioid analgesia and/or increased opioid misuse.

METHODS

The authors conducted a 6½-month prospective cohort study of oral opioid therapy, with an active drug/placebo run-in period, in 81 CLBP patients with low, moderate, and high levels of NA. Treatment included an opioid titration phase with a prescribing physician blinded to NA group assignment and a 4-month continuation phase, during which subjects recorded daily pain levels using an electronic diary. The primary outcome was the percent improvement in average daily pain, summarized weekly.

RESULTS

There was an overall 25% dropout rate. Despite the high NA group being prescribed a higher average daily dose of morphine equivalents, linear mixed model analysis revealed that the 24 study completers in each of the high NA and low NA groups had an average 21 versus 39% improvement in pain, respectively (P < 0.01). The high NA group also had a significantly greater rate of opioid misuse (39 vs. 8%, P < 0.05) and significantly more and intense opioid side effects (P < 0.01).

CONCLUSIONS

These results indicate that the benefit and risk considerations in CLBP patients with high NA versus low NA are distinctly different. Thus, NA is an important phenotypic variable to characterize at baseline, before deciding whether to prescribe opioids for CLBP.

Incidence and prognostic factors of chronic pain after isolated musculoskeletal extremity injury

BACKGROUND

Chronic pain in patients is usually related to an episode of pain following acute injury, emphasizing the need to prevent progression from acute to chronic pain. Multiple factors in the acute phase might be responsible for perpetuating the pain. The presentation of patients at the emergency department (ED) presents a prime opportunity to identify patients at high risk for chronic pain and to start appropriate treatment.

METHODS

The PROTACT study is a prospective follow-up study aiming to estimate the incidence and prognostic factors responsible for the development of chronic pain after musculoskeletal injury. Data including sociodemographic, pain, clinical, injury- or treatment-related and psychological factors of 435 patients were collected from registries and questionnaires at ED visit, 6-week, 3- and 6-month follow-up.

RESULTS

At 6 months post-injury, 43.9% of the patients had some degree of pain (Numeric Rating Scale (NRS) ≥1) and 10.1% had chronic pain (NRS ≥4). Patients aged over 40 years, in poor physical health, with pre-injury chronic pain, pain catastrophizing, high urgency level and severe pain at discharge were found to be at high risk for chronic pain.

CONCLUSIONS

Two prognostic factors, severe pain at discharge and pain catastrophizing, are potentially modifiable. The implementation of a pain protocol in the ED and the use of cognitive-behavioural techniques involving reducing catastrophizing might be useful.

The German PASS-20 in patients with low back pain: new aspects of convergent, divergent, and criterion-related validity

BACKGROUND

The PASS-20 (McCracken and Dhingra, Pain Res Manag 7:45-50, 2002) is a shortened version of the Pain Anxiety Symptoms Scale (PASS), a self-report measure of pain anxiety. The PASS-20 demonstrates good psychometric characteristics but has not yet been validated in a German population.

PURPOSE

The aims of the present study were to (1) examine the factor structure and psychometric characteristics of the German PASS-20; (2) investigate its construct validity with respect to depression, fear-avoidance, and endurance; and (3) determine its criterion-related validity with a special emphasis on pain, disability, and quality of life.

METHOD

A principal component analysis was performed on a sample (N = 195) of patients with acute, subacute, and chronic low back pain. Reliability was examined with Cronbach's α. Validity was assessed by correlating the PASS-20 to measures of depression, anxiety, disability, quality of life, and avoidance-endurance-related behavioral pain responses.

RESULTS

The original four-factor structure proposed for the PASS-20 was replicated using the original subscale labels. The reliability of the total score and the subscales was satisfactory to excellent, and both convergent and divergent validity were moderate to high in the expected directions, showing positive correlations with anxiety, fear, depression, and fear-avoidance and negative correlations with endurance and quality of life. The PASS-20 showed unique predictive ability and advantages over the Tampa Scale of Kinesiophobia.

CONCLUSIONS

The results for the German PASS-20 support the original factor structure and provide evidence of satisfactory psychometric characteristics and usefulness in patients with low back pain.

Fear and anxiety in the transition from acute to chronic pain: there is evidence for endurance besides avoidance

Substantial evidence reveals that the fear of pain and pain anxiety play a significant role in the development of chronic pain and disability, although underlying mechanisms remain widely unknown. Recent studies indicate that endurance pain responses are important besides avoidance. The purpose of this brief narrative review is to provide an overview of research that argues for the integration of the mechanisms of associative learning, motivation and emotion regulation in order to understand the questions of how and why individuals respond with pain responses, which lead to long-term suffering. By using the avoidance-endurance model of pain, we provide a concept that elucidates a range of responses to pain, fear and anxiety that mediate the transition from acute to chronic pain.

Current and future trends in psychology and chronic pain: time for a change?

Psychological approaches to chronic pain have produced significant success and are widely accepted. Yet it can be difficult for those outside the field to understand the many different variables, processes and methods that are a part of these approaches. This is partly because these approaches are characterized by a wide variety of models, each with its own primary focus and background assumptions, and these can change over time. It may be difficult to create greater consistency and integration between currently disparate psychological approaches, but there may be advantages to doing so. This integration could be helped by an appropriately designed and appropriately organizing theoretical model. It is suggested that what is called the psychological flexibility model could provide such a point of integration.

Brain structural signatures of negative symptoms in depression and schizophrenia

Negative symptoms occur in several major mental health disorders with undetermined mechanisms and unsatisfactory treatments; identification of their neural correlates might unveil the underlying pathophysiological basis and pinpoint the therapeutic targets. In this study, participants with major depressive disorder (n = 24), schizophrenia (n = 22), and healthy controls (n = 20) were assessed with 10 frequently used negative symptom scales followed by principal component analysis (PCA) of the scores. A linear model with the prominent components identified by PCA was then regressed on gray and white-matter volumes estimated from T1-weighted magnetic resonance imaging. In depressed patients, negative symptoms such as blunted affect, alogia, withdrawal, and cognitive impairment, assessed mostly via clinician-rated scales were inversely associated with gray matter volume in the bilateral cerebellum. In patients with schizophrenia, anhedonia, and avolition evaluated via self-rated scales inversely related to white-matter volume in the left anterior limb of internal capsule/anterior thalamic radiation and positively in the left superior longitudinal fasiculus. The pathophysiological mechanisms underlying negative symptoms might differ between depression and schizophrenia. These results also point to future negative symptom scale development primarily focused on detecting and monitoring the corresponding changes to brain structure or function.

Longitudinal relationships between anxiety, depression, and pain: results from a two-year cohort study of lower extremity trauma patients

Previous studies have shown that pain, depression, and anxiety are common after trauma. A longitudinal relationship between depression, anxiety, and chronic pain has been hypothesized. Severe lower extremity trauma patients (n = 545) were followed at 3, 6, 12, and 24 months after injury using a visual analog "present pain intensity" scale and the depression and anxiety scales of the Brief Symptom Inventory. Structural model results are presented as Standardized Regression Weights (SRW). Multiple imputation was used to account for missing data. A single structural model including all longitudinal pain intensity, anxiety symptoms, and depression symptoms time-points yielded excellent fit measures. Pain weakly predicted depression (3-6 months SRW = 0.07, P = .05; 6-12 months SRW = 0.06, P = .10) and anxiety (3-6 months SRW = 0.05, P = .21; 6-12 months SRW = 0.08, P = .03) during the first year after injury, and did not predict either construct beyond 1 year. Depression did not predict pain over any time period. In contrast, anxiety predicted pain over all time periods (3-6 months SRW = 0.11, P = .012; 6-12 months SRW = 0.14, P = .0065; 12-24 months SRW = 0.18, P < .0001). The results suggest that in the early phase after trauma, pain predicts anxiety and depression, but the magnitude of these relationships are smaller than the longitudinal relationship from anxiety to pain over this period. In the late (or chronic) phase after injury, the longitudinal relationship from anxiety on pain nearly doubles and is the only significant relationship. Despite missing data and a single item measure of pain intensity, these results provide evidence that negative mood, specifically anxiety, has an important role in the persistence of acute pain.

Conceptual overlap of psychological constructs in low back pain

The biopsychosocial model is increasingly accepted in low back pain (LBP) research and clinical practice. In order to assess the role of psychological factors in the development and persistence of pain, a wide array of measures has been developed. Yet there is likely to be considerable conceptual overlap between such measures, and consequently, a lack of clarity about the importance of psychological factors. The aims of this study were to investigate the extent of any such overlap. An observational cohort study of 1591 LBP patients consulting in primary care completed data on a range of psychological instruments. Exploratory and confirmatory factor analyses (EFA and CFA, respectively) were carried out at the subscale level (n=20) to investigate factor structure. The influences of the derived factors on clinical outcomes (pain intensity and self-reported disability) were then tested using linear regression. EFA yielded 4 factors, termed "Pain-related distress," "Cognitive coping," "Causal beliefs," and "Perceptions of the future," which accounted for 65.5% of the variance. CFA confirmed the validity of these factors models. The pain-related distress factor was found to have the strongest association to LBP patients' outcomes, accounting for 34.6% of the variance in pain intensity, and 51.1% of the variance in disability. Results confirmed that considerable overlap exists in psychological measures commonly used in LBP research. Most measures tap into patients' emotional distress. These findings help us to understand how psychological constructs relate together; implications for future research and clinical practice are discussed.

Fear of injury predicts self-reported and behavioral impairment in patients with chronic low back pain

Fear of injury has been posited as crucial in pain-related anxiety and in the development of chronic pain; however, research has only measured fear of injury indirectly through other constructs (eg, fear of illness and fear of movement). The current study tested fear of injury as an independent contributor to pain-related anxiety and impairment. Patients (n = 78; 37% women) in a work-hardening treatment program for chronic low back pain completed self-report measures of pain-related anxiety, anxiety sensitivity, fear of injury, current pain, and impairment. Behavioral measures of impairment included lifting capacity, treatment outcomes, and days absent from treatment. Structural equation modeling tested the role of fear of injury within contemporary theory. Fit for the theoretical model was excellent and superior to an alternative model. Variance accounted for in pain-related anxiety by fear of injury, anxiety sensitivity, and current pain was 64%, while pain-related anxiety and current pain predicted 49% of variance in latent impairment. Fear of injury directly predicted pain-related anxiety (β = .42) and indirectly predicted impairment through pain-related anxiety (β = .19). Fear of injury may warrant theoretical and clinical consideration as an important contributor to pain-related anxiety and impairment; however, research is needed to explore how it may be causally related with other constructs.

PERSPECTIVE

Fear of injury directly predicts pain-related anxiety and indirectly predicts self-reported and behavioral impairment. Fear of injury may warrant inclusion in contemporary theories of chronic pain. Clinicians may benefit from considering the construct in interventions for chronic pain.

Psychological factors predict local and referred experimental muscle pain: a cluster analysis in healthy adults

BACKGROUND

Recent studies suggest an underlying three- or four-factor structure explains the conceptual overlap and distinctiveness of several negative emotionality and pain-related constructs. However, the validity of these latent factors for predicting pain has not been examined.

METHODS

A cohort of 189 (99 female, 90 male) healthy volunteers completed eight self-report negative emotionality and pain-related measures (Eysenck Personality Questionnaire - Revised, Positive and Negative Affect Schedule, State-Trait Anxiety Inventory, Pain Catastrophizing Scale, Fear of Pain Questionnaire; Somatosensory Amplification Scale, Anxiety Sensitivity Index and Whiteley Index). Using principal axis factoring, three primary latent factors were extracted: general distress, catastrophic thinking and pain-related fear. Using these factors, individuals clustered into three subgroups of high, moderate and low negative emotionality responses. Experimental pain was induced via intramuscular acidic infusion into the anterior tibialis muscle, producing local (infusion site) and/or referred (anterior ankle) pain and hyperalgesia.

RESULTS

Pain outcomes differed between clusters (multivariate analysis of variance and multinomial regression), with individuals in the highest negative emotionality cluster reporting the greatest local pain (p = 0.05), mechanical hyperalgesia (pressure pain thresholds; p = 0.009) and greater odds (2.21 odds ratio) of experiencing referred pain when compared to the lowest negative emotionality cluster.

CONCLUSION

Our results provide support for three latent psychological factors explaining the majority of the variance between several pain-related psychological measures, and that individuals in the high negative emotionality subgroup are at increased risk for (1) acute local muscle pain; (2) local hyperalgesia; and (3) referred pain using a standardized nociceptive input.

Relationship of neuroticism and laboratory pain in healthy children: does anxiety sensitivity play a role?

Both neuroticism, a higher-order, stable personality trait, and anxiety sensitivity (AS), a lower-order pain-related construct, have been associated with pain, although no research exists examining the relationship of both these constructs to acute pain in children. In the current study, 99 healthy children (53 girls) completed self-report measures of neuroticism and AS before undergoing pain tasks involving cold and pressure pain. We hypothesized that both neuroticism and AS would be correlated with acute pain responses, but that AS would at least partially mediate the relationship between neuroticism and pain responses. Results indicated significant correlations between neuroticism, AS, and anticipatory anxiety, pain intensity and pain bother. Mediational models revealed that AS partially mediated relationships between neuroticism and pain intensity/bother, and fully mediated relationships between neuroticism and anticipatory anxiety. These data suggest that, at least in children, neuroticism may be best understood as a vulnerability factor for elevated pain responses, especially when coupled with a fear of bodily sensations.

Potential psychosocial risk factors for chronic TMD: descriptive data and empirically identified domains from the OPPERA case-control study

Case-control studies have consistently associated psychosocial factors with chronic pain in general, and with temporomandibular disorders (TMD) specifically. Moreover, a handful of prospective studies suggest that preexisting psychosocial characteristics represent risk factors for new onset TMD. The current study presents psychosocial findings from the baseline case-control study of the Orofacial Pain Prospective Evaluation and Risk Assessment (OPPERA) cooperative agreement. For this study, 1,633 TMD-free controls and 185 TMD cases completed a battery of psychosocial instruments assessing general psychosocial adjustment and personality, affective distress, psychosocial stress, somatic awareness, and pain coping and catastrophizing. In bivariate and demographically adjusted analyses, odds of TMD were associated with higher levels of psychosocial symptoms, affective distress, somatic awareness, and pain catastrophizing. Among controls, significant gender and ethnic group differences in psychosocial measures were observed, consistent with previous findings. Principal component analysis was undertaken to identify latent constructs revealing 4 components: stress and negative affectivity, global psychosocial symptoms, passive pain coping, and active pain coping. These findings provide further evidence of associations between psychosocial factors and TMD. Future prospective analyses in the OPPERA cohort will determine if the premorbid presence of these psychosocial factors predicts increased risk for developing new onset TMD.

PERSPECTIVE

This article reports baseline psychosocial findings from the OPPERA Study, a large prospective cohort study designed to discover causal determinants of TMD pain. Findings indicate significant differences between TMD cases and TMD-free controls across multiple psychosocial constructs, and future analyses will determine whether these psychosocial factors increase risk for new onset TMD.

Exploratory factor analysis of the pain outcomes profile

The Pain Outcomes Profile (POP) is a brief, multidimensional measure intended to assess pain intensity, functioning, and affect. It is presented as a practical measure with clinical utility. Results of studies support its concurrent, construct and predictive validity at the scale level. However, there have been no published studies of the measure at the item level. The present study was intended to assess the construct validity of the POP by way of factor analysis. A sample of 447 assessments of patients at a chronic non-cancer pain outpatient treatment center was employed. The 20 substantive items comprising the POP were entered into a factor analysis with oblique rotation. Five salient factors were obtained. Item-inclusion was generally consistent with factor loadings although noteworthy exceptions were observed in the Fear, Mobility and Vitality scales. Recommendations for further study and limitations of the current project are delineated.

Pain catastrophizing: an updated review

Pain catastrophizing has been described for more than half a century which adversely affects the pain coping behavior and overall prognosis in susceptible individuals when challenged by painful conditions. It is a distinct phenomenon which is characterized by feelings of helplessness, active rumination and excessive magnification of cognitions and feelings toward the painful situation. Susceptible subjects may have certain demographic or psychological predisposition. Various models of pain catastrophizing have been proposed which include attention-bias, schema-activation, communal-coping and appraisal models. Nevertheless, consensus is still lacking as to the true nature and mechanisms for pain catastrophizing. Recent advances in population genomics and noninvasive neuroimaging have helped elucidate the known determinants and neurophysiological correlates behind this potentially disabling behavior.

Global catastrophizing vs catastrophizing subdomains: assessment and associations with patient functioning

OBJECTIVE

The primary objectives of the current study were to 1) confirm the three-factor model of the Pain Catastrophizing Scale (PCS) items in a Japanese sample and 2) identify the catastrophizing subdomain(s) most closely associated with measures of pain and functioning in a sample of individuals with chronic pain.

DESIGN

This was based on a cross-sectional observational study.

SETTING

This study was conducted in a university-based clinic.

PATIENTS

One hundred and sixty outpatients with chronic pain participated in this study.

OUTCOME MEASURES

Patients completed the PCS, the Brief Pain Inventory, and the Hospital Anxiety and Depression Scale; 30 patients completed the PCS again between 1 and 4 weeks later.

RESULTS

Confirmatory factor analysis supported a three-factor structure of the Japanese version of the PCS, and univariate and multivariate associations with validity criterion supported the validity of the measure. Catastrophic helplessness was shown to make a unique contribution to the prediction of pain intensity, pain interference and depression, and catastrophic magnification made a unique contribution to the prediction of anxiety.

CONCLUSIONS

The findings support the cross-cultural generalizability of the three-factor structure of the PCS and indicate that the PCS-assessed catastrophizing subdomains provide greater explanatory power than the PCS total score for understanding pain-related functioning.

The illness/injury sensitivity index: validation of a German version of the ISI-R

Three fundamental fears-anxiety sensitivity, fear of negative evaluation, and illness/injury sensitivity-are considered integral components of anxiety-related psychopathology and also bear connections with chronic pain. Scales measuring the first two fears, the Anxiety Sensitivity Index and the Fear of Negative Evaluation Scale, have been translated into German; however, the nine-item Illness/Injury Sensitivity Index-Revised (ISI-R) that measures fears of injury and illness has not been available in German language yet. The aim of this study therefore was a translation of the ISI-R into German language and an initial validation of the translated scale in two different samples. The German ISI-R was translated by both professionals and laypersons, and a final version was decided on by consensus. In Study 1, participants included 96 undergraduate students (85% women) who completed the German version of the ISI as part of a larger study. An exploratory factor analysis with oblique rotation was conducted and suggested a two-factor-solution with one factor representing fears of illness and the other fears of injury. This factor structure was confirmed via a confirmatory factor analysis (CFA) in Study 2. Participants included 117 community members (79% women). Convergent validity was supported using a visual analogue scale for fear of illness in both samples and the German translation of the Whiteley Index in Study. Overall, the results supported the German translation of the ISI-R. Comprehensive results, limitations, and directions for future research are discussed.

Overlap of cognitive concepts in chronic widespread pain: an exploratory study

BACKGROUND

A wide variety of cognitive concepts have been shown to play an important role in chronic widespread pain (CWP). Although these concepts are generally considered to be distinct entities, some might in fact be highly overlapping. The objectives of this study were to (i) to establish inter-relationships between self-efficacy, cognitive coping styles, fear-avoidance cognitions and illness beliefs in patients with CWP and (ii) to explore the possibility of a reduction of these cognitions into a more limited number of domains.

METHODS

Baseline measurement data of a prospective cohort study of 138 patients with CWP were used. Factor analysis was used to study the associations between 16 different cognitive concepts.

RESULTS

Factor analysis resulted in three factors: 1) negative emotional cognitions, 2) active cognitive coping, and 3) control beliefs and expectations of chronicity.

CONCLUSION

Negative emotional cognitions, active cognitive coping, control beliefs and expectations of chronicity seem to constitute principal domains of cognitive processes in CWP. These findings contribute to the understanding of overlap and uniqueness of cognitive concepts in chronic widespread pain.

Measuring children's distress during burns dressing changes: literature search for measures appropriate for indigenous children in South Africa

BACKGROUND

Virtual reality is consistently reported as effective in reducing pain and anxiety in children during burns dressing changes in recent Western studies. Pain scales are a commonly reported outcome measure. Virtual reality is persuasive for all children in distress during medical procedures, because it is a nonaddictive, novel, and inexpensive form of distraction which can be applied repeatedly with good effect. We intend to use virtual reality in South Africa for the many children hospitalized with severe burns from mechanisms rarely seen in the Western world (paraffin/kerosene stoves exploding, electrical fires, shack/township fires, boiling liquid spills). Many severely burnt children are indigenous South Africans who did not speak English, and whose illiteracy levels, cultures, family dynamics, and experiences of pain potentially invalidate the use of conventional pain scales as outcome measures. The purpose of this study was to identify objective measures with sound psychometric properties and strong clinical utility, to assess distress during burns dressing changes in hospitalized indigenous South African children. Choice of measures was constrained by the burns dressing change environment, the ethics of doing no harm whilst measuring distress in vulnerable children, and of capturing valid measures of distress over the entire burns dressing change procedure.

METHODS

We conducted two targeted systematic reviews of the literature. All major library databases were searched, and measures with strong psychometric properties and sound clinical utility were sought.

RESULTS

Seven potentially useful measures were identified, ie, child's and caregivers' heart rate, which was measured continuously throughout the procedure, observed physical manifestations of distress using different scales (FLACCs [Face, Legs, Activity, Cry, Consolability Scale] and/ or Pain Behavior Checklist), time taken, and number of staff required to complete the procedure, and staff perspectives on the ease of use of the procedure.

CONCLUSION

These psychometrically sound, clinically useful measures are alternatives to conventional pain scales, and should support valid research into the effectiveness of virtual reality for illiterate children with non-Western cultures and languages.

Elevated pain sensitivity in chronic pain patients at risk for opioid misuse

This study employed quantitative sensory testing (QST) to evaluate pain responses in chronic spinal pain patients at low risk and high risk for opioid misuse, with risk classification based on scores on the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). Patients were further subgrouped according to current use of prescription opioids. Of the 276 chronic pain patients tested, approximately 65% were taking opioids; a median split was used to further categorize these patients as being on lower or higher doses of opioids. The high-risk group (n = 161) reported higher levels of clinical pain, had lower pressure and thermal pain thresholds at multiple body sites, had lower heat pain tolerance, and rated repetitive mechanical stimuli as more painful relative to the low-risk group (n = 115; P's < .01). In contrast, QST measures did not differ across opioid groups. Multiple linear regression analysis suggested that indices of pain-related distress (ie, anxiety and catastrophizing about pain) were also predictive of hyperalgesia, particularly in patients taking opioids. Collectively, regardless of opioid status, the high-risk group was hyperalgesic relative to the low-risk group; future opioid treatment studies may benefit from the classification of opioid risk, and the examination of pain sensitivity and other factors that differentiate high- and low-risk groups.

PERSPECTIVE

This study demonstrates that chronic spinal pain patients at high risk for misuse of prescription opioids are more pain-sensitive than low-risk patients, whether or not they are currently taking opioids. Indices of pain-related distress were important predictors of pain sensitivity, particularly among those patients taking opioids for pain.