Beneficial Effects of Improvement in Depression, Pain Catastrophizing, and Anxiety on Pain Outcomes: A 12-Month Longitudinal Analysis

Effect of Acupuncture Treatment on the Ocular Pain, Mental State and Ocular Surface Characteristics of Patients with Dry Eye Disease: A Non-Randomized Pilot Study

Background

Ocular pain is a prevalent symptom of dry eye disease (DED), which often accompanies potential psychological issues. The study aimed to explore whether acupuncture could improve ocular pain, mental state, and dry eye parameters in patients with DED.

Methods

The non-randomized pilot study included 48 patients divided into two groups: the acupuncture group (n=27) and the 0.3% sodium hyaluronate (SH) group (n=21). Participants in the acupuncture group underwent treatments on six bilateral acupuncture points (BL1, BL2, ST1, LI 20, SI1 and SI3) 3 times per week for 4 weeks. Patients in the SH group received 0.3% SH 4 times per day for 4 weeks. Ocular pain was assessed using the numerical rating scale (NRS), and mental state was evaluated through the self-rating anxiety scale (SAS) and self-rating depression scale (SDS). Ocular surface parameters, concentrations of inflammatory cytokines, and corneal nerve morphological indicators were measured at baseline, the first week, and the fourth week. Randomization procedures were not used in this study, and outcome assessors and statistical analysts were blinded.

Results

Compared with baseline, both NRS scores (from 5.91 ± 1.52 to 1.94 ± 1.57) and ocular surface discomfort index (OSDI) scores (from 49.75 ± 14.92 to 29.64 ± 18.79) were decreased after 1 and 4 weeks of treatment in both groups (all p < 0.05). At 4 weeks, the acupuncture group showed significant improvements, including increased tear break-up time (TBUT) and corneal perception, decreased SAS and SDS scores, and reduced concentrations of interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α concentration in tears (all p < 0.05). These changes were not observed in the SH group (all p > 0.05).

Conclusion

Acupuncture treatment could improve ocular surface characteristics in patients with DED, and more importantly, it alleviates their ocular pain and depressive state. The anti-inflammatory effect of acupuncture may be involved in this process. Future research with larger, randomized controlled trials (RCTs) is necessary to confirm these findings and clarify the mechanisms involved.

Prehabilitation: The underutilised weapon for chronic pain management

Objective

Prehabilitation encompasses preparatory clinical intervention(s) delivered during the period between diagnosis and treatment commencement. Despite widespread successful usage preoperatively, psychological prehabilitation is neglected in outpatient chronic pain management. Although pain management waitlists are associated with treatment attrition and psychological and physical decline, this time window is underutilised in preventing escalation. Waitlists present an under-explored opportunity to 'prehabilitate' patients waiting for treatment. This topical review aimed to: (1) examine the effectiveness of psychological prehabilitation for pain services; (2) evaluate the psychological and physical decline associated with waiting for pain management; (3) highlight key psychological prehabilitative targets for increasing treatment engagement; (4) promote pain management psychological prehabilitation within personalised pain medicine, building recommendations for future interventions.

Methods

Studies regarding the impact of waitlists and prehabilitation for chronic pain were reviewed.

Results

Findings demonstrated that the psychological constructs of patient expectations, health locus of control, self-efficacy and pain catastrophizing dynamically influence attrition, treatment engagement and outcomes while waiting. These constructs are amenable to change, emphasising their potential utility within a targeted waitlist intervention.

Conclusions

Prehabilitating chronic pain patients towards treatment engagement could circumvent cycles of failed treatment seeking, preventing psychological and physical decline, and reducing healthcare utilisation. Utilising the waitlist to identify psychosocial risk factors (external health locus of control, low self-efficacy and high pain catastrophizing) would identify who requires additional support to prevent increased risk of treatment failure, enhancing personalised care before prescribed treatment is accessed. This review cements the urgent need for pain services to engage proactively with prehabilitation innovation.

Anxiety, pain catastrophizing, and pain outcomes among older adults with chronic orofacial pain

Although chronic orofacial pain (COFP) is common among older adults, the role of psychological factors in pain outcomes among this population has received limited attention. This study examined the role of anxiety and pain catastrophizing, two corelates of pain in other populations, in pain intensity and interference among 166 older adults with COFP (79% female, Mage = 68.84, SD = 5.56). Participants completed an online survey including measures of anxiety, pain catastrophizing, and pain intensity/interference. We applied mediation analyses to test indirect associations between anxiety and pain outcomes via pain catastrophizing. Results indicated that anxiety was positively associated with pain intensity and pain interference (bs = .70-1.12, ps < .05). There was also an indirect association between anxiety and pain interference through pain catastrophizing (b = .35, 95% CI [.0383, .7954]), indicating pain catastrophizing partially accounts for this relationship. Assessing and addressing anxiety and pain catastrophizing has the potential to improve treatment outcomes in this population.

The impact of pre-operative depression on pain outcomes after major surgery: a systematic review and meta-analysis

Symptoms of depression are common among patients before surgery. Depression may be associated with worse postoperative pain and other pain-related outcomes. This review aimed to characterise the impact of pre-operative depression on postoperative pain outcomes. We conducted a systematic review of observational studies that reported an association between pre-operative depression and pain outcomes after major surgery. Multilevel random effects meta-analyses were conducted to pool standardised mean differences and 95%CI for postoperative pain scores in patients with depression compared with those without depression, at different time intervals. A meta-analysis was performed for studies reporting change in pain scores from the pre-operative period to any time-point after surgery. Sixty studies (n = 501,962) were included in the overall review, of which 18 were eligible for meta-analysis. Pre-operative depression was associated with greater pain scores at < 72 h (standardised mean difference 0.97 (95%CI 0.37-1.56), p = 0.009, I2  = 41%; moderate certainty) and > 6 months (standardised mean difference 0.45 (95%CI 0.23-0.68), p < 0.001, I2  = 78%; low certainty) after surgery, but not at 3-6 months after surgery (standardised mean difference 0.54 (95%CI -0.06-1.15), p = 0.07, I2  = 83%; very low certainty). The change in pain scores from pre-operative baseline to 1-2 years after surgery was similar between patients with and without pre-operative depression (standardised mean difference 0.13 (95%CI -0.06-0.32), p = 0.15, I2  = 54%; very low certainty). Overall, pre-existing depression before surgery was associated with worse pain severity postoperatively. Our findings highlight the importance of incorporating psychological care into current postoperative pain management approaches in patients with depression.

An Investigation of Associations between Pain Catastrophizing and Pain Disability in a Diverse Sample of Persons with Endometriosis

OBJECTIVE

This study sought to investigate associations between components of pain catastrophizing (using the Pain Catastrophizing Scale; rumination, magnification, and helplessness) and components of pain disability (using the Pain Disability Index; family/home responsibilities, recreation, social activity, occupation, sexual behaviour, self-care, life-support activity) in a diverse sample of persons with endometriosis.

METHODS

A total of 686 persons with a self-reported clinician-identified diagnosis of endometriosis participated in this study. Two-tailed independent samples t tests were used to examine between-group differences in pain disability and pain catastrophizing among those below and above clinically relevant moderate pain intensity levels. Between-group differences in pain disability among those below and above the clinically relevant pain catastrophizing level, and between-group differences in pain catastrophizing among those below and above the clinically relevant moderate pain disability level, were also analyzed.

RESULTS

Experiencing moderate or greater levels of pain intensity was associated with increased levels of pain disability and pain catastrophizing (P < 0.001). Strong associations between clinically relevant levels of pain catastrophizing and increased levels of pain disability (P < 0.001), in addition to between clinically relevant levels of moderate pain disability and increased levels of pain catastrophizing (P < 0.001), were found at both the total and subdomain levels.

CONCLUSION

Pain catastrophizing significantly affects pain disability and vice versa. Future research should examine the temporal relationship between catastrophizing and disability to inform intervention practices. Health care providers are strongly encouraged to evaluate the effects of endometriosis in patients using a biopsychosocial framework.

Pain management for post-treatment survivors of complex cancers: a qualitative study of opioids and cannabis

Aim: We aimed to understand experiences with opioids and cannabis for post-treatment cancer survivors. Patients & methods: We conducted seven focus groups among head and neck and lung cancer survivors, using standard qualitative methodology to explore themes around 1) post-treatment pain and 2) utilization, perceived benefits and perceived harms of cannabis and opioids. Results & conclusion: Survivors (N = 25) experienced addiction fears, stigma and access challenges for both products. Opioids were often perceived as critical for severe pain. Cannabis reduced pain and anxiety for many survivors, suggesting that anxiety screening, as recommended in guidelines, would improve traditional pain assessment. Opioids and cannabis present complex harms and benefits for post-treatment survivors who must balance pain management and minimizing side effects.

The temporal effect of emotional distress on psychological and physical functioning in endometriosis: A 12-month prospective study

Psychological factors of emotional distress and cognition have an important role in the understanding and management of endometriosis; however, their temporal relationship with key pain variables is not fully understood. This exploratory study sought to establish the temporal relationship between psychological and pain-related factors in a 12-month prospective study of 208 Australian women with endometriosis. Participants, aged 18-50 years and living in Australia, were recruited via social media and completed baseline (May 2019) and 12-month follow-up (June 2020) surveys. Participants who reported a diagnosis of endometriosis and menses in the past 12 months were included in the study. Structural equation modelling was used to determine the temporal effects of psychological and pain-related factors in endometriosis. In a covariate-adjusted model, baseline emotional distress was the only variable to predict pain catastrophizing (β = .24, p < .01), functional pain disability (β = .16, p < .05) and concomitant emotional distress (β = .55, p < .001) 12 months later, adjusting for age and chronic illness. Women who exhibit symptoms of distress may be at risk of poorer psychological and physical function at 12 months. Further research is required to understand the impact of psychological management early in the disease course.

Psychological management of patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): a systematic review

OBJECTIVES

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a complex condition. Despite recommendations for the inclusion of non-pharmacological treatment in the management of CP/CPPS, the focus has predominantly been on the inclusion of physical therapies with minimal discussion of psychological interventions. Therefore, this systematic review aimed to evaluate peer-reviewed studies of psychological interventions for men with CP/CPPS to determine their therapeutic efficacy and quality of intervention.

METHODS

The review was registered in PROSPERO and based on PRISMA 2020 protocol. The systematic literature search was conducted in six databases. Quantitative studies of psychological intervention for adult men with CP/CPPS that provided outcome measures of pain, quality of life and/or psychological symptoms were reviewed. The Oxford level of evidence and Quality Assessment Tool for Quantitative Studies developed by the Effective Public Health Practice were employed.

RESULTS

A total of 4,503 studies were reviewed; seven met the inclusion criteria. The included studies were randomised controlled trials, cohort, repeated measures, and case-series studies, with most including combined treatment for CP/CPPS. Cognitive therapy, cognitive behavioural therapy, or paradoxical relaxation training were found to be effective. However, high risks of bias were found in all included studies, limiting the generalisability and reliability of findings.

CONCLUSIONS

Evidence is preliminary but shows promise for psychological treatment either as a combined or standalone treatment for CP/CPPS. However, there is a need to develop research with a more rigorous methodology to evaluate psychological treatments for men with CP/CPPS.

Prevalence and Correlates of Depression and Anxiety in Patients with Functional Anorectal Pain

Purpose

Patients with functional anorectal pain (FAP) often experience psychological distress, impaired quality of life, increased healthcare utilisation, and even suicidal tendencies. However, limited data exists on the psychological correlates of FAP in Chinese patients. Therefore, this study aimed to examine the prevalence of depression, anxiety, and related psychosocial factors in Chinese patients with FAP.

Methods

We used a cross-sectional research design and recruited 100 patients with FAP from SuBei Hospital's multidisciplinary clinic for pelvic floor disorders between January and December 2021. Information on patients' demographic and disease characteristics was also collected. Depressive and anxiety symptoms were assessed using the Patient Health Questionnaire Depression (PHQ-9) and the Generalised Anxiety Disorder Questionnaire (GAD-7). Multiple logistic regression analysis was used to examine factors associated with depression and anxiety.

Results

The prevalence of depressive and anxiety symptoms among patients with FAP was 55% and 46%, respectively. Being a woman, specific marital status (single, divorced, separated, or widowed), longer FAP duration, and sleep disturbance were significantly associated with an increased risk of depressive symptoms. Additionally, specific marital status (single, divorced, separated, or widowed), sleep disturbance, and high Visual Analogue Scale scores were associated with anxiety symptoms.

Conclusion

Depressive and anxiety symptoms are prevalent in patients with FAP. Several socio-demographic and clinical predictors have been identified. There is a need for psychologists to be involved in the treatment of patients with FAP. Thus, multidisciplinary treatment may be the optimal treatment strategy.

White matter microstructure predicts measures of clinical symptoms in chronic back pain patients

Chronic back pain (CBP) has extensive clinical and social implications for its sufferers and is a major source of disability. Chronic pain has previously been shown to have central neural factors underpinning it, including the loss of white matter (WM), however traditional methods of analyzing WM microstructure have produced mixed and unclear results. To better understand these factors, we assessed the WM microstructure of 50 patients and 40 healthy controls (HC) using diffusion-weighted imaging. The data were analyzed using fixel-based analysis (FBA), a higher-order diffusion modelling technique applied to CBP for the first time here. Subjects also answered questionnaires relating to pain, disability, catastrophizing, and mood disorders, to establish the relationship between fixelwise metrics and clinical symptoms. FBA determined that, compared to HC, CBP patients had: 1) lower fibre density (FD) in several tracts, specifically the right anterior and bilateral superior thalamic radiations, right spinothalamic tract, right middle cerebellar peduncle, and the body and splenium of corpus callosum; 2) higher FD in the genu of corpus callosum; and 3) lower FDC - a combined fibre density and cross-section measure - in the bilateral spinothalamic tracts and right anterior thalamic radiation. Exploratory correlations showed strong negative relationships between fixelwise metrics and clinical questionnaire scores, especially pain catastrophizing. These results have important implications for the intake and processing of sensory data in CBP that warrant further investigation.

Examining the roles of depression, pain catastrophizing, and self-efficacy in quality of life changes following chronic pain treatment

Background

Adults with chronic pain have a lower quality of life (QOL) compared to the general population. Chronic pain requires specialized treatment to address the multitude of factors that contribute to an individual's pain experience, and effectively managing pain requires a biopsychosocial approach to improve patients' QOL.

Aim

This study examined adults with chronic pain after a year of specialized treatment to determine the role of cognitive markers (i.e., pain catastrophizing, depression, pain self-efficacy) in predicting changes in QOL.

Methods

Patients in an interdisciplinary chronic pain clinic (N = 197) completed measures of pain catastrophizing, depression, pain self-efficacy, and QOL at baseline and 1 year later. Correlations and a moderated mediation were completed to understand the relationships between the variables.

Results

Higher baseline pain catastrophizing was significantly associated with increased mental QOL (b = 0.39, 95% confidence interval [CI] 0.141; 0.648) and decreased depression (b = -0.18, 95% CI -0.306; -0.052) over a year. Furthermore, the relationship between baseline pain catastrophizing and the change in depression was moderated by the change in pain self-efficacy (b = -0.10, 95% CI -0.145; -0.043) over a year. Patients with high baseline pain catastrophizing reported decreased depression after a year of treatment, which was associated with greater QOL improvements but only in patients with unchanged or improved pain self-efficacy.

Conclusions

Our findings highlight the roles of cognitive and affective factors and their impact on QOL in adults with chronic pain. Understanding the psychological factors that predict increased mental QOL is clinically useful, because medical teams can optimize these positive changes in QOL through psychosocial interventions aimed at improving patients' pain self-efficacy.

Prevalence of chronic pain in a national cohort of patients with limb-girdle muscular dystrophy: a cross-sectional study

PURPOSE

The aim was to investigate the prevalence, characteristics, predictors, and consequences of chronic pain in a national cohort of patients with limb-girdle muscular dystrophy (LGMD).

MATERIALS AND METHODS

Questionnaires were sent to all Danish LGMD patients (≥18 years of age) registered with the National Rehabilitation Center for Neuromuscular Diseases.

RESULTS

Of 209 patients, 121 responded. 44.7% of the patients experienced persistent (daily or constant) chronic pain lasting more than 3 months. 21.0% of patients experienced chronic pain that was not daily. Most pain patients experienced three or more pain problems, primarily in the lower back, neck, shoulders, hips, and legs. Symptoms suggestive of neuropathic pain were sometimes present. Patients with persistent chronic pain reported moderate pain interference with daily activities, greater psychological distress, and lower quality of life compared to patients without pain but did not differ regarding physical functioning. Sex, age, LGMD duration, LGMD type, mechanical ventilation use, mobility, arm function, or performance on activities of daily living did not predict chronic pain.

CONCLUSION

Chronic pain is common in patients with LGMD. Chronic pain should be considered an important component of LGMD and addressed in the clinic and rehabilitation setting from a biopsychosocial perspective.Implication for rehabilitationChronic pain is highly prevalent in patients with limb-girdle muscular dystrophy.Health professionals need to systematically ask patients about pain and the influence of pain on everyday life irrespective of LGMD-duration and extent of muscle wastage.Chronic pain and psychological distress need to be addressed in the clinic and rehabilitation setting as an additional disabling component of LGMD and this should be done within a biopsychosocial framework.

Nociception level index variations in patients with complex regional pain syndrome: a pilot study

The nociception level index (NOL) is a multi-parameter index that incorporates changes in autonomic parameters to evaluate nociception, with more painful stimuli causing more pronounced index variations. How this nociception monitor relates to the pain experience is uncertain, and patients with chronic pain may respond differently to acute pain due to alterations in pain processing. The goal of this pilot study was to evaluate NOL index variations after a painful physiotherapy exercise in patients with upper limb complex regional pain syndrome. Baseline NOL indexes were recorded using a finger probe (PMD-200™ Monitor, Medasense, Israel) and patient reported baseline pain scores using an 11-point numeric rating scale (NRS). Patients then performed a painful physiotherapy exercise and NOL index and pain scores were again recorded. The same procedure and recordings were repeated after a stellate ganglion block. Data were analyzed using a paired Student T test and a P value < 0.05 was considered statistically significant. Twenty patients (12/20 female, 10/20 right-sided) were included in this study. Patients reported moderate baseline pain (4.0 ± 2.7) despite having a low baseline NOL index (7.66 ± 5.76 out of 100). NRS and NOL index scores increased significantly during exercise, both before and after the block. The NOL index increased significantly when patients reported increased pain, indicating that it could eventually be useful in the objective assessment of acute pain in the chronic pain patients. However, NOL index was not able to reflect pain levels at rest, before the painful stimulation, in this chronic pain population. Further studies are needed to better assess NOL index utility at rest and to confirm these findings in this specific chronic pain population.

Pain Catastrophizing Scale Associated With Other Patient-Reported Outcome Measures in Plantar Fasciitis and Chronic Ankle Instability Patients

BACKGROUND

The Pain Catastrophizing Scale (PCS) is a measure of how patients emotionally respond to pain. It is composed of 3 subscales-rumination, magnification, and helplessness-which address intrusive thoughts of pain, expectations of negative outcomes, and inability to cope with pain. Our purpose is to compare baseline PCS scores with other baseline patient-reported outcome measures (PROMs) in patients with plantar fasciitis (PF) or chronic ankle instability (CAI).

METHODS

We retrospectively reviewed 201 patients who reported at least 1 pretreatment PCS subscore and were diagnosed with PF or CAI between 2015 and 2020 in a single fellowship-trained foot and ankle surgeon's clinic. Demographics, comorbidities, treatments, other baseline PROMs (i.e., visual analog scale [VAS], Pain Disability Index [PDI], 12-Item Short Form Survey [SF-12], 8-Item Somatic Symptom Scale [SSS-8]), and postoperative outcomes were recorded.

RESULTS

The PCS total score and its subscores significantly correlated with the total score and/or subscores of each PROM. Higher PCS total score significantly correlated with worse VAS (P<.001), SF-12 mental (P=.007), PDI total (P<.001), and SSS-8 (P<.001) scores. Only the PCS magnification subscore was significantly greater among patients who did (n=41) undergo surgery (P=.043). Those who had previously undergone foot and/or ankle surgery had significantly higher PCS rumination (P=.012), magnification (P=.006), helplessness (P=.008), and total (P=.003) scores. Likewise, those with a history of substance abuse also had significantly higher PCS scores (P=.005; P=.003; P=.006; P=.003).

CONCLUSION

The correlations between PCS scores and other baseline PROMs indicate that strong pain catastrophizers with PF or CAI may be at risk for poor treatment outcomes. PCS scores could be used to help with treatment for such high-risk patients.

Comorbidities of bladder pain syndrome in the context of the HITOP distress category: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

The aim of this systematic review and meta-analysis is, looking at different care settings, to examine prevalence rates of psychological distress-level comorbidities in female interstitial cystitis/bladder pain syndrome (IC/BPS) patients, their impact on Quality of Life (QoL), and the correlation between such comorbidities and symptom severity.

METHODS

A systematic literature search according to PRISMA guidelines was conducted in PubMed, PsycInfo, Web of Science, Science Direct, and Google Scholar.

RESULTS

Twenty-nine studies were found that met inclusion criteria. Prevalence rates of depression and anxiety are higher in IC/BPS patients compared to the general population; however, due to a wide array of measurements, statistical comparisons between care settings were only possible in two cases showing mixed results. No studies meeting inclusion criteria exist that examine PTSD and borderline personality disorder, though rates of past traumatic experiences seem to be higher in patients than in healthy controls. Psychological comorbidities of the distress category, especially depression, are found in most studies to be related to symptom severity, also yielding statistically significant associations.

CONCLUSIONS

While there is still need for studies focused on some of the comorbidities as well as on different care settings, the data already show that psychological comorbidities of the distress category play an important role in IC/BPS patients regarding suffering, QoL, and symptom severity, thus emphasizing the need for highly specialized interdisciplinary treatment.

Patient-specific affect-abdominal pain interactions in endometriosis: an experience sampling method (ESM) study

OBJECTIVES

Cross-sectional studies show that endometriosis-related pain is associated with affect. Measuring these symptoms in real-time in a longitudinal perspective yields the ability to analyze the temporal relationship between variables. The aim was to evaluate the association between affect and abdominal pain, using the Experience Sampling Method (ESM) as a real-time, randomly repeated assessment.

METHODS

Thirty-four endometriosis patients and 31 healthy subjects completed up to 10 real-time self-assessments concerning abdominal pain and affective symptoms during seven consecutive days.

RESULTS

Endometriosis patients experienced more abdominal pain and negative affective symptoms, and scored lower on positive affect compared to healthy controls. A significant association was found between abdominal pain and both positive and negative affect in endometriosis patients. For healthy controls, less strong or non-significant associations were found. When looking at abdominal pain as a predictor for affect and vice versa, we found that only in endometriosis patients, pain was subsequently accompanied by negative affect, and positive affect may alleviate pain in these patients.

CONCLUSIONS

This study confirms a concurrent and temporal relationship between affect and abdominal pain in endometriosis patients and supports the use of real-time symptom assessment to interpret potential influencers of abdominal complaints in patients with endometriosis.

Inverse Association Between Persistence With Antidepressant Medication and Onset of Chronic Pain in Patients With Depression: A Retrospective Cohort Study

PURPOSE/BACKGROUND

Despite the known involvement of depression in chronic pain, the association between persistence with and adherence to antidepressant medication and onset of chronic pain in patients with depression remains unclear.

METHODS/PROCEDURES

This retrospective cohort study used a Japanese claims database to extract data for adult patients with depression who were prescribed antidepressants between April 2014 and March 2020. Patients were divided into groups according to duration of continuous prescription of antidepressants (≥6 months [persistent group] and <6 months [nonpersistent group]) and medication possession ratio (≥80% [good adherence group] and <80% [poor adherence group]). The outcome was onset of chronic pain, which was defined as continuous prescription >3 months of analgesics and diagnosis of pain-related condition after discontinuation of the first continuous antidepressant prescription. The risk of onset of chronic pain was compared between the paired groups.

FINDINGS/RESULTS

A total of 1859 patients were selected as the study population and categorized as the persistent (n = 406) and nonpersistent (n = 1453) groups, and good adherence (n = 1551) and poor adherence (n = 308) groups. Risk of onset of chronic pain was significantly lower in the persistent group than in the nonpersistent group after controlling for confounding via standardized mortality ratio weighting (hazard ratio, 0.38; 95% confidence interval, 0.18-0.80; P = 0.011). There was no significant difference between the good and poor adherence groups.

IMPLICATIONS/CONCLUSIONS

Antidepressant persistence for ≥6 months is recommended and may reduce the onset of chronic pain in patients with depression.

Efficacy and cost-effectiveness of an online mindfulness program (MindOnLine) to reduce fear of recurrence among people with cancer: study protocol for a randomised controlled trial

INTRODUCTION

Fear of cancer recurrence (FCR) is a common condition among cancer survivors that can lead to significant levels of distress, anxiety and depression. Online mindfulness programmes may provide the mechanism to support cancer survivors manage FCR and distress, and improve people's well-being over the short, medium and long term. The primary aim of this study is to determine the potential efficacy of MindOnLine, a 9 session mindfulness-based programme for survivors of breast, prostate and colorectal cancer. A formal economic programme will also be conducted.

METHODS AND ANALYSIS

A single-blind randomised controlled trial to determine the efficacy and cost-efficacy of a MindOnLine programme for cancer survivors. A total of 400 people living with cancer will be recruited via online advertisements on social media platforms, peak consumer advocacy groups or through outpatient services at healthcare providers across Victoria, Australia. People will be randomly allocated to either the MindOnLine programme (n=200) or waitlist control (n=200). Participant assessments will occur at baseline, at 9 weeks and 9-month follow-up. The primary outcome is change in Fear of Recurrence Index Score total score between baseline and 9 weeks; secondary outcomes are changes in depression and anxiety, quality of life and mindfulness. The economic analysis comprises a cost-consequences analysis where all outcomes will be compared with costs.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Peter MacCallum Cancer Centre (20-53) and Deakin University (2020-284). All participants will be required to provide written informed consent. Findings will be disseminated in peer reviewed journals and among key stakeholder organisations including hospitals, cancer and community organisations and Government. If successful the project will be rolled out nationally with a formal implementation plan.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (12620000645954); Pre-results. Registered 6 June 2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379520&isReview=true.

An interdisciplinary chronic pain rehabilitation program effectively treats impairment in sexual function, depression, alexithymia, and pain in women with chronic pelvic pain

PURPOSE

Chronic pelvic pain (CPP) in women is often associated with marked emotional distress and disability, with particular impairments in sexual functioning. Research supports the efficacy of interdisciplinary chronic pain rehabilitation programs (ICPRPs) in treating chronic pain, however less is known about their utility in CPP.

METHODS

This retrospective study examined pain-related sexual impairment, emotional symptoms, and pain severity in CPP patients before and after completing a 3-4 week ICPRP. Predictors of post-treatment sexual impairment were also investigated. Participants included 58 female CPP patients and 58 age-matched females with non-pelvic chronic pain (NPCP).

RESULTS

All participants reported robust improvements across outcome measures. Women with CPP reported greater pre- and post-treatment impairment in sexual function than NPCP patients, despite significant treatment-related improvements. In contrast, CPP patients also reported higher levels of depression at baseline but showed greater treatment related-improvements. In participants with CPP, treatment-related improvements in depression, alexithymia, and pain severity significantly explained decreases in pain-related sexual impairment following treatment, whereas none of these variables explained sexual impairment outcomes in women with NPCP.

CONCLUSION

Results demonstrate that ICPRPs can effectively treat CPP, particularly through changes in depression and alexithymia. Future research should examine whether specific interventions can be added in ICPRPS to address CPP-related sexual impairment.

Pain Intensity Predicts Pain Catastrophizing During the Postpartum Period: A Longitudinal Random Intercept Cross-Lagged Panel Study

OBJECTIVE

Pain catastrophizing is an important psychological predictor of pain. Recent evidence suggests the relationship between catastrophizing and pain intensity could be bidirectional, but most studies have been conducted on chronic pain patients and using criticized statistical methods. The present study aimed to examine if the relationship between pain intensity and catastrophizing was bidirectional in the context of childbirth.

METHODS

A total of 504 women without chronic pain were recruited on their 32-37 gestational week. They completed measures of catastrophizing and pain intensity on the first encounter and then again at 1, 3, and 6 months postpartum. The temporal relationship between the variables was assessed using a random intercept cross-lagged panel model.

RESULTS

The hypothesis of reciprocal association did not receive support, as pain intensity predicted catastrophizing during the postpartum period, but catastrophizing did not show an effect over pain intensity at any moment.

CONCLUSIONS

Pain intensity predicting catastrophizing is consistent with previous literature, while the lack of effect of catastrophizing over pain intensity is an unexpected result, which may suggest that catastrophizing plays a different role in the postpartum period. These results highlight the importance of timely efforts for pain management during the postpartum period and contribute to the theoretical conceptualization of catastrophizing.

Use of Complementary and Integrative Health Therapies Prior to Intensive Functional Restoration in Active Duty Service Members with Chronic Pain

OBJECTIVE

Psychosocial factors are known to predict chronic pain, and the use of complementary and integrative health (CIH) therapies to address pain is emerging among military population. However, conflicting results on pain outcomes warrant additional research. This study aimed to (1) evaluate the benefit of adding a CIH pain management program to standard rehabilitative care (SRC), as compared to SRC alone, as precursor to an intensive functional restoration (FR) program; (2) identify factors that predict improvement in pain outcomes following treatment; and (3) determine the proportion of participants who experience clinically meaningful response.

DESIGN

Pragmatic randomized controlled clinical trial. Participants were randomized to a 3-week course of either SRC alone or SRC+CIH (stage 1), followed by a 3- to 6-week course of FR (stage 2).

SETTING AND SUBJECTS

Active duty service members with chronic pain.

METHODS

Participants completed either SRC alone or SRC+CIH (stage 1), followed by a course of FR (stage 2). Patient-reported and provider-determined outcomes were collected at baseline, after stage 1, and after stage 2. A covariance pattern model with unstructured residual covariance matrix was used to compare treatment arms while accounting for dependency due to repeated measurements.

RESULTS

A total of 210 service members participated. Most were Army (82%) and male (84%). Participants randomized to the SRC+CIH intervention had greater improvement in the pain impact score than those in the SRC alone group. Predictors of outcomes were baseline impact score, anger, depression, and educational status.

CONCLUSIONS

This study found that military service members with the highest pain impact benefit the most from interdisciplinary pain care.

The association between sleep quality, preoperative risk factors for chronic postoperative pain and postoperative pain intensity 12 months after knee and hip arthroplasty

BACKGROUND

Chronic postoperative pain following total joint replacement (TJA) is a substantial clinical problem, and poor sleep may affect predictive factors for postoperative pain, such as pain catastrophizing. However, the magnitude of these associations is currently unknown. This exploratory study investigated (1) the relationship between preoperative sleep quality, clinical pain intensity, pain catastrophizing, anxiety, and depression and (2) their associations with chronic postoperative pain following TJA.

METHODS

This secondary analysis from a larger randomized controlled trial included rest pain intensity (preoperative and 12 months postoperative; visual analogue scale, VAS), preoperative Pittsburgh Sleep Quality Index (PSQI), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS) data from 74 knee and 89 hip osteoarthritis (OA) patients scheduled for TJA. Poor sleepers were identified based on preoperative PSQI scores higher than 5.

RESULTS

Poor sleepers demonstrated higher preoperative VAS, pain catastrophizing, anxiety, and depression compared with good sleepers (all p < 0.003). Preoperative PSQI (β = 0.23, p = 0.006), PCS (β = 0.44, p < 0.005), and anxiety (β = 0.18, p = 0.036) were independent factors for preoperative VAS. Preoperative VAS (β = 0.32, p < 0.005), but not preoperative sleep quality (β = -0.06, p = 0.5), was an independent factor for postoperative VAS.

CONCLUSION

The OA patients reporting poor preoperative sleep quality show higher preoperative pain, pain catastrophizing, anxiety, and depression. High preoperative pain intensity, but not poor sleep quality, was associated with higher chronic postoperative pain intensity. Future studies are encouraged to explore associations between sleep and chronic postoperative pain.

Hope in the context of chronic musculoskeletal pain: relationships of hope to pain and psychological distress

Introduction

The cognitive model of hope suggests that people with high levels of hope are able to think about the ways to goals (pathways) and motivated to pursue those pathways to reach their goals (agency). We hypothesized that higher levels of hope would be related to lower levels of pain and less psychological distress (ie, anxiety and depression) and better adjustment.

Objectives

This study aims to examine the relationship, if any, between cognition of hope and chronic musculoskeletal pain.

Methods

One hundred and six patients with chronic musculoskeletal pain were recruited by convenient sampling from 2 public hospitals in Hong Kong. We assessed the hope level, psychological distress, and health outcomes by psychometric inventories.

Results

Zero-order correlation results showed that hope was inversely associated with psychological distress (ie, anxiety and depression) and positively related to subjective self-efficacy. There was no significant relationship with severity of pain. Patients presented with longer duration of chronic musculoskeletal pain have higher hope level while pain developed after injury on duty have lower hope level.

Conclusion

The findings of this cross-sectional study highlight the potential importance of hope in understanding adjustment to chronic musculoskeletal pain. Future longitudinal research could help reveal how hope and adjustment interact over the treatment of chronic pain cases.

Composite measures of pain, anxiety, and depressive (PAD) symptoms: Construct and predictive validity

OBJECTIVE

Pain, anxiety, and depression (PAD) are common, co-occurring symptoms that adversely affect one another and may respond to common treatments. PAD composite measures would be useful for tracking treatment response in patients with PAD symptoms. The goal of this study is to compare 3 different PAD composite scales in terms of construct validity, responsiveness, and utility in predicting global improvement.

METHOD

The sample consisted of 294 primary care patients enrolled in a telecare trial for treating pain, anxiety, and depression. Assessments at baseline and 3 months included the Brief Pain Inventory, PHQ-9 depression scale, GAD-7 anxiety scale, PROMIS measures, Medical Outcomes Study Short-Form items, disability measures, and patient-reported global improvement. Construct validity of the PAD composite measures, their responsiveness, and their ability to predict global improvement was analyzed using Pearson correlations, standardized response means, and receiver operating characteristics analysis.

RESULTS

PAD composite measures correlated strongly with one another, and moderately with measures of function, vitality, and disability. Each PAD composite measure demonstrated similar responsiveness in detecting improvement at 3 months as assessed by standardized response means (SRMs) and area under the curve (AUC analyses).The SRMs for partial and substantial global improvement corresponded to moderate (Cohen's d of 0.58 to 0.69) and large (0.81 to 0.93) effect sizes, respectively.

CONCLUSIONS

Three different PAD composite measures demonstrate good construct validity as well as responsiveness in detecting global improvement of pain, anxiety and depression at 3 months.

Pain Catastrophizing Throughout the Perioperative Period in Adolescents With Idiopathic Scoliosis

OBJECTIVES

Pain catastrophizing in children and adolescents has been associated to unfavorable postsurgical outcomes. However, pain catastrophizing is rarely measured throughout the perioperative period. Using a prospective longitudinal approach, the present study aimed to identify how pain catastrophizing changes over the perioperative period in pediatric surgical patients with adolescent idiopathic scoliosis.

MATERIALS AND METHODS

Adolescent patients undergoing spinal fusion surgery completed the Pain Catastrophizing Scale for Children and additional questionnaires to assess pain intensity, state and trait anxiety, and kinesiophobia before surgery, and 1, 2, 5 days, 6 weeks, and 6 months after surgery.

RESULTS

Patients who had higher levels of pain catastrophizing before surgery were more likely to be anxious, avoid activity that may cause pain, report higher pain intensity before surgery and anticipate more pain after surgery. Low pain catastrophizers increased into a moderate level of pain catastrophizing before decreasing after discharge from the hospital. Meanwhile, moderate and high pain catastrophizers both decreased into lower and moderate levels of catastrophizing, respectively, after discharge from the hospital.

DISCUSSION

These findings demonstrate that pain catastrophizing in adolescents changes over the perioperative period. Observing changes in pain catastrophizing throughout the perioperative period may help in recognizing when patients are most vulnerable during this time. Decreasing pain catastrophizing before surgery or in the acute postoperative period through therapies that target pain catastrophizing may help reduce the patient's likelihood of experiencing unfavorable postoperative outcomes.

A Latent Approach to Understanding Pain in Nursing Home Residents Who are Unable to Self-Report Pain

CONTEXT

Pain assessment in people with cognitive impairment is challenging.

OBJECTIVE

The study sought to 1) identify pain subgroups based on staff-assessed pain, agitated and reactive behavior, functional status, and symptoms of depression; and 2) understand if cognitive impairment was associated with transitions between pain subgroups at nursing home admission, 3 months, and 6 months.

METHODS

Using national Minimum Data Set 3.0 data (2011-2016), we included 26,816 newly admitted residents with staff-assessed pain at admission, 3 months, and 6 months. Pain subgroups were identified by latent class analysis at each time point. Transitions between pain subgroups were described using latent transition analysis.

RESULTS

Five latent statuses of pain were identified at admission: "Behavioral and Severe Depression" (prevalence stable, severe or worsening cognitive impairment: 11%, mild/moderate or improved cognitive impairment: 10%), "Functional" (21%; 25%), "Physical" (22%; 23%), "Behavioral" (23%, 19%), and "Low" (23%; 24%). Regardless of change in cognitive status, most residents remained in the same pain latent class. Among residents with stable, severe or worsening cognitive impairment, 11% in the "Behavioral" class transitioned to the "Behavioral and Severe Depression" class by 3 months. Fewer residents transitioned between latent classes in the 3- to 6-month period (>80% remained in their 3-month class).

CONCLUSION

For nursing home residents unable to self-report pain, consideration of additional indicators including functioning, depressive symptoms, and agitation may be useful in identifying pain subgroups. Longitudinal changes in the pain subgroups over 6 months post-admission highlight that residents with severe cognitive impairment may be at risk for worsening pain.

Multifocal Pain as a Predictor of Pain Outcomes in Military Veterans with Chronic Musculoskeletal Pain: A Secondary Data Analysis of a Randomized Controlled Trial

OBJECTIVE

We aimed to examine 1) the relationship between multifocal pain and clinical characteristics, including demographics, pain outcomes, somatic symptoms, health-related quality of life, depression, and anxiety, and 2) whether multifocal pain was independently associated with treatment response.

METHODS

We conducted a secondary data analysis on veterans with chronic pain enrolled in the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial with complete data at 9 months (n = 222). We examined baseline relationships and used multivariable linear regression to examine whether multifocal pain was independently associated with outcomes that included Brief Pain Inventory (BPI) Interference scale and Graded Chronic Pain Scale (GCPS) scores between baseline and 9 months.

RESULTS

The sample had a mean BPI Interference score of 5.3 ± 2.2 and a mean GCPS score of 65.6 ± 13.7, 55% had significant depression (Patient Health Questionnaire 9-item depression scale [PHQ-9] score of ≥10), and 42% had significant anxiety (Generalized Anxiety Disorder Scale [GAD-7] score of ≥10). Veterans reporting three or more pain sites (the "more diffuse pain" group) had significantly less improvement on GCPS (b = 4.6, standard error [SE] = 2.3, P = 0.045), BPI Interference (b = 1.0, SE = 0.2, P = 0.0011), and health-related quality of life (Short-Form 36-item scale, Physical Component Summary) (b = 4.1, SE = 1.0, P < 0.0001) than did veterans reporting fewer than three pain sites (the "less diffuse pain" group). More diffuse pain was not associated with changes in PHQ-9 or GAD-7 scores.

CONCLUSIONS

Multifocal pain predicted worse pain outcomes between baseline and 9 months in veterans enrolled in a trial for treating chronic musculoskeletal pain.

Depression, Anxiety, and Correlating Factors in Endometriosis: A Systematic Review and Meta-Analysis

Background: Endometriosis stage is not directly related to the burden of symptoms, and recurrence of symptoms occurs frequently. It is suggested that symptoms are associated with psychological distress, as in depression and anxiety disorders. Our aim was to explore the strength of the associations between endometriosis and depression or anxiety and to review correlating factors. Materials and Methods: A literature search was carried out using the electronic databases Embase, PubMed, Web-of-science, and PsycINFO. Search terms related to depression, anxiety, and endometriosis were combined resulting in 1,837 records. Articles were included when describing an association between patients with endometriosis and symptoms of depression or anxiety assessed by validated tools, structured psychiatric interviews, or a documented diagnosis. With 47 articles a systematic qualitative review was performed. Seventeen studies were eligible for meta-analysis. Results: Endometriosis patients experienced significantly more symptoms of depression (standardized mean difference [SMD] of 0.71 (95% confidence interval [CI] 0.36-1.06)) and anxiety (SMD 0.60 (95% CI 0.35-0.84)) compared with healthy controls, but no differences were found comparing endometriosis patients with other chronic pelvic pain patients (SMD -0.01 [95% CI -0.17 to 0.15] for depression and SMD -0.02 [95% CI -0.22 to 0.18] for anxiety). Besides the effect of pain, other correlating factors included age, quality of life, quality of sleep, fatigue, sexual function, gastrointestinal symptoms, comorbidity, self-esteem, emotional self-efficacy, coping style, social adjustment, pain imagery, and pain sensitization. Conclusion: This systematic review supports the assumption that symptoms of depression and anxiety occur frequently in endometriosis patients and are related to chronic pain. Correlating factors should further be investigated.

Emerging Role of Serum Glucocorticoid-Regulated Kinase 1 in Pathological Pain

Currently, the management of acute and chronic pain in clinical practice remains unsatisfactory due to the existence of limited effective treatments, and novel therapeutic strategies for pathological pain are urgently needed. In the past few decades, the role of serum and glucocorticoid-inducible kinase 1 (SGK1) in the development of pain and diurnal rhythms has been implicated in numerous studies. The expression levels of SGK1 mRNA and protein were found to be elevated in the spinal cord and brain in various pathological pain models. Blocking SGK1 significantly attenuated pain-like responses and the development of pathological pain. These studies provide strong evidence that SGK1 plays a role in the development of various types of pathological pain and that targeting SGK1 may be a novel therapeutic strategy for pain management. In this review article, we provide evidence from animal models for the potential role of SGK1 in the regulation of pathological pain caused by inflammation, nerve injury, psychiatric disorders, and chronic opioid exposure.

Efficacy of Online-Based Acceptance and Commitment Therapy for Chronic Pain: A Systematic Review and Meta-Analysis

Acceptance and Commitment Therapy (ACT) has been widely tested for chronic pain, with demonstrated efficacy. Nevertheless, although there is meta-analytical evidence on the efficacy of face-to-face ACT, no reviews have been performed on online ACT in this population. The aim of this meta-analysis is to determine the efficacy of online ACT for adults with chronic pain, when compared with controls. PubMed, PsycINFO, CENTRAL, and Web of Knowledge were searched for randomized controlled trials (RCTs) of online-delivered ACT for chronic pain. Effects were analyzed at post-treatment and follow-up, by calculating standardized mean differences. Online-delivered ACT was generally favored over controls (5 RCTs, N = 746). At post-treatment, medium effects for pain interference and pain acceptance, and small effects for depression, mindfulness, and psychological flexibility were found. A medium effect for pain interference and acceptance, and small effects for pain intensity, depression, anxiety, mindfulness, and psychological flexibility were found at follow-up. ACT-related effects for pain interference, pain intensity, mindfulness, and anxiety increased from post-treatment to follow-up. Nevertheless, the current findings also highlight the need for more methodologically robust RCTs. Future trials should compare online ACT with active treatments, and use measurement methods with low bias. PERSPECTIVE: This is the first meta-analytical review on the efficacy of online ACT for people with chronic pain. It comprises 5 RCTs that compared online ACT with active and/or inactive controls. Online ACT was more efficacious than controls regarding pain interference, pain intensity, depression, anxiety, mindfulness, and psychological flexibility.

Pain intensity and physical performance among individuals with fibromyalgia in mid-to-late life: The influence of depressive symptoms

This study investigated the mediating role of depressive symptoms among 147 middle-aged and older adults with FM in the relationship between pain intensity and 4 objective measures of physical performance: Fullerton Advanced Balance scale (FAB), 6-Minute Walk Test (6MWT), 30-Second Chair Stand (30SCS), and 8-Foot Up and Go Test (8FUPGT). Asymptotic mediation analyses revealed that depressive symptoms fully mediated the relationship between pain intensity and FAB (95% CI [-0.40, -0.10]) and 8FUPGT (CI [0.02, 0.11]) and partially mediated the relationship to 6MWT (CI [-9.15, -2.20]) and 30SCS (CI [-0.29, -0.06]). Findings support the evaluation of co-morbid depression in FM.

The Resurrection of Interdisciplinary Pain Rehabilitation: Outcomes Across a Veterans Affairs Collaborative

OBJECTIVE

Despite empirical support for interdisciplinary pain rehabilitation programs improving functioning and quality of life, access to this treatment approach has decreased dramatically over the last 20 years within the United States but has grown significantly in the Department of Veterans Affairs (VA). Between 2009 and 2019, VA pain rehabilitation programs accredited by the Commission on Accreditation of Rehabilitation Facilities increased 10-fold in the VA, expanding from two to 20. The aim of this collaborative observational evaluation was to examine patient outcomes across a subset of six programs at five sites.

METHODS

Outcomes were assessed using agreed-upon measures of patient-reported pain intensity, pain interference across various domains, pain catastrophizing, and sleep.

RESULTS

A total of 931 patients enrolled in the selected VA interdisciplinary pain programs, with 84.1% of participants completing the full course of treatment. Overall, all programs showed significant improvements from pretreatment to posttreatment in nearly all patient-reported outcomes. The effect sizes ranged from medium to large. Notably, the results demonstrate that positive outcomes were typical despite differences in structure and resources across programs.

CONCLUSIONS

The adverse impacts of opioid use have highlighted the importance of chronic pain treatment approaches that emphasize team-based care focused on functional improvements. This study represents the first and largest analysis of outcomes across chronic pain rehabilitation programs and demonstrates the need for increased access to similar comprehensive approaches to pain management across the health care system. Further, it suggests that a variety of structures may be effective, encouraging flexibility in adopting this interdisciplinary approach.

Chronic Pain in Relation to Depressive Disorders and Alcohol Abuse

Chronic pain disorders have been associated separately with neuropsychiatric conditions such as depression and alcohol abuse. However, in individuals who suffer from non-cancer chronic pain disorders, it is not clear if the burden of depressive disorders is similar for those with and without a history of alcohol abuse. Using data from the Collaborative Psychiatric Epidemiology Surveys (CPES), we found depressive disorders to have a high burden in men and women with a history of alcohol abuse, independently of the presence or absence of chronic pain. We also found that, although the incidence of persistent depressive disorder was comparable in men and women with a history of alcohol abuse, and significantly higher than in control men and women, the incidence of a major depressive episode was higher in women with a history of alcohol abuse independently of the presence or absence of chronic pain. The age of onset of depressive disorders, independently of pain status, was younger for individuals with a history of alcohol abuse. The findings of this study have important implications for the clinical management of individuals who suffer from chronic pain comorbidly with depression and/or alcohol abuse.

Psychological interventions for depression and anxiety: a systematic review and meta-analysis of Iranian chronic pain trials

Background: Chronic pain is commonly associated with anxiety and depression, making it more challenging to be managed. Psychological interventions are suggested for such complicated issues which are well evident in the United States and Europe. However, generalizing the evidence to Iranian population - as a Middle Eastern society - might be questionable. We aimed to synthesize our evidence on the effectiveness of these interventions among Iranian populations. Methods: This was a systematic review and meta-analysis. Persian and English literature were searched through Iran-doc, Elm-net, and PubMed until March 2019 using the following terms (or its Persian synonyms): chronic pain; persistent pain; chronic fatigue; fibromyalgia; neuropath*; LBP; irritable bowel; CFS; psycho*; cogniti*; acceptance; meaning; mindfulness; relaxation; biopsychosocial; rehabilitation; educat*. Eligible trials were randomized trials that evaluated the effectiveness of psychological interventions on Iranian adults with chronic pain. No setting restriction was considered. Risk of bias for each trial was assessed, and the random-effect model was used to pool summary effect across trials. Results: In all 30 eligible RCTs, the risk of bias for randomization was low except for one study. The pooled standardized mean difference (SMD) for depression and anxiety were 1.33 (95%CI: -1.42 to -0.68) and 1.25 (95% CI: -1.55 to -0.96), respectively. Conclusion: This study suggests that psychological interventions are highly effective in reducing depression and anxiety in Iranian patients with chronic pain, compared to what observed in the U.S. and European studies. However, there are still some methodological issues to be addressed. Future research should focus on high-quality trials with considerations on the methodological issues reported in the present study.

The Role of Nonmedical Therapeutic Approaches in the Rehabilitation of Complex Regional Pain Syndrome

Purpose of the Review

Nonmedical therapeutic approaches are fundamental to the management of of Complex Regional Pain Syndrome (CRPS) in order to promote the best outcome for patients. This review focuses on three key approaches underpinning CRPS rehabilitation, namely, physiotherapy and occupational therapy, psychological approaches and education and self-management.

Recent Findings

Recently published European standards outline the quality of therapeutic care that people with CRPS must receive. Early initiated therapy is essential to optimise outcomes, underpinned by patient education. Therapists should promote early movement of the affected limb and encourage re-engagement with usual activities as immobilisation is known to have negative outcomes. There is evidence to support the possible long-term benefit of graded motor imagery and mirror therapy. Psychological assessment should include identification of depression and post-traumatic stress disorder, as treatment of these conditions may improve the trajectory of CRPS. Novel therapies include neurocognitive approaches and those addressing spatial bias, both of which should provide a focus for future research.

Summary

There exists a broad range of nonmedical therapeutic approaches to rehabilitation for CPRS that are thought to be important. However, the evidence for their efficacy is limited. Further research using standardised outcomes would be helpful in developing targeted therapies for the future.

The Influence of Clinical, Functional, and Psychosocial Factors on Walking Time in Individuals With Chronic Low Back Pain

OBJECTIVE

The purpose of this study was to investigate whether clinical, functional, and psychosocial factors are associated with walking time in patients with chronic low back pain.

METHODS

This study included patients aged ≥18 years with low back pain for at least 3 months who visited our outpatient clinic between October 2017 and February 2018. We used the following scales/questionnaires: International Physical Activity Questionnaire for self-reported walking time, Numerical Pain Rating Scale for pain intensity, self-report assessing symptom duration, Roland Morris Disability Questionnaire for disability, Patient-Specific Functional Scale for function, Pain Catastrophizing Scale for pain catastrophizing, and screening questions to assess depression and anxiety. Odds ratios (ORs) with their respective 95% CIs were obtained using logistic regression analysis.

RESULTS

Neither clinical nor functional factors were associated with the total walking time. Among psychosocial factors, only anxiety showed a negative association with the total walking time (OR 0.23, 95% CI 0.06-0.82)-an association that persisted even after adjusting for confounders (OR 0.15, 95% CI 0.03-0.77).

CONCLUSION

Anxiety was shown to be associated with the total walking time in patients with CLBP. No clinical or functional factors seem to be associated with walking in this study sample.

Depression symptoms and cognitive impairment in older nursing home residents in the USA: A latent class analysis

OBJECTIVES

To identify subgroups of nursing home (NH) residents in the USA experiencing homogenous depression symptoms and evaluate if subgroups vary by cognitive impairment.

METHODS

We identified 104 465 newly admitted, long-stay residents with depression diagnosis at NH admission in 2014 using the Minimum Data Set 3.0. The Patient Health Questionnaire-9 was used to measure depression symptoms and the Brief Interview of Mental Status for cognitive impairment (intact; moderately impaired; severely impaired). Latent class analysis (LCA) with logistic regression was used to: (a) construct the depression subgroups and (b) estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of the associations between the subgroups and cognitive impairment level, adjusting for demographic and clinical characteristics.

RESULTS

The best-fitted LCA model suggested four subgroups of depression: minimal symptoms (latent class prevalence: 42.4%), fatigue (32.0%), depressed mood (14.5%), and multiple symptoms (11.2%). Odds of subgroup membership varied by cognitive impairment. Compared to residents with intact cognition, those with moderate or severe cognitive impairment were less likely to belong to the fatigue subgroup [aOR(95% CI): moderate: 0.75 (0.71-0.80); severe: 0.26 (0.23-0.29)] and more likely to belong to the depressed mood subgroup [aOR (95% CI): moderate: 4.54 (3.55-5.81); severe: 6.41 (4.86-8.44)]. Residents with moderate cognitive impairment had increased odds [aOR (95% CI): 1.19 (1.12-1.27)] while those with severe impairment had reduced odds of being in the multiple symptoms subgroup [aOR (95% CI): 0.63 (0.58-0.68)].

CONCLUSIONS

Findings provide a basis for improving depression management with consideration of both subgroups of depression symptoms and levels of cognitive function.

Mediators of Pain and Physical Function in Female and Male Patients with Chronic Pain

Purpose

Chronic pain is often multifactorial and accompanied by psychological distress, catastrophizing thoughts, reduced physical function, and socio-economic worries. In this explorative study, we investigated potential mediators in the relationships of psychological and demographic variables with chronic pain and physical function in women and men.

Patients and Methods

The study included 301 patients admitted to a multidisciplinary pain clinic. Prior to their first consultation, patients completed a questionnaire including items on demographics (age, education, occupational and financial situation), catastrophizing thoughts, psychological distress, pain intensity, and physical function. Hierarchical multiple regression analyses examined demographic and psychological factors associated with pain intensity and physical function. Mediation and reversed mediation models were tested and developed based on calculated relations in the regression analyses between demographic, psychological, pain intensity and physical function variables.

Results

Fifty-eight percent were females and mean age 43.8 and 46.0 years for women and men, respectively. In the regression analyses, psychological factors accounted better for pain intensity than demographic variables, while physical function was best accounted for by demographic variables. Among women, catastrophizing thoughts mediated significantly the relationships between education and pain intensity, and between education and physical function. Psychological distress mediated significantly the relationships between financial situation and pain intensity, and between financial situation and physical function in women. In men, the only significant mediation model was psychological distress mediating the relationship between financial situation and pain intensity. Some of the reversed models revealed indirect effects, indicating bidirectionality.

Conclusion

The results indicate that there might be gender-specific mediators in how demographic variables are associated with pain intensity and physical function. This suggests an awareness among clinicians of potential gender-specific factors mediating pain problems, and the need for a gender-specific, multidisciplinary approach in the treatment of chronic pain.

Pain Catastrophizing Mediates the Association Between Mindfulness and Psychological Distress in Chronic Pain Syndrome

AIM

Trait mindfulness has been found to be inversely associated with emotional distress such as depression and anxiety among patients suffering from pain. The current study investigated the putative mechanisms underlying these associations by examining whether pain catastrophizing mediates the association between mindfulness and psychological distress and whether this model differs in patients suffering from chronic pain compared to patients experiencing nonchronic pain in a medical rehabilitation setting.

METHODS

Forty-eight patients in their subacute stage of recovery participated in the study. Seventeen participants had a diagnosis of chronic pain. Trait mindfulness was assessed using the Mindful Attention Awareness Scale, pain catastrophizing was assessed using the Pain Catastrophizing Scale, depression symptoms were assessed using the Patient Health Questionnaire, and anxiety was assessed using the Generalized Anxiety Disorder scale. Two mediation models were used, with pain catastrophizing mediating the association between mindfulness and depression and anxiety.

RESULTS

Catastrophizing significantly mediated the association between trait mindfulness and depression (P < 0.05, confidence interval [CI] = -0.35, -0.05). Catastrophizing also mediated the relationship between trait mindfulness and anxiety (P < 0.05, CI = -0.34, -0.04). Two moderated mediation models were tested, in which pain catastrophizing fully mediated the relationship between trait mindfulness and depression and anxiety, but only in patients with chronic pain.

CONCLUSIONS

The negative association between trait mindfulness and psychological distress may thus be partly attributed to pain catastrophizing: individuals high in trait mindfulness engage in less catastrophic thinking and therefore experience less distress. Importantly, this was only observed in the patients with chronic pain. These results further underscore the need to cope with pain catastrophizing and encourage mindfulness among patients with chronic pain.

The GCs-SGK1-ATP Signaling Pathway in Spinal Astrocytes Underlied Presurgical Anxiety-Induced Postsurgical Hyperalgesia

BACKGROUND

Patients undergoing surgery often feel anxious. Accumulating evidence indicated that presurgical anxiety was related to the more severe postsurgical pain. An animal model was established that exposed Sprague-Dawley rats to a single-prolonged stress (SPS) procedure to induce presurgical anxiety-like behaviors. The experiment revealed that presurgical anxiety not only aggravated but also prolonged postsurgical pain. However, the underlying mechanisms were unknown.

METHODS

The rats in group C + Cort, group I + Cort, group A + Cort, and group AI + Cort were injected with corticosterone. The rats in group C + RU486, group I + RU486, group A + RU486, and group AI + RU486 were injected with mifepristone (RU486). The rats in group C + GSK650394 and group AI + GSK650394 were injected with GSK650394. The rats in group C + FC1 and group AI + FC1 were injected with fluorocitrate (FC) 30 minutes before SPS, 30 minutes before incision, and on postoperative days 1, 2, 3, 4, and 5. The rats in group C + FC2 and group AI + FC2 were injected with FC on postoperative days 7, 8, 9, 10, 11, 12, and 13. The paw withdrawal mechanical threshold was assessed 24 hours before SPS and from postoperative days 1 to 28. The level of corticosterone was determined by enzyme-linked immunosorbent assay. The expression of serum/glucocorticoid regulated kinase 1 (SGK1), interleukin-1β, and tumor necrosis factor-α was visualized by Western blot. The concentrations of adenosine triphosphate (ATP) were measured by ATP assay kit.

RESULTS

This study showed SPS elevated plasma glucocorticoids and ATP release from astrocytes, which meant the mechanical pain hypersensitivity in presurgical anxiety-induced postsurgical hyperalgesia was dependent on GCs-SGK1-ATP signaling pathway. SGK1 protein level in astrocytes was increased in response to the glucocorticoid stimuli and enhanced the extracellular release of ATP. Furthermore, spinal astrocytes played a key role in the maintenance. Targeting spinal astrocytes in maintenance phase prevented the pathological progression.

CONCLUSIONS

These data suggested an important signaling pathway that affected the pain sensitivity after operation caused by presurgical anxiety.

A Mixed Methods Analysis of Acute Upper Extremity Pain as Measured by the Patient Reported Outcomes Measurement Information System

Introduction

Chronic pain affects U.S. service member’s (SMs) more disproportionately than individuals in the general public. SMs have unique cultural pressures to ignore or deny acute pain; therefore, the beliefs and behaviors of this group may cause them to self-report their acute pain in a specific manner. This study evaluated the strength of the relationship of the patient reported outcomes measurement information system (PROMIS) upper extremity computer adaptive test (CAT) and assessed U.S. active duty SMs experience of acute pain and function compared to the quick disabilities of the arm, shoulder, and hand (QuickDASH). In addition, the PROMIS pain interference CAT, PROMIS pain behavior CAT, and PROMIS anxiety CAT were correlated to the PROMIS upper extremity CAT and QuickDASH questionnaires.

Materials and Methods

This mixed methods, sequential, explanatory study included a convenience sample of 26 participants from two occupational therapy clinics. Participants were administered five self-report questionnaires at initial evaluation and at follow up (30–90 day). At follow up, 12 participants completed a semi-structured interview. Categorical variables were summarized using percentages and analyzed using a chi-square goodness of fit test. A Pearson correlation coefficient was used to analyze the linear relationship between the QuickDASH and specified PROMIS questionnaires. This study was approved by the Institutional Review Board at Brooke Army Medical Center, reference number C.2017.173d.

Results

The initial and follow up scores from the self-report questionnaires demonstrated a good to excellent correlation between the PROMIS upper extremity CAT and the QuickDASH (r = –0.65; r = –0.81; p &lt; 0.001). Qualitative data were gathered during a semi-structured interview of 12 participants after the follow up and were analyzed using thematic analysis. Three themes emerged from qualitative analysis of data: (1) impact of military culture, (2) psychosocial effects of acute pain, and (3) therapist contributions to disability awareness.

Conclusions

This study demonstrates several cultural and psychosocial influences concerning the experience of SMs with acute UE disability and pain, which were not previously reported for this population.

Painful Life Events in Psychiatric Disorders: A Quantitative and Qualitative Analysis

We reported in a previous study the painful events experienced in the past in subjects with schizophrenia or major depression, in comparison to controls, and related them to the experimental pain sensitivity, anxiety, and the diagnosis. We present here the detailed analysis of these past painful events, with the aim of determining whether schizophrenic, depressive and control groups are qualitatively (type of painful events experienced, emotional or sensory components associated with pain) and quantitatively (duration, severity, and intensity) comparable concerning their past painful experiences. The questionnaire used relies on memory and feelings and will provide an indication about the way pain is experienced and memorized in daily life. The reported history of pain was not the same in the three groups. Depressed subjects differed from the others by the number of reported painful events. Painful events of everyday life, such as trauma without fracture and wounds, were the most highly reported painful events for all groups. Surprisingly, the daily pain events are associated to affective component of pain perception. Other kinds of event were differently reported between the groups. Experience of pain appears to be memorized and reported differently depending on the psychiatric disorder and type of event. The characteristics of each individual, their previous experience, contribute to the expression of psychiatric disorders, including in the field of pain. Past pain experience should be taken into account when attending someone for pain.

Euthanasia requests in a Canadian psychiatric outpatient clinic: A case series part 2 of the McGill University euthanasia in psychiatry case series

The Canadian province of Quebec enacted in 2014 a legislation that permitted medical assistance in dying (MAID) under specific conditions and the rest of Canada followed suit in June 2016. In this article, which is the second in a set of case series of requests for MAID in Canadian psychiatry, we present the cases of two patients who made a request for MAID to their treating psychiatrist in an outpatient clinic. While one is advanced in age and suffering from intense physical and psychic pain with little if any psychiatric comorbidity, the other is a young and medically healthy woman who nonetheless suffers from extensive psychiatric comorbidity. This article discusses both cases in light of recent scientific literature and case law that is slowly emerging in Canada, focusing on the concepts of the end of life and its legal definition as well as psychic suffering and its management in those wishing to receive physician-assisted dying. In our conclusion, we stress the need to clarify the definition of treatment resistance, the necessity to determine each physician's role when many are involved, as well as the importance of treating psychic pain holistically, which can sometimes require going beyond standard psychiatric care.