The Role of Perceived Stress and Life Stressors in the Development of Chronic Musculoskeletal Pain Disorders: A Systematic Review

'Ask a hundred people, you get a hundred definitions': A comparison of lay and expert understanding of stress and its associations with health

The understanding an individual holds about stress can influence their appraisal of it and have implications for subsequent health, yet knowledge of such understanding is scarce. This study explored discrepancies between lay and expert understanding of stress and links made between stress and health. Twenty-six lay members of the local community aged 18-62 years, and seven expert stress researchers, participated in individual semi-structured interviews. Thematic analysis of the two datasets was conducted separately, then findings compared to identify similarities and differences between lay and scientific understanding. Whilst many similarities were identified, we found three important discrepancies: (i) Lay participants demonstrated a strong awareness of the indirect effects of stress on health via health behaviours; (ii) compared to experts, lay participants showed less awareness of a direct path between stress and physical health; (iii) lay participants showed less understanding of social determinants of stress and collective measures for stress management that went beyond individual responsibility. Discrepancies identified serve to highlight potential misunderstandings in lay conceptualisation of stress and its links with health. These findings have potential to facilitate the work of practitioners who serve as intermediaries to translate scientific knowledge into therapeutic benefit, through improved awareness and communication surrounding stress understanding.

Pain in alcohol use disorder: Evaluating effects of childhood trauma, perceived stress, and psychological comorbidity

The relationship between pain and alcohol use disorder (AUD) is complex and bidirectional. The current study examines risk factors for pain in a large comprehensively phenotyped sample including individuals from across the spectrum of alcohol use and misuse. Participants (n = 1101) were drawn from the National Institute on Alcohol Abuse and Alcoholism Natural History Protocol and included treatment-seeking AUD inpatients (AUD+Tx, n = 369), individuals with AUD not seeking treatment (AUD+, n = 161), and individuals without AUD (AUD-, n = 571). General linear models were utilized to test the effects of AUD status, history of childhood trauma exposure, perceived stress, and psychological comorbidity on daily percent time in pain, as well as change in daily percent time in pain across the inpatient stay in AUD+Tx individuals. Overall, 60.2% individuals reported any pain, with a significantly higher prevalence in the AUD+Tx group (82.1%) compared to the AUD+ (56.5%) and AUD- (47.1%) groups. Daily percent time in pain was also highest in the AUD+Tx group (30.2%) and was further increased in those with a history of childhood abuse and comorbid posttraumatic stress disorder (PTSD). Years of heavy drinking and craving were also associated with increased percent time in pain in the AUD+Tx group. Percent time in pain decreased following acute withdrawal in the AUD+Tx group but plateaued around 25% just prior to discharge. Individuals seeking inpatient treatment for AUD, especially those with a history of childhood trauma and/or comorbid PTSD, report greater percent time in pain compared to those not seeking treatment and those without AUD. The prolonged experience of pain in abstinent AUD inpatients after the resolution of acute withdrawal may signal the early stages of protracted withdrawal. Integrative treatments targeting pain and other symptoms of protracted withdrawal may be effective in improving overall function in people with severe AUD.

Mental health markers and protective factors in students with symptoms of physical pain across WEIRD and non-WEIRD samples - a network analysis

BACKGROUND

Studies conducted in Western societies have identified variables associated with chronic pain, but few have done so across cultures. Our study aimed to clarify the relationship between specific mental health markers (i.e., depression, anxiety, posttraumatic stress disorder [PTSD], perceived stress) as well as specific protective factors (i.e., social support and self-efficacy) related to physical pain among university students across non-WEIRD and WEIRD samples.

METHOD

A total of 188 university students (131 women and 57 men) were included in the study. We used network analysis to ascertain mental health markers especially central to the experience of physical pain.

RESULTS

No statistically significant difference was found between mental health markers (i.e., depression, anxiety, perceived stress, and PTSD) and protective factors (i.e., social support and self-efficacy) associated with physical pain symptoms for Swiss students versus Indian students (M = 0.325, p = .11). In addition, networks for Swiss versus Indian students did not differ in global strength (S = 0.29, p = .803). Anxiety was the most central mental health marker, and social support was the most important protective factor related to physical pain in both countries. However, for Swiss students, perceived stress, and for Indian students, PTSD symptoms were central mental health markers related to physical pain.

CONCLUSION

Our results identify factors that may serve as important treatment targets for pain interventions among students of both countries before it becomes chronic.

Exploring Gender Differences in Veterans in a Secondary Analysis of a Randomized Controlled Trial of Mindfulness for Chronic Pain

Background

Although studies have documented higher rates of chronic pain among women Veterans compared to men Veterans, there remains a lack of comprehensive information about potential contributors to these disparities.

Materials and Methods

This study examined gender differences in chronic pain and its contributors among 419 men and 392 women Veterans, enrolled in a mindfulness trial for chronic pain. We conducted descriptive analyses summarizing distributions of baseline measures, obtained by survey and through the electronic health record. Comparisons between genders were conducted using chi-square tests for categorical variables and t-tests for continuous measures.

Results

Compared to men, women Veterans were more likely to have chronic overlapping pain conditions and had higher levels of pain interference and intensity. Women had higher prevalence of psychiatric and sleep disorder diagnoses, greater levels of depression, anxiety, post-traumatic stress disorder, fatigue, sleep disturbance, stress and pain catastrophizing, and lower levels of pain self-efficacy and participation in social roles and activities. However, women were less likely to smoke or have a substance abuse disorder and used more nonpharmacological pain treatment modalities.

Conclusion

Among Veterans seeking treatment for chronic pain, women differed from men in their type of pain, had greater pain intensity and interference, and had greater prevalence and higher levels of many known biopsychosocial contributors to pain. Results point to the need for pain treatment that addresses the comprehensive needs of women Veterans.

Clinical Trial Registration Number: NCT04526158. Patient enrollment began on December 4, 2020.

Stressful life events and low back pain in older men: A cross-sectional and prospective analysis using data from the MrOS study

BACKGROUND

Stressful life events, such as loss of a partner, loss of a pet or financial problems, are more common with increasing age and may impact the experience of pain. The aim of the current study is to determine the cross-sectional and prospective association between stressful life events and low back pain reporting in the Osteoporotic Fracture in Men Study, a cohort of older men aged ≥65 years.

METHODS

At a study visit (March 2005-May 2006), 5149 men reported whether they had experienced a stressful life event or low back pain in the prior 12 months. Following that visit, data on low back pain patients were gathered through triannual questionnaires every 4 months for 1 year. Multivariable logistic regression analyses estimated the association of stressful life events with recent past low back pain or future low back pain.

RESULTS

N = 2930, (57%) men reported at least one stressful life event. The presence of a stressful life event was associated with greater odds of any low back pain (OR = 1.42 [1.26-1.59]) and activity-limiting low back pain (OR = 1.74 [1.50-2.01]) in the same period and of any low back pain (OR = 1.56 [1.39-1.74]) and frequent low back pain (OR = 1.80 [1.55-2.08]) in the following year.

CONCLUSION

In this cohort of men, the presence of stressful life events increased the likelihood of reporting past and future low back pain.

SIGNIFICANCE

Stressful life events such as accident or illness to a partner are common in later life and may impact the experience of pain. We present cross-sectional and prospective data highlighting a consistent association between stressful life events and low back pain in older men. Further, there is evidence to suggest that this relationship is upregulated by an individual's living situation. This information may be used to strengthen a biopsychosocial perspective of an individual's pain experience.

Does Osteopathic Heart-Focused Palpation Modify Heart Rate Variability in Stressed Participants with Musculoskeletal Pain? A Randomised Controlled Pilot Study

Heart rate variability (HRV) describes fluctuations in time intervals between heartbeats and reflects autonomic activity. HRV is reduced in stressed patients with musculoskeletal pain and improved after osteopathic manipulative treatment and mind-body interventions. Heart-focused palpation (HFP) combines manual and mind-body approaches to facilitate relaxation. This randomised controlled pilot study investigated the feasibility and sample size for a future randomised controlled trial and the effect of a single treatment with HFP or sham HFP (SHAM) on short-term HRV. A total of Thirty-three adults (47.7 ± 13.5 years old) with stress and musculoskeletal pain completed the trial with acceptable rates of recruitment (8.25 subjects per site/month), retention (100%), adherence (100%), and adverse events (0%). HFP (n = 18), but not SHAM (n = 15), significantly increased the root mean square of successive RR interval differences (p = 0.036), standard deviation of the NN intervals (p = 0.009), and ratio of the low-frequency to high-frequency power band (p = 0.026). HFP and SHAM significantly decreased the heart rate (p < 0.001, p = 0.009) but not the stress index and ratio of the Poincaré plot standard deviation along and perpendicular to the line of identity (p > 0.05). A power analysis calculated 72 participants. Taken together, the study was feasible and HFP improved HRV in stressed subjects with musculoskeletal pain, suggesting a parasympathetic effect.

COVID-19 pandemic stress and cancer symptom burden

OBJECTIVES

In a sample of patients with cancer (n=1145) who were assessed during the height of the COVID-19 pandemic, latent profile analysis was used to identify subgroups of patients with distinct stress profiles and to evaluate for differences in demographic and clinical characteristics and symptom severity scores among these subgroups.

METHODS

Patients completed measures of cancer-specific and COVID-19 stress, global stress, social isolation, loneliness, depression, state and trait anxiety, morning and evening fatigue, morning and evening energy, sleep disturbance, cognitive function, and pain. Latent profile analysis was used to identify subgroups of patients with distinct stress profiles. Differences among the subgroups in study measures were evaluated using parametric and non-parametric tests.

RESULTS

Using clinically meaningful cut-off scores for the stress measures, four distinct stress profiles were identified (ie, none class (51.3%); low stress and moderate loneliness class (24.4%), high stress and moderate loneliness class (14.0%), and very high stress and moderately high loneliness class (high, 10.3%)). Risk factors associated with membership in the high class included: younger age, lower annual household income, lower functional status and higher comorbidity burden. The two worst stress profiles reported clinically meaningful levels of all of the common symptoms associated with cancer and its treatments.

CONCLUSION

Findings from this study, obtained prior to the availability of COVID-19 vaccines and anti-viral medications, provide important 'benchmark data' to evaluate for changes in stress and symptom burden in patients with cancer in the postvaccine era and in patients with long COVID-19.

Bidirectional Associations Between Pain and Perceived Stress Among Veterans: Depressive Disorder as a Predisposing Factor

OBJECTIVE

Military veterans who were injured in combat very often report pain along with co-occurring perceived stress and preexisting depressive disorder. The systems model of pain is a theoretical model suggesting that pain and perceived stress are bidirectionally associated at the within-person level, and associations are heightened among those with depressive disorder. However, the systems model of pain has not been adequately tested. Testing the systems model of pain could illuminate salient treatment targets for combat-injured veterans with pain and co-occurring psychological problems.

METHODS

The present study empirically tests the systems model of pain among a sample of combat-injured veterans ( N = 902) surveyed five times during an 18-month period. We used a multigroup, autoregressive latent trajectory with structured residual statistical model to test the within-person associations between pain and perceived stress and determine whether associations differ between veterans with and without a positive screen for depressive disorder.

RESULTS

In line with the systems model of pain, pain and perceived stress were bidirectionally associated only among combat-injured veterans with depressive disorder. Among such veterans, perceived stress was positively associated with subsequent pain ( b = 0.12; 95% confidence interval = 0.06-0.17), and pain was positively associated with subsequent perceived stress ( b = 0.44; 95% CI = 0.11-0.77).

CONCLUSIONS

Our work highlights the interplay between pain and its psychological correlates among a particularly at-risk population. Clinicians addressing pain and perceived stress among combat-injured veterans should be prepared to identify and address depressive disorder.

Prevalence and Risk Factors of De Novo Widespread Post-COVID Pain in Nonhospitalized COVID-19 Survivors: A Nationwide Exploratory Population-Based Survey

This survey investigated the prevalence of de novo widespread musculoskeletal post-COVID pain and risk factors for its development in nonhospitalized COVID-19 survivors. A nationwide exploratory cross-sectional study was conducted, including a cohort of 593,741 Danish residents who had suffered from a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection from March 2020 to December 2021. A questionnaire was distributed to the Danish population via the digital mail system (e-Boks). Self-reported demographic data, previous medical comorbidities (diagnosed), socioeconomic data, time of infection, prior chronic pain conditions (diagnosed), development of de novo widespread pain after infection, pain medication, and pain intensity information were collected. Responders consisted of 130,443 nonhospitalized participants (58.2% women; mean age: 50.2 years). At a mean of 14.4 (standard deviation 6.0) months after infection, 6,875 (5.3%) patients reported the presence of de novo widespread musculoskeletal post-COVID pain. Almost 75% of the patients reported a moderate to severe intensity of the pain. In conclusion, de novo widespread post-COVID pain was present in 5.3% of nonhospitalized COVID-19 survivors 1 year after infection (14.4 ± 6.0 months). Older age, female sex, higher BMI, and history of migraine, whiplash, stress, type-2 diabetes, neurological disorders, and lower socioeconomic status were risk factors associated with the development of de novo widespread post-COVID pain in nonhospitalized patients. As de novo widespread pain is considered a sign of sensitization, this group will require specialized pain management attention. PERSPECTIVE: This article presents de novo widespread post-COVID pain prevalence in a cohort of 130,443 citizens infected with COVID-19. The study identifies potential risk factors associated with the development of these new pain symptoms. The results may increase focus on this patient group and potentially help identify predictors for postinfection pain development.

Risk factors and injury prevention strategies for overuse injuries in adult climbers: a systematic review

Introduction

Climbing is an increasingly popular activity and imposes specific physiological demands on the human body, which results in unique injury presentations. Of particular concern are overuse injuries (non-traumatic injuries). These injuries tend to present in the upper body and might be preventable with adequate knowledge of risk factors which could inform about injury prevention strategies. Research in this area has recently emerged but has yet to be synthesized comprehensively. Therefore, the aim of this study was to conduct a systematic review of the potential risk factors and injury prevention strategies for overuse injuries in adult climbers.

Methods

This systematic review was conducted in accordance with the PRISMA guidelines. Databases were searched systematically, and articles were deemed eligible based upon specific criteria. Research included was original and peer-reviewed, involving climbers, and published in English, German or Czech. Outcomes included overuse injury, and at least one or more variable indicating potential risk factors or injury prevention strategies. The methodological quality of the included studies was assessed with the Downs and Black Quality Index. Data were extracted from included studies and reported descriptively for population, climbing sport type, study design, injury definition and incidence/prevalence, risk factors, and injury prevention strategies.

Results

Out of 1,183 records, a total of 34 studies were included in the final analysis. Higher climbing intensity, bouldering, reduced grip/finger strength, use of a "crimp" grip, and previous injury were associated with an increased risk of overuse injury. Additionally, a strength training intervention prevented shoulder and elbow injuries. BMI/body weight, warm up/cool downs, stretching, taping and hydration were not associated with risk of overuse injury. The evidence for the risk factors of training volume, age/years of climbing experience, and sex was conflicting.

Discussion

This review presents several risk factors which appear to increase the risk of overuse injury in climbers. Strength and conditioning, load management, and climbing technique could be targeted in injury prevention programs, to enhance the health and wellbeing of climbing athletes. Further research is required to investigate the conflicting findings reported across included studies, and to investigate the effectiveness of injury prevention programs.

Systematic Review Registration

https://www.crd.york.ac.uk/, PROSPERO (CRD42023404031).

Cognitive-Affective-Behavioral Pathways Linking Adversity and Discrimination to Daily Pain in African-American Adults

The tendency to ruminate, magnify, and experience helplessness in the face of pain - known as pain catastrophizing - is a strong predictor of pain outcomes and is associated with adversity. The ability to maintain functioning despite adversity - referred to as resilience - also influences pain outcomes. Understanding the extent to which pain catastrophizing and resilience influence relations between adversity and daily pain in healthy African-American adults could improve pain risk assessment and mitigate racial disparities in the transition from acute to chronic pain. This study included 160 African-American adults (98 women). Outcome measures included daily pain intensity (sensory, affective) and pain impact on daily function (pain interference). Adversity measures included childhood trauma exposure, family adversity, chronic burden from recent stressors, and ongoing perceived stress. A measure of lifetime racial discrimination was also included. Composite scores were created to capture early-life adversity (childhood trauma, family adversity) versus recent-life adversity (perceived stress, chronic burden). Increased pain catastrophizing was correlated with increased adversity (early and recent), racial discrimination, pain intensity, and pain interference. Decreased pain resilience was correlated with increased recent-life adversity (not early-life adversity or racial discrimination) and correlated with increased pain intensity (not pain-related interference). Bootstrapped multiple mediation models revealed that relationships between all adversity/discrimination and pain outcomes were mediated by pain catastrophizing. Pain resilience, however, was not a significant mediator in these models. These findings highlight opportunities for early interventions to reduce cognitive-affective-behavioral risk factors for persisting daily pain among African-American adults with greater adversity exposure by targeting pain catastrophizing.

Stressors and Pain across the Late-Life Span: Findings from Two Parent Longitudinal Studies of Aging and Health

OBJECTIVE

The objective is to determine associations between stressors and pain across the late-life span.

METHOD

Multilevel linear modeling was applied separately to harmonized repeated measures data from the Longitudinal Late-Life Health study (LLLH; n = 342; 13-year interval) and the Health and Retirement Study (HRS; n = 2959; 8-year interval).

RESULTS

In both the LLLH and HRS samples, independent of age, gender, and race, participants with higher average stressor levels experienced more numerous painful conditions and higher pain severity over the study intervals. In the HRS sample, they also experienced higher levels of pain interference. In general, participants' stressor levels did not influence rates of increase in their pain. Gender and race had few moderating effects on associations between stressors and pain.

DISCUSSION

Stressors and pain are associated across the late-life span. Future research should focus on the mediating mechanisms that account for this association and the moderating factors that affect its strength.

Racial and Ethnic Disparities in the Incidence of High-Impact Chronic Pain Among Primary Care Patients with Acute Low Back Pain: A Cohort Study

OBJECTIVE

We assessed whether race or ethnicity was associated with the incidence of high-impact chronic low back pain (cLBP) among adults consulting a primary care provider for acute low back pain (aLBP).

METHODS

In this secondary analysis of a prospective cohort study, patients with aLBP were identified through screening at seventy-seven primary care practices from four geographic regions. Incidence of high-impact cLBP was defined as the subset of patients with cLBP and at least moderate disability on Oswestry Disability Index [ODI >30]) at 6 months. General linear mixed models provided adjusted estimates of association between race/ethnicity and high-impact cLBP.

RESULTS

We identified 9,088 patients with aLBP (81.3% White; 14.3% Black; 4.4% Hispanic). Black/Hispanic patients compared to White patients, were younger and more likely to be female, obese, have Medicaid insurance, worse disability on ODI, and were at higher risk of persistent disability on STarT Back Tool (all P < .0001). At 6 months, more Black and Hispanic patients reported high-impact cLBP (30% and 25%, respectively) compared to White patients (15%, P < .0001, n = 5,035). After adjusting for measured differences in socioeconomic and back-related risk factors, compared to White patients, the increased odds of high-impact cLBP remained statistically significant for Black but not Hispanic patients (adjusted odds ration [aOR] = 1.40, 95% confidence interval [CI]: 1.05-1.87 and aOR = 1.25, 95%CI: 0.83-1.90, respectively).

CONCLUSIONS

We observed an increased incidence of high-impact cLBP among Black and Hispanic patients compared to White patients. This disparity was partly explained by racial/ethnic differences in socioeconomic and back-related risk factors. Interventions that target these factors to reduce pain-related disparities should be evaluated.

CLINICALTRIALS.GOV IDENTIFIER

NCT02647658.

Digital Therapeutics (DTx) Expand Multimodal Treatment Options for Chronic Low Back Pain: The Nexus of Precision Medicine, Patient Education, and Public Health

Digital therapeutics (DTx, software as a medical device) provide personalized treatments for chronic diseases and expand precision medicine beyond pharmacogenomics-based pharmacotherapies. In this perspective article, we describe how DTx for chronic low back pain (CLBP) can be integrated with pharmaceutical drugs (e.g., NSAIDs, opioids), physical therapy (PT), cognitive behavioral therapy (CBT), and patient empowerment. An example of an FDA-authorized DTx for CLBP is RelieVRx, a prescription virtual reality (VR) app that reduces pain severity as an adjunct treatment for moderate to severe low back pain. RelieVRx is an immersive VR system that delivers at-home pain management modalities, including relaxation, self-awareness, pain distraction, guided breathing, and patient education. The mechanism of action of DTx is aligned with recommendations from the American College of Physicians to use non-pharmacological modalities as the first-line therapy for CLBP. Herein, we discuss how DTx can provide multimodal therapy options integrating conventional treatments with exposome-responsive, just-in-time adaptive interventions (JITAI). Given the flexibility of software-based therapies to accommodate diverse digital content, we also suggest that music-induced analgesia can increase the clinical effectiveness of digital interventions for chronic pain. DTx offers opportunities to simultaneously address the chronic pain crisis and opioid epidemic while supporting patients and healthcare providers to improve therapy outcomes.

Applying the behavioural change wheel to guide the implementation of a biopsychosocial approach to musculoskeletal pain care

Achieving high value, biopsychosocial pain care can be complex, involving multiple stakeholders working synergistically to support the implementation of quality care. In order to empower healthcare professionals to assess, identify and analyse biopsychosocial factors contributing to musculoskeletal pain, and describe what changes are needed in the whole-of-system to navigate this complexity, we aimed to: (1) map established barriers and enablers influencing healthcare professionals' adoption of a biopsychosocial approach to musculoskeletal pain against behaviour change frameworks; and (2) identify behaviour change techniques to facilitate and support the adoption and improve pain education. A five-step process informed by the Behaviour Change Wheel (BCW) was undertaken: (i) from a recently published qualitative evidence synthesis, barriers and enablers were mapped onto the Capability Opportunity Motivation-Behaviour (COM-B) model and Theoretical Domains Framework (TDF) using "best fit" framework synthesis; (ii) relevant stakeholder groups involved in the whole-of-health were identified as audiences for potential interventions; (iii) possible intervention functions were considered based on the Affordability, Practicability, Effectiveness and Cost-effectiveness, Acceptability, Side-effects/safety, Equity criteria; (iv) a conceptual model was synthesised to understand the behavioural determinants underpinning biopsychosocial pain care; (v) behaviour change techniques (BCTs) to improve adoption were identified. Barriers and enablers mapped onto 5/6 components of the COM-B model and 12/15 domains on the TDF. Multi-stakeholder groups including healthcare professionals, educators, workplace managers, guideline developers and policymakers were identified as target audiences for behavioural interventions, specifically education, training, environmental restructuring, modelling and enablement. A framework was derived with six BCTs identified from the Behaviour Change Technique Taxonomy (version 1). Adoption of a biopsychosocial approach to musculoskeletal pain involves a complex set of behavioural determinants, relevant across multiple audiences, reflecting the importance of a whole-of-system approach to musculoskeletal health. We proposed a worked example on how to operationalise the framework and apply the BCTs. Evidence-informed strategies are recommended to empower healthcare professionals to assess, identify and analyse biopsychosocial factors, as well as targeted interventions relevant to various stakeholders. These strategies can help to strengthen a whole-of-system adoption of a biopsychosocial approach to pain care.

Chronic pain and its correlates among long-term breast cancer survivors

PURPOSE

Chronic pain is a common symptom affecting quality of life for breast cancer survivors. However, its prevalence and correlate factors in long-term breast cancer survivors, particularly Asian women, are understudied. The reported study is to address these knowledge gaps.

METHODS

We evaluated pain severity and frequency, and their associations with clinical features and lifestyle factors among 3640 5-year breast cancer survivors who participated in the Shanghai Breast Cancer Survival Study. Demographic, clinical, and lifestyle information was collected at study enrollment, which occurred 6 months post-diagnosis, and pain was assessed at the 5-year post-diagnosis follow-up survey.

RESULTS

In total, 42% of participants reported experiencing pain. Pain is more prevalent among survivors with low educational attainment or low income. Multivariable polytomous regression analyses showed that pain was positively associated with metastasis or recurrence (moderate pain OR: 2.17, 95% CI: 1.45, 3.26, frequent pain OR: 1.92, 95% CI: 1.37, 2.70), triple negative status (infrequent pain OR: 1.36, 95% CI: 1.04, 1.78), obesity (frequent pain OR: 1.80, 95% CI: 1.41, 2.31), and multiple comorbidities. Exercise (OR: 0.65, 95%: 0.49, 0.88), chemotherapy (OR: 0.59, 95% CI: 0.41, 0.849), and HER2-positive and ER/PR-negative status (OR: 0.64, 95% CI: 0.43, 0.97) were inversely associated with moderate pain.

CONCLUSIONS

Chronic pain is highly prevalent among long-term breast cancer survivors in China and was associated with obesity, physical inactivity, and several clinical factors.

IMPLICATIONS FOR CANCER SURVIVORS

This study highlights the importance of promoting weight control and exercise to alleviate chronic pain.

High intensity training improves symptoms of central sensitization at six-month follow-up in persons with chronic nonspecific low back pain: Secondary analysis of a randomized controlled trial

BACKGROUND

High intensity training (HIT) improves disability and physical fitness in persons with chronic nonspecific low back pain (CNSLBP). However, it remains unclear if HIT affects pain processing and psychosocial factors.

OBJECTIVE

To evaluate 1) the effects of HIT on symptoms of central sensitization and perceived stress and 2) the relationship of symptoms of central sensitization and perceived stress with therapy success, at six-month follow-up, in persons with CNSLBP.

METHODS

This is a secondary analysis of a previously published randomized controlled trial. Persons with CNSLBP (n = 51, age=43.6y) completed the Central Sensitization Inventory (CSI) and Perceived Stress Scale (PSS) at baseline (PRE) and six months after 12-week of HIT consisting of concurrent exercise therapy (FU). Two groups were formed based on CSI scores (low-CSI/high-CSI). First, linear mixed models were fitted for each outcome, with time and groups as covariates. Multiple comparisons were executed to evaluate group (baseline), time (within-group), and interaction (between-group) effects. Second, correlation and regression analyses were performed to evaluate if baseline and changes in CSI/PSS scores were related to therapy success, operationalized as improvements on disability (Modified Oswestry Disability Index), and pain intensity (Numeric Pain Rating Scale).

RESULTS

Total sample analyses showed a decrease in both CSI and PSS. Within-group analyses showed a decrease of CSI only in the high-CSI group and a decrease of PSS only in the low-CSI group. Between-group analyses showed a pronounced decrease favouring high-CSI (mean difference: 7.9; 95%CI: 2.1, 12.7) and no differences in PSS (mean difference: 0.1; 95%CI: -3.0, 3.2). CSI, but not PSS, was weakly related to therapy success.

CONCLUSION

HIT improves symptoms of central sensitization in persons with CNSLBP. This effect is the largest in persons with clinically relevant baseline CSI scores. HIT also decreases perceived stress.

Accumulation of long-term diseases is associated with musculoskeletal pain dimensions among middle-aged individuals with musculoskeletal pain

BACKGROUND

Long-term diseases often co-occur with musculoskeletal (MSK) pain. In middle-aged individuals with MSK pain, it remains unclear whether an accumulation (two or more) of long-term diseases is associated with MSK pain dimensions, including pain frequency, bothersomeness of pain, pain intensity and number of pain sites.

METHODS

This cross-sectional study included data from the Northern Finland Birth Cohort 1966 collected in 2012-2014 when the participants were 46 years of age. We included participants who reported having MSK pain during the previous year (collected retrospectively) and provided self-reported information related to MSK pain dimensions, long-term diseases and potential confounders (n = 4469). The association between long-term diseases and pain dimensions was modelled by general linear and logistic regression models, with beta (β) coefficients, odds ratios (ORs) and their 95% confidence intervals (CIs) being presented. Unadjusted models were followed by models adjusted for sex, educational level and smoking.

RESULTS

The presence of accumulated long-term diseases was associated with over two-fold higher odds of daily pain (adjusted OR 2.6, 95% CI 2.0-3.4) and significantly higher levels of bothersomeness of pain and pain intensity (adjusted β 1.1, 95% CI 0.9-1.4; adjusted β 1.0, 95% CI 0.8-1.1, respectively), relative to the absence of long-term diseases. Females with accumulated long-term diseases had a stronger relationship to number of pain sites than males. Associations between one long-term disease and pain dimensions were significant but smaller in magnitude.

CONCLUSION

There is a need for a better understanding of the relationships between accumulated long-term diseases and MSK pain.

SIGNIFICANCE

This study on middle-aged individuals with musculoskeletal pain showed that the presence of long-term diseases was clearly associated with pain frequency, bothersomeness of pain, pain intensity and number of pain sites. Compared with no long-term diseases, the association between accumulated (two or more) long-term diseases and pain dimensions was stronger than the association between one long-term disease and pain dimensions.

Negative effects of the COVID-19 pandemic on the musculoskeletal system and depression in healthcare professionals

BACKGROUND

During the COVID-19 pandemic, it is thought that healthcare workers are most exposed to musculoskeletal disorders. However, there are limited studies in the literature examining the musculoskeletal disorders among healthcare workers during the COVID-19 pandemic.

OBJECTIVE

The aim of this study was to examine musculoskeletal problems and psychological disorders in healthcare personnel working at Dicle University Faculty of Medicine and Research Hospitals during the COVID-19 pandemic and to come up with solutions for rehabilitation.

METHODS

The Cornell Musculoskeletal Disorder Questionnaire (CMDQ) was used to assess musculoskeletal problems in the past week. Additionally, Beck depression inventory (BDI) was used to evaluate the psychological state of the participants. Questions on demographic characteristics, habits, the presence and localisation of musculoskeletal system (MSS) diseases, severity and duration of pain, chronic diseases, trauma history and working conditions were included in the questionnaire prepared by the researchers.

RESULTS

The study included 74 nurses, 42 residents, 26 specialists, 24 technicians, 16 dentists, 12 physiotherapists, and 26 other allied health personnel. Dentists had the highest total CMDQ score (160.73) whereas resident doctors had the lowest total CMDQ score (98.33). Low back, neck and back pain were the most common MSS problems. BDI was highest in nurses and 70.27% of the nurses were women. The total workplace ergonomics score was found to be 25.91%, and the visual analogue scale (VAS) was highest in nurses (6.72).

CONCLUSIONS

While MSS pain is concentrated on the waist, neck and back regions in all healthcare workers. We concluded that the uncertainty associated with the pandemic, delay in preventive measures such as vaccination and medication, rapid and strong transmission of the disease and increasing number of deaths have led to an increase in stress, depression and burnout among healthcare workers.

Wearable-Measured Sleep and Resting Heart Rate Variability as an Outcome of and Predictor for Subjective Stress Measures: A Multiple N-of-1 Observational Study

The effects of stress may be alleviated when its impact or a decreased stress-resilience are detected early. This study explores whether wearable-measured sleep and resting HRV in police officers can be predicted by stress-related Ecological Momentary Assessment (EMA) measures in preceding days and predict stress-related EMA outcomes in subsequent days. Eight police officers used an Oura ring to collect daily Total Sleep Time (TST) and resting Heart Rate Variability (HRV) and an EMA app for measuring demands, stress, mental exhaustion, and vigor during 15-55 weeks. Vector Autoregression (VAR) models were created and complemented by Granger causation tests and Impulse Response Function visualizations. Demands negatively predicted TST and HRV in one participant. TST negatively predicted demands, stress, and mental exhaustion in two, three, and five participants, respectively, and positively predicted vigor in five participants. HRV negatively predicted demands in two participants, and stress and mental exhaustion in one participant. Changes in HRV lasted longer than those in TST. Bidirectional associations of TST and resting HRV with stress-related outcomes were observed at a weak-to-moderate strength, but not consistently across participants. TST and resting HRV are more consistent predictors of stress-resilience in upcoming days than indicators of stress-related measures in prior days.

Vascular-Metabolic Risk Factors and Psychological Stress in Patients with Chronic Tinnitus

Little is known about molecular correlates of chronic tinnitus. We examined interrelationships between vascular−metabolic risk factors, perceived stress, and other routine blood values in patients with chronic tinnitus. Two-hundred patients (51% female) were screened for 49 blood parameters pertaining to vascular−metabolic risk, immune function, and redox processes. They further completed perceived stress- and tinnitus-related distress questionnaires. Following descriptive analyses, gender-specific sets of age- and tinnitus-severity-adjusted regression models investigated associations between perceived stress and blood parameters. Patients reported mildly elevated levels of perceived stress. Elevated levels of total cholesterol (65% and 61% of female and male patients, respectively), non-HDL-c (43/50%), LDL-c (56/59%), and lipoprotein_a (28/14%) were accompanied by high rates of overweight (99/100%) and smoking (28/31%). A low-level inflammatory state was accompanied by reduced reactive oxygen species (ROS)-neutralizing capacity (reduced co-enzyme Q10 and SOD1 levels). Most vascular risk factors were not correlated with perceived stress, except for fibrinogen (ß = −0.34) as well as C-reactive protein (ß = −0.31, p < 0.05) in men, and MCV (ß = −0.26, p < 0.05) in women. Interrelations between blood parameters and stress levels need to be investigated within psychobehavioural frameworks across varying distress levels. Alongside psychological interventions, a low-level inflammatory state may be a route for pharmacological therapeutics.

Factors associated with back pain in children aged 6 to 12 years of age, an eight months prospective study

Associated factors of back pain (BP) development before puberty and its persistence are poorly documented. We investigated the association and possible temporality between prior BP history (PBPH), muscular endurance (ME), aerobic capacity (AC), sport activity variables (SAV) and BP in children aged 6 to 12. We collected baseline characteristics (demographics, PBPH, ME, AC and SAV) of children from three primary schools in Canada. Parents replied to weekly text messages regarding their children BP status over an 8-month period. Logistic regression models were adjusted for potential confounders. Data from 242 children (46% female; 8.6 ± 1.7 years) were included. Over the 8-month survey BP prevalence was 48.1%, while the cumulative incidence was 31.9%. The occurrence of at least one BP event was associated with PBPH [OR (IC 95%) = 6.33 (2.35-17.04)] and high AC [2.89 (1.21-6.90)]. High AC was also associated with the development of a first BP episode [2.78 (1.09-7.07)], but ME and SAV were not. BP appears to be relatively common before puberty. BP history seems to be strongly associated with BP recurrence in children. Aerobic capacity is associated with first BP episode development.

Couriers' safety and health risks before and during the COVID-19 pandemic

Objectives

This study aimed to examine the safety and health hazards of motorized couriers and investigate working conditions and driving behavior possibly associated with involvement in road accidents while driving motorcycles or cars. In light of the outbreak of COVID-19, the study was aimed to explore factors that affect the couriers’ behaviors related to decreasing the risk of contracting an infectious disease.

Methods

A sample of 237 Israeli couriers, about half who drove a two-wheeled vehicles and the others who drove cars, answered an online survey questionnaire. The questionnaire examined organizational, occupational, and personal factors regarding their working conditions, behavior on the road, musculoskeletal disorders, road accidents, and perceptions of and compliance with regulations regarding COVID-19. The data were analyzed by multiple regression in SPSS 25, structural equation modeling and mediation tests in R 3.6.2.

Results

According to the couriers’ self-report, 37% reported musculoskeletal pains at least once a day, 13% of them were involved in work-related road accidents and 10% reported feeling stress at least once a week. More than 60% of the couriers reported increased stress due to the COVID-19 pandemic. Weekly working hours, shift duration and stress were related to involvement in accidents through the mediation of driving while feeling unwell. Reported stress and the weight of parcels were related to musculoskeletal pains.

Conclusions

The findings suggest that stress and attributes of work overloads experienced by couriers are associated with reduced safety and impaired health. Organizational, individual, and societal factors were correlated with the degree to which the couriers adhered to COVID-19 regulations. The increased prevalence of new modes of employment relationships in the field highlights the importance of research on employment conditions and safety and health aspects related to this occupation.

The effectiveness of Chair Massage on Stress and Pain in Oncology

Background

There is a high prevalence of moderate-to-high levels of chronic stress among nurses, as well as an occurrence of musculoskeletal disorders.

Purpose

To evaluate the effectiveness of chair massage to reduce chronic stress and musculoskeletal pain in the Oncology Nursing team.

Setting

Two teaching cancer hospitals, one public and the other private, in São Paulo city, Brazil.

Participants

A total of 60 women from the Oncology Nursing team.

Research Design

A randomized controlled trial divided into two groups: chair massage and control without intervention.

Intervention

The massage group received two chair massage sessions lasting 15 minutes, twice a week, for three weeks.

Main Outcome Measure

Reduction of stress and pain measured by the List of Signs and Symptoms (LSS) and the Brief Pain Inventory (BPI), respectively.

Results

The average age was 32 (± 5.3) years. There was a reduction of stress measured by the LSS with a statistical difference in the group-time interaction (p < .001), with a Cohen’s d value of 1.21 between groups. The BPI analysis showed a statistically significant difference in the group-time interaction for general activity (p < .008), mood (p < .03), work (p < .000), and sleep (p = .03), with reduced pain interference in these components.

Conclusion

Chair massage reduced stress and pain interference in the team’s daily life activities, bringing a positive impact in the context of work stress and pain in Oncology nursing professionals.

Brain Circuits Involved in the Development of Chronic Musculoskeletal Pain: Evidence From Non-invasive Brain Stimulation

It has been well-documented that the brain changes in states of chronic pain. Less is known about changes in the brain that predict the transition from acute to chronic pain. Evidence from neuroimaging studies suggests a shift from brain regions involved in nociceptive processing to corticostriatal brain regions that are instrumental in the processing of reward and emotional learning in the transition to the chronic state. In addition, dysfunction in descending pain modulatory circuits encompassing the periaqueductal gray and the rostral anterior cingulate cortex may also be a key risk factor for pain chronicity. Although longitudinal imaging studies have revealed potential predictors of pain chronicity, their causal role has not yet been determined. Here we review evidence from studies that involve non-invasive brain stimulation to elucidate to what extent they may help to elucidate the brain circuits involved in pain chronicity. Especially, we focus on studies using non-invasive brain stimulation techniques [e.g., transcranial magnetic stimulation (TMS), particularly its repetitive form (rTMS), transcranial alternating current stimulation (tACS), and transcranial direct current stimulation (tDCS)] in the context of musculoskeletal pain chronicity. We focus on the role of the motor cortex because of its known contribution to sensory components of pain via thalamic inhibition, and the role of the dorsolateral prefrontal cortex because of its role on cognitive and affective processing of pain. We will also discuss findings from studies using experimentally induced prolonged pain and studies implicating the DLPFC, which may shed light on the earliest transition phase to chronicity. We propose that combined brain stimulation and imaging studies might further advance mechanistic models of the chronicity process and involved brain circuits. Implications and challenges for translating the research on mechanistic models of the development of chronic pain to clinical practice will also be addressed.

Moderation of the Stressor-Strain Process in Interns by Heart Rate Variability Measured with a Wearable and Smartphone App: a Within-Subject Design Using Continuous Monitoring

Background

The emergence of smartphones and wearable sensor technologies enables easy and unobtrusive monitoring of physiological and psychological data related to an individual’s resilience. Heart rate variability (HRV) is a promising biomarker for resilience based on between-subject population studies, but observational studies that apply a within-subject design and use wearable sensors in order to observe HRV in a naturalistic real-life context are needed.

Objective

This study aims to explore whether resting HRV and total sleep time (TST) are indicative and predictive of the within-day accumulation of the negative consequences of stress and mental exhaustion. The tested hypotheses are that demands are positively associated with stress and resting HRV buffers against this association, stress is positively associated with mental exhaustion and resting HRV buffers against this association, stress negatively impacts subsequent-night TST, and previous-evening mental exhaustion negatively impacts resting HRV, while previous-night TST buffers against this association.

Methods

In total, 26 interns used consumer-available wearables (Fitbit Charge 2 and Polar H7), a consumer-available smartphone app (Elite HRV), and an ecological momentary assessment smartphone app to collect resilience-related data on resting HRV, TST, and perceived demands, stress, and mental exhaustion on a daily basis for 15 weeks.

Results

Multiple linear regression analysis of within-subject standardized data collected on 2379 unique person-days showed that having a high resting HRV buffered against the positive association between demands and stress (hypothesis 1) and between stress and mental exhaustion (hypothesis 2). Stress did not affect TST (hypothesis 3). Finally, mental exhaustion negatively predicted resting HRV in the subsequent morning but TST did not buffer against this (hypothesis 4).

Conclusions

To our knowledge, this study provides first evidence that having a low within-subject resting HRV may be both indicative and predictive of the short-term accumulation of the negative effects of stress and mental exhaustion, potentially forming a negative feedback loop. If these findings can be replicated and expanded upon in future studies, they may contribute to the development of automated resilience interventions that monitor daily resting HRV and aim to provide users with an early warning signal when a negative feedback loop forms, to prevent the negative impact of stress on long-term health outcomes.

Changes in Perceived Stress After Yoga, Physical Therapy, and Education Interventions for Chronic Low Back Pain: A Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

Perceived stress and musculoskeletal pain are common, especially in low-income populations. Studies evaluating treatments to reduce stress in patients with chronic pain are lacking. We aimed to quantify the effect of two evidence-based interventions for chronic low back pain (cLBP), yoga and physical therapy (PT), on perceived stress in adults with cLBP.

METHODS

We used data from an assessor-blinded, parallel-group randomized controlled trial, which recruited predominantly low-income and racially diverse adults with cLBP. Participants (N = 320) were randomly assigned to 12 weeks of yoga, PT, or back pain education. We compared changes in the 10-item Perceived Stress Scale (PSS-10) from baseline to 12- and 52-week follow-up among yoga and PT participants with those receiving education. Subanalyses were conducted for participants with elevated pre-intervention perceived stress (PSS-10 score ≥17). We conducted sensitivity analyses using various imputation methods to account for potential biases in our estimates due to missing data.

RESULTS

Among 248 participants (mean age = 46.4 years, 80% nonwhite) completing all three surveys, yoga and PT showed greater reductions in PSS-10 scores compared with education at 12 weeks (mean between-group difference = -2.6, 95% confidence interval [CI] = -4.5 to -0.66, and mean between-group difference = -2.4, 95% CI = -4.4 to -0.48, respectively). This effect was stronger among participants with elevated pre-intervention perceived stress. Between-group effects had attenuated by 52 weeks. Results were similar in sensitivity analyses.

CONCLUSIONS

Yoga and PT were more effective than back pain education for reducing perceived stress among low-income adults with cLBP.

Hippocampus shape deformation: a potential diagnostic biomarker for chronic back pain in women

ABSTRACT

Sex differences in the quality and prevalence of chronic pain are manifold, with women generally presenting higher incidence and severity. Uncovering chronic pain-related sex differences inform neural mechanisms and may lead to novel treatment routes. In a multicenter morphological study (total n = 374), we investigated whether the shape of subcortical regions would reflect sex differences in back pain. Given the hormone-dependent functions of the hippocampus, and its role in the transition to chronic pain, this region constituted our primary candidate. We found that the anterior part of the left hippocampus (alHP) presented outer deformation in women with chronic back pain (CBP), identified in CBP in the United States (n = 77 women vs n = 78 men) and validated in a Chinese data set (n = 29 women vs n = 58 men with CBP, in contrast to n = 53 female and n = 43 male healthy controls). Next, we examined this region in subacute back pain who persisted with back pain a year later (SBPp; n = 18 women vs n = 18 men) and in a subgroup with persistent back pain for 3 years. Weeks after onset of back pain, there was no deformation within alHP, but at 1 and 3 years women exhibited a trend for outer deformation. The alHP partly overlapped with the subiculum and entorhinal cortex, whose functional connectivity, in healthy subjects, was associated with emotional and episodic memory related terms (Neurosynth, reverse inference). These findings suggest that in women the alHP undergoes anatomical changes with pain persistence, highlighting sexually dimorphic involvement of emotional and episodic memory-related circuitry with chronic pain.

Two birds with one stone.-Addressing depressive symptoms, emotional tension and worry improves tinnitus-related distress and affective pain perceptions in patients with chronic tinnitus

BACKGROUND

Psychological factors link the co-occurrence of tinnitus-related distress and pain perceptions in patients with chronic tinnitus.

OBJECTIVE

This study examines, if treatment-related changes in these factors ameliorate both tinnitus-related distress and pain perceptions in a sample of patients with chronic tinnitus.

METHODS

N = 1238 patients with chronic tinnitus provided pre- and post-treatment ratings of tinnitus-related distress and affective or sensory pain perceptions alongside measures of depressive symptoms and perceived stress. Treatment comprised an intensive tinnitus-specific multimodal treatment program. Using serial indirect-effects analyses, we examined association patterns between baseline values and change rates of those variables that were found to respond to treatment.

RESULTS

Small effect sizes emerged for changes in tinnitus-related distress, affective (but not sensory) pain perceptions, depressive symptoms, emotional tension and worry. At pre- or post-treatment respectively, baseline values and change rates intercorrelated. Across timepoints, (1) baseline tinnitus-related distress and affective pain perceptions were positively associated with improvements in tinnitus-related distress, affective pain perceptions and depressive symptoms. (2) Baseline depressive symptoms or emotional tension mediated positive associations between baseline tinnitus-related distress and improvement in affective pain perceptions. (3) Change in depressive symptoms mediated the effect of baseline tinnitus-related distress on change in affective pain perceptions-partly through associated change in emotional tension or worry. Mood-independent aspects of emotional tension were negatively associated with improvement in affective pain perceptions.

CONCLUSIONS

Depressive symptoms, emotional tension and worry emerge as key predictors of treatment response and transdiagnostic treatment targets for alleviating tinnitus-related distress and functionally associated affective pain perceptions.

Investigating key predictors of persistent low back pain: A focus on psychological stress

AIM

To investigate the degree to which psychological stress, self-reported pain scores, and pain sensitivity during an acute state of low back pain (LBP) predict the development of persistent LBP trajectories.

BACKGROUND

Identifying which factors influence LBP trajectories is critical to understand why some individuals experience persistent LBP and to illuminate areas for nursing intervention.

METHODS

A secondary data analysis of a prospective study examining trajectories of LBP was conducted. The sample was comprised of 217 adults with acute-onset LBP recruited from the community and followed over 24 weeks. Variables of interest included demographic data, perceived stress scores, self-reported pain scores, and somatosensory characteristics collected within the first 4 weeks of LBP onset. The data were analyzed using non-parametric bivariate comparisons and a semi-parametric Cox proportional hazards model with interval-censoring.

RESULTS

Individuals with higher psychological stress scores were less likely to experience pain resolution (Hazard ratio [HR] = 0.555, 95% confidence interval [CI] = 0.36-0.85, p = 0.02). After adjustment for covariates in the final model, the analysis revealed household income (HR = 2.79, 95% CI [1.63-4.67], p < 0.001) to be the dominant predictor of LBP persistence in this sample.

CONCLUSION

Heightened psychological stress and pain severity as well as decreased pressure pain thresholds were indicated as influential factors of LBP trajectories. Household income was identified as the dominant predictor, demonstrating that individuals with a higher household income were more likely to resolve their pain. Strategies which integrate assessment of stress, self-reported pain scores, pain sensitivity, and social determinants for patients experiencing pain are needed to advance nursing care.

Life Stressors: Elevations and Disparities Among Older Adults with Pain

OBJECTIVE

To examine stressor elevations among older adults with pain, and gender and race disparities in the dual burdens of late-life pain and stressors.

DESIGN

Cross-sectional.

SETTING

Community.

SUBJECTS

Participants in the Longitudinal Late-Life Health study (LLLH; N = 1,884) and the Health and Retirement Study (HRS; N = 7,704).

METHODS

Pain and stressor measures were harmonized across the LLLH and HRS samples. Analyses of covariance were conducted to determine the effects of older adults' pain, gender, race, and interactions between these factors, on their stressors in nine separate life domains, and in stressors overall.

RESULTS

In both the LLLH and HRS samples, older adults with painful conditions (joint, back, headache, chest pain), more numerous painful conditions, more severe pain, and more pain interference had elevated stressors in all life domains, compared with older adults without or with less serious pain. Pain was more prevalent among women and nonwhites than men and whites. Stressor exposure was higher for men than women in most life domains; it was higher for nonwhites than whites in all life domains. For certain types of pain and life domains, pain and gender, as well as pain and race, interacted to predict stressor elevations.

CONCLUSIONS

Late-life pain is associated with elevations in stressors, and there are gender and race disparities in the dual burdens of heightened pain and elevated stressors in later life. Pain and stressors are not consistently more strongly linked among older women than older men, or among older nonwhite than older white persons.

Tinnitus-related distress and pain perceptions in patients with chronic tinnitus - Do psychological factors constitute a link?

OBJECTIVE

To investigate the co-occurrence of tinnitus-related distress and pain experiences alongside psychological factors that may underlie their association.

METHOD

Patients with chronic tinnitus (N = 1238) completed a questionnaire battery examining tinnitus-related distress and affective and sensory pain perceptions. A series of simple, parallel- and serial multiple mediator models examined indirect effects of psychological comorbidities as well as -process variables including depressivity, perceived stress and coping attitudes. Moderator and moderated mediation analyses examined differential relational patterns in patients with decompensated vs. compensated tinnitus.

RESULTS

There were significant associations between tinnitus-related distress and pain perceptions. These were partially mediated by most specified variables. Psychological comorbidities appeared to influence tinnitus-pain associations through their impact on depressivity, perceived stress, and coping attitudes. Some specific differences in affective vs. sensory pain perception pathways emerged. Patients with decompensated tinnitus yielded significantly higher symptom burden across all measured indices. Tinnitus decompensation was associated with heightened associations between [1] tinnitus-related distress and pain perceptions, depressivity and negative coping attitudes; and [2] most psychological comorbidities and sensory, but not affective pain perception. Moderated mediation analyses revealed stronger indirect effects of depressivity and anxiety in mediating affective-, and anxiety in mediating sensory pain perception in patients with decompensated tinnitus.

CONCLUSION

Psychological constructs mediate the co-occurrence of tinnitus- and pain-related symptoms across different levels of tinnitus-related distress. Psychological treatment approaches should conceptualize and address individualised interactions of common cognitive-emotional processes in addressing psychosomatic symptom clusters across syndromatic patients with varying distress levels.

Exploring stress, cognitive, and affective mechanisms of the relationship between interpersonal trauma and opioid misuse

BACKGROUND

People with a history of interpersonal trauma, including intimate partner violence, sexual assault, and adverse childhood experiences, are disproportionately affected by the current opioid epidemic. Interpersonal trauma has been shown to increase risk for chronic pain conditions, prescription opioid use, and opioid misuse. Stress, cognition, and affective function have been examined as potential mechanisms that may influence opioid misuse among individuals with a history of interpersonal trauma. However, no studies have examined these factors simultaneously, despite their interrelatedness.

OBJECTIVE

The purpose of this study was to 1) examine perceived stress, perceived cognitive function, depressive symptoms, and PTSD symptoms as potential mechanisms of opioid misuse among individuals with a history of interpersonal trauma, 2) examine the types of interpersonal trauma that are associated with opioid misuse, and 3) assess the mediating role of pain and opioid prescription.

METHODS

A cross-sectional, observational study design was conducted. Data were collected through a confidential self-report online survey using validated instruments (n = 230). A series of regression analyses were conducted to identify mechanistic factors and interpersonal trauma types associated with opioid misuse, opioid prescription, and pain intensity. Structural equation modeling was used to examine mediating effects of pain intensity and opioid prescription.

RESULTS

Opioid prescription, depressive symptoms, and intimate partner violence increased the odds of reporting opioid misuse. Pain intensity and adverse childhood experiences increased the odds of opioid prescription. Higher levels of perceived stress and depressive symptoms were associated with increased pain intensity. Pain intensity emerged as a mediator of the relationship between depressive symptoms and opioid misuse.

CONCLUSIONS

Our work shows that there are likely several pathways through which interpersonal trauma can lead to opioid misuse. Interventions aimed at improving depressive symptoms and coping with traumatizing events should be included as part of comprehensive trauma-informed pain management practices.

Which Psychological Factors Are Involved in the Onset and/or Persistence of Musculoskeletal Pain? An Umbrella Review of Systematic Reviews and Meta-Analyses of Prospective Cohort Studies

OBJECTIVE

The objective of this study was to summarize the current status of knowledge about the longitudinal association between vulnerability or protective psychological factors and the onset and/or persistence of musculoskeletal (MSK) pain.

METHODS

PubMed, CINAHL, PsycINFO, PubPsych, Scopus, Web of Science, gray literature, and manual screening of references were searched from inception to June 15, 2019. Systematic reviews with or without meta-analysis that explored the longitudinal association between psychological factors and the onset and/or persistence of MSK pain were identified. The AMSTAR-2 tool was used to assess the risk of bias.

RESULTS

Fifty-nine systematic reviews that included 286 original research studies were included, with a total of 249,657 participants (127,370 with MSK pain and 122,287 without MSK pain at baseline). Overall, our results found that exposure to many psychological vulnerability factors such as depression, anxiety, psychological distress, and fear, among others, may increase the risk of the onset and persistence of MSK pain across time. In addition, our results also showed that a range of psychological factors considered to be "protective" such as self-efficacy beliefs, better mental health, active coping strategies, or favorable expectations of recovery may reduce the risk of the onset and persistence of MSK pain. However, all these systematic reviews were evaluated to have critically low confidence based on the AMSTAR-2 tool, indicating that findings from these reviews may be informative, but should be interpreted with caution.

DISCUSSION

The large number of methodological flaws found across reviews gives rise to a call to action to develop high-quality systematic reviews in this field.