Cognitive determinants of pain and disability in patients with chronic whiplash-associated disorder: a cross-sectional observational study

Temporal Relations Between Pain Catastrophizing and Adverse Health and Mental Health Outcomes After Whiplash Injury

OBJECTIVES

Pain catastrophizing has been shown to be a prognostic indicator for pain severity and the co-occurrence of mental health conditions such as depression and post-traumatic stress disorder after whiplash injury. However, the pattern of available findings is limited in its implications for the possible "antecedent" or "causal" role of pain catastrophizing. The purpose of the present study was to examine the temporal relations between pain catastrophizing, pain severity, depressive symptoms, and post-traumatic stress symptoms (PTSS) in individuals receiving treatment for whiplash injury.

MATERIALS AND METHODS

The sample consisted of 388 individuals enrolled in a multidisciplinary program for whiplash injury. Participants completed self-report measures of pain catastrophizing, pain severity, depressive symptoms, and PTSS at the time of admission, mid-treatment (4 week), and treatment completion (7 week). A cross-lagged panel analysis was used to examine the temporal relations between pain catastrophizing, pain severity, depressive symptoms, and PTSS across all 3 timepoints.

RESULTS

Model fit was acceptable after the inclusion of modification indices. Pain catastrophizing at the time of admission predicted all other variables at 4 weeks. Pain catastrophizing at 4 weeks also predicted all other variables at 7 weeks. In addition, some bidirectional relations were present, particularly for variables assessed at week 4 and week 7.

DISCUSSION

Findings support the view that pain catastrophizing might play a transdiagnostic role in the onset and maintenance of health and mental health conditions. The findings call for greater emphasis on the development of treatment techniques that target pain catastrophizing in intervention programs for whiplash injury.

A classification algorithm to predict chronic pain using both regression and machine learning - A stepwise approach

This secondary data analysis study aimed to (1) investigate the use of two sense-based parameters (movement and sleep hours) as predictors of chronic pain when controlling for patient demographics and depression, and (2) identify a classification model with accuracy in predicting chronic pain. Data collected by Oregon Health & Science University between March 2018 and December 2019 under the Collaborative Aging Research Using Technology Initiative were analyzed in two stages. Data were collected by sensor technologies and questionnaires from older adults living independently or with a partner in the community. In Stage 1, regression models were employed to determine unique sensor-based behavioral predictors of pain. These sensor-based parameters were used to create a classification model to predict the weekly recalled pain intensity and interference level using a deep neural network model, a machine learning approach, in Stage 2. Daily step count was a unique predictor for both pain intensity (75% Accuracy, F1 = 0.58) and pain interference (82% Accuracy, F1 = 0.59). The developed classification model performed well in this dataset with acceptable accuracy scores. This study demonstrated that machine learning technique can be used to identify the relationship between patients' pain and the risk factors.

Neck Disability Index Is Better in Classification of Recovery after Whiplash Injury in Comparison with Ultrasound Shear Wave Elastography of Trapezius Muscle

A prospective observational study comparing shear wave elastography (SWE) of trapezius muscle with Neck Disability Index (NDI) in a prediction model of health status six months after a whiplash injury. Both SWE values, measured by two radiologists, and NDI scores were obtained at baseline and after physical therapy (PT) (6-month period). Those values were compared with a 3-point Likert scale (no, partial or full recovery). Twenty-two subjects completed the study. A decrease in trapezius stiffness was detected by both radiologists, statistically significant for one (Δ10.1 kPa; p = 0.04) but not for the second radiologist (Δ8.63 kPa; p = 0.07). The measurements showed excellent intra-observer (ICC 0.75–0.94) and inter-observer (ICC 0.78–0.88) reliability. After six months, fully recovered patients showed lower NDI scores than partially recovered patients (Δ22.98; p < 0.001). SWE values did not differ with the recovery status (55.6 ± 9.7 vs. 57 ± 15.8, Δ1.45; p = 0.82). The single most accurate variable in classifying health status six months after whiplash injury was the relative change of NDI, and it showed the highest accuracy (73.9%) and low Akaike information criterion (AIC = 39.2). Overall, the most accurate classification was obtained when combining NDI and SWE after physical therapy with an accuracy of 77.3% and a decrease in AIC (32.8).

The relationship between pain severity, kinesiophobia, and quality of life in patients with non-specific chronic neck pain

BACKGROUND

Kinesiophobia is an important problem that increases neck pain and causes it to become chronic.

OBJECTIVE

This study aims to compare the relationship between pain, quality of life, and kinesophobia in non-specific chronic neck pain.

METHODS

In total 87 patients were included in the study. Pain was assessed with Visual Analog Scale (VAS), kinesiophobia with Tampa Kinesiophobia Scale (TKS), and quality of life with Health Status Questionnaire Short Form-36 (SF-36).

RESULTS

The median age was 50 (40-59) years and the median complaint duration was 12 (8-48) months. The median value of VAS at rest was 4 (2-6) and the median value of VAS during the activity was 7 (5-8). The median TKS scores were 41 (39-45), the median SF-36 general health scores were 61 (45-75), and the median SF-36 mental health scores were 72 (52-80). There was a weak correlation between the TSK scores and gender, education level, and SF-36 general health scores (r= 0.206, p= 0.023; r=-0.235, p= 0.004; r= 0.236/p= 0.027 respectively). There was no relationship between kinesiophobia and the other variables.

CONCLUSION

TSK scores showed a correlation with gender, education level, and SF-36 general health scores. We conclude that as the education level decreases, kinesophobia scores increase, and as kinesophobia scores increase, the quality of life decreases.

The Relationship Between Level of Catastrophizing and Mental Health Comorbidity in Individuals With Whiplash Injuries

OBJECTIVES

Pain catastrophizing has been shown to be correlated with measures of mental health problems such as depression and post-traumatic stress disorder (PTSD). However, the clinical implications of findings reported to date remain unclear. To date, no study has been conducted to determine meaningful cut-scores on measures of catastrophizing indicative of the heightened risk of mental health comorbidity. One objective of the present study was to identify the cut-score on the Pain Catastrophizing Scale (PCS) indicative of the heightened risk of the comorbidity of depression and PTSD. A second objective was to determine whether mental health comorbidity mediated the relationship between catastrophizing and occupational disability.

MATERIALS AND METHODS

The sample consisted of 143 individuals with whiplash injuries. Pain severity, pain catastrophizing, depression, and post-traumatic stress symptoms were assessed after admission to a rehabilitation program. Mental health comorbidity was operationally defined as obtaining a score above the clinical threshold on measures of depressive and/or post-traumatic stress symptom severity.

RESULTS

A receiver operating characteristic curve analysis revealed that a PCS score of 22 best distinguished between participants with and without mental health comorbidity. Results also revealed that mental health comorbidity mediated the relationship between catastrophizing and occupational disability.

DISCUSSION

The findings suggest that a score of ≥22 on the PCS should alert clinicians to the possibility that patients might also be experiencing clinically significant symptoms of depression or PTSD. Greater attention to the detection and treatment of mental health conditions associated with whiplash injury might contribute to more positive recovery outcomes.

Cognitive factors are associated with disability and pain, but not fatigue among physiotherapy attendees with persistent pain and fatigue

OBJECTIVES

Most research exploring the relationship between cognitive factors and pain, disability and fatigue in patients with persistent pain/fatigue has been performed in multi disciplinary environments. It is unclear whether these associations are consistent in other contexts. This study therefore aimed to establish the relationships between these factors in patients with persistent pain/fatigue referred for physiotherapy treatment.

DESIGN

Cross-sectional observational study assessing the association between cognitive factors (self-efficacy and catastrophizing) and levels of pain, disability, mental fatigue and physical fatigue in patients with persistent pain/fatigue disorders. Data were analysed using regression analyses.

SETTING

Two out-patient physiotherapy departments, Manchester, UK.

PARTICIPANTS

166 patients with persistent pain and fatigue disorders chronic widespread pain, fibromyalgia and chronic fatigue syndrome/myalgic encephalopathy).

MAIN OUTCOME MEASURES

Disability was assessed using the Fibromyalgia Impact Questionnaire, whilst mental and physical fatigue were assessed with the sub-scales of the Chalder Fatigue Scale. Pain intensity was measured with a Numeric Pain Rating Scale, self-efficacy with the Chronic Pain Self-efficacy Questionnaire and catastrophizing with the Pain Catastrophizing Scale.

RESULTS

Cognitive factors were significantly associated with pain (self-efficacy beliefs β=-0.30, P<0.05; catastrophizing β=0.24, P<0.05) and disability (self-efficacy beliefs β=-0.62, P<0.05), but not fatigue.

CONCLUSIONS

Similar associations were observed in patients referred to physiotherapy as to those observed in patients treated in multi disciplinary clinical environments. Self-efficacy beliefs appear to be particularly strong determinants of disability, but exert a lesser influence over pain or fatigue. Targeting self-efficacy may be an effective method to reduce disability in patients with persistent pain and fatigue disorders.

Biopsychosocial factors associated with non-recovery after a minor transport-related injury: A systematic review

Background

Globally, road transport accidents contribute significantly to mortality and burden of disability. Up to 50 million people suffer a transport-related non-fatal injury each year, which often leads to long-term disability. A substantial number of people with minor injuries struggle to recover and little is known about the factors leading to poor or non-recovery. The aim of this paper is to present a systematic review of biopsychosocial factors related to poor or non-recovery after a minor transport-related injury.

Methods and findings

Studies were selected through searches of PubMed, Medline, Embase, and Cochrane library. Methodological quality was assessed using a Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklist for quantitative cohort studies and Standards for Reporting Qualitative Research (SRQR) checklist for qualitative articles. Data were extracted using the Cochrane data extraction tool based on the biopsychosocial model of health (BPS). In total, there were 37 articles included. However, heterogeneity of the techniques and tools used to assess factors and outcomes across studies meant that pooling of results to determine biopsychosocial factors most predictive of poor or non-recovery was not possible. Hence, a narrative synthesis was conducted and shown multiple factors to be associated with poorer outcomes or non-recovery, most being identified in the biological and psychological domain of the BPS model. Factors that were the most representative across studies and have shown to have the strongest associations with poor or non-recovery were high initial pain intensity, pain duration and severity, pre-accident physical and mental health status and pain catastrophising.

Conclusions

This review demonstrates the complexity of recovery and a challenge in reporting on predictors of recovery. It is evident that a range of multi-factorial biopsychosocial factors impact recovery. These factors are often inter-connected and multi-faceted and therefore, it was not feasible to select or focus on one single factor. In defining the most predictive factors, further research is required, yet the consensus around which tools to use to measure recovery outcomes is needed and is highly recommended. Regardless of the descriptive nature, the review demonstrated that high levels of post-injury pain are associated with poorer outcomes such as chronic pain and physical and mental disability. Therefore, early targeting of modifiable factors such as pain, pain catastrophizing and arising comorbidities such as PTSD, depression and anxiety may assist in reducing chronic pain and ongoing related disabilities.

Systematic review trial registration number

Systematic review protocol was registered in International Prospective Register for Systematic Reviews (PROSPERO) on 14 December 2016. Registration number CRD42016052276.

Acceptance in chronic neck pain: associations with disability and fear avoidance beliefs

Chronic neck pain can result in significant levels of disability. Physiotherapy treatments often aim to modify cognitive factors and this approach benefits some, but not all, patients. Research from other pain conditions suggests that acceptance may be related to disability; however, it is unclear whether these associations exist in patients with neck pain. Moreover, it is unclear to what extent other cognitive factors are related to acceptance. Feasibly, if these factors are related, existing treatments may already be indirectly modifying acceptance. The aim of this study was therefore to establish the associations between acceptance and disability, and between acceptance and other cognitive factors. Cross-sectional data were collected from 149 patients and regression analyses were carried out. In the first analysis, disability was the dependent variable and the proportion of variance explained by two acceptance subscales (activities engagement and pain willingness) was calculated. In the second analyses, the acceptance subscales were the dependent variables. Measures of pain-related fear, catastrophizing and pain vigilance and awareness were entered as explanatory variables and the proportion of variance explained was calculated. In the first analysis, acceptance explained 18% of variance in disability (P<0.001). In the second analysis, cognitive factors explained 7% (P<0.05) of variance in activities engagement and 58% (P<0.001) of pain willingness. On this basis, treatments that enhance acceptance may reduce disability. Moreover, as cognitive factors were strongly related to pain willingness, but not activity engagement, alternative treatments may be required to maximize acceptance. Further studies are warranted to assess acceptance-based treatments in patients with neck pain.

The processes underpinning reductions in disability among people with chronic neck pain. A preliminary comparison between two distinct types of physiotherapy intervention

PURPOSE

To establish whether different processes underpin changes in disability in people with neck pain who underwent two types of active physiotherapy intervention.

MATERIALS AND METHODS

This study was a sub-analysis of a randomized controlled trial assessing whether the addition of Interactive Behavioral Modification Therapy (a cognitively informed physiotherapy treatment) to a Progressive Neck Exercise Program improved outcome in patients with chronic neck pain. Regression analyses were performed to determine the extent to which demographics, changes in pain, and changes in certain cognitive factors were related to changes in disability.

RESULTS

In the progressive neck exercise group, changes in levels of pain intensity were the only factor significantly related to change in disability, explaining 33% of the variance. In the interactive behavioral modification therapy group, changes in pain intensity, and catastrophizing together explained 54% of the variance in change in disability. Only changes in catastrophizing displayed a significant β value in the final model.

CONCLUSIONS

Different processes appear to underpin changes in disability in patients undergoing cognitively informed physiotherapy to those undergoing a primarily exercise-based approach. Implications for rehabilitation Certain cognitive factors are known to be related to levels of disability in patients with chronic neck pain Specifically targeting these factors results in more patients making a clinically meaningful reduction in disability Different processes appear to underpin reductions in disability when people with neck pain are treated with cognitively informed physiotherapy to when treated with exercise alone, which may account for why more patients improve when treated in this manner. Reductions in catastrophizing appear to be particularly important and efforts should be made to assess and treat catastrophic thoughts in people with chronic neck pain.

The Relation between the Fear-Avoidance Model and Constructs from the Social Cognitive Theory in Acute WAD

In the fear-avoidance (FA) model social cognitive constructs could add to explaining the disabling process in whiplash associated disorder (WAD). The aim was to exemplify the possible input from Social Cognitive Theory on the FA model. Specifically the role of functional self-efficacy and perceived responses from a spouse/intimate partner was studied. A cross-sectional and correlational design was used. Data from 64 patients with acute WAD were used. Measures were pain intensity measured with a numerical rating scale, the Pain Disability Index, support, punishing responses, solicitous responses, and distracting responses subscales from the Multidimensional Pain Inventory, the Catastrophizing subscale from the Coping Strategies Questionnaire, the Tampa Scale of Kinesiophobia, and the Self-Efficacy Scale. Bivariate correlational, simple linear regression, and multiple regression analyses were used. In the statistical prediction models high pain intensity indicated high punishing responses, which indicated high catastrophizing. High catastrophizing indicated high fear of movement, which indicated low self-efficacy. Low self-efficacy indicated high disability, which indicated high pain intensity. All independent variables together explained 66.4% of the variance in pain disability, p < 0.001. Results suggest a possible link between one aspect of the social environment, perceived punishing responses from a spouse/intimate partner, pain intensity, and catastrophizing. Further, results support a mediating role of self-efficacy between fear of movement and disability in WAD.

Comparison of pain, kinesiophobia and quality of life in patients with low back and neck pain

[Purpose] The purpose of this study was to compare patients with low back and neck pain with respect to kinesiophobia, pain, and quality of life. [Subjects and Methods] Three-hundred patients with low back (mean age 43.2±11 years) and 300 with neck pain (mean age 42.8±10.2 years) were included in this study. Pain severity was evaluated by using the Short-Form McGill Pain Questionnaire, which includes a Visual Analogue Scale, quality of life by the Nottingham Health Profile, and kinesiophobia by the Tampa Scale for Kinesiophobia. [Results] Pain severity was similar in both groups, with a Visual Analogue Scale score of 6.7±2 in the low back pain and 6.8±2 in the neck pain group. Nottingham Health Profile pain [z=−4.132] and physical activity scores [z=−5.640] in the low back pain group were significantly higher. Kinesiophobia was also more severe in the low back pain group, with a mean 42.05±5.91 versus 39.7±6.0 Tampa Scale for Kinesiophobia score [z=−4.732]. [Conclusion] Patients with low back pain developed more severe kinesiophobia, regardless of the pain severity, and had greater pain perception and lower physical activity levels. Kinesiophobia adversely affects the quality of life and requires effective management of low back pain.

A pilot study - the potential value of an activity-based feedback system for treatment of individuals with chronic lower back pain

PURPOSE

The aim of this pilot study was to evaluate the potential value of a new personalized activity-based feedback treatment.

METHOD

A prognostic cohort study was carried out in the daily environment of the patients. Seventeen individuals with chronic lower back pain (CLBP) symptoms for >3 months were included. Patients were from the Netherlands, aged 18-65 years. Patients wore an accelerometer and a Personal Digital Assistant (PDA) for 15 d. Patients received continuous and time-related personalized feedback and were instructed to follow the activity pattern as displayed on the PDA. Technical performance and compliance with the system were rated. Objective and subjective activity scores were compared for exploring awareness. The absolute difference between the activity pattern of the patient and the norm value used was calculated and expressed as mean difference. Pain intensity was measured using the VAS.

RESULTS

The technical performance and compliance with the system were rated moderate. More than half of the patients were aware of their activity level during the feedback days (67%). A positive effect of the feedback was seen in a trend which showed a decrease in the absolute difference between the activity pattern of the patient and the norm value (p = 0.149) and a significant decrease in pain intensity levels (p = 0.005).

CONCLUSIONS

This pilot study suggested that an individual-tailored feedback system that focuses on the activity behavior of the patient has potential as the treatment of individuals with CLBP. Implications for Rehabilitation Activity-based feedback for individuals with chronic low back pain: Many patients are not aware of their activity patterns. The activity patterns of patients differ from those of healthy controls. It is important to make patients aware of their activity patterns in order to change activity behavior. An individual-tailored feedback system seems promising in decreasing pain intensity levels for a subgroup of patients.

Predictive capacity of pain beliefs and catastrophizing in Whiplash Associated Disorder

INTRODUCTION

Beliefs about pain are known to be important factors in recovery, most notably in LBP. Relatively less is known about the role of pain beliefs in Whiplash Associated Disorder (WAD). The widely advocated cognitive-behavioural approach to pain management necessitates cognitive factors such as pain beliefs be examined, even early after injury. The primary purpose of this study was to explore the predictive capacity of early post-injury pain beliefs and catastrophizing in patients with WAD.

METHODS

Patients (n=72) undergoing treatment for acute WAD in physical therapy and chiropractic clinics were invited to participate in the study. Research participants were asked to complete measures of beliefs (Survey of Pain Attitudes (SOPA) and Pain Beliefs and Perception Inventory (PBPI)) and catastrophizing (Pain Catastrophizing Scale) at baseline (within 6 weeks of injury), and 3 and 6 months post-injury. In addition, pain severity and self-reported disability using the Whiplash Disability Questionnaire (WDQ) were recorded at each measurement occasion. Baseline belief and catastrophizing scores were examined for their relationship with future pain and disability using multiple linear regression.

RESULTS

Expectancy beliefs (PBPI Permanence and SOPA Medical Cure) were negatively correlated with pain intensity at 6-months and uniquely accounted for 16% and 14% of explained variance, respectively, after controlling for baseline pain intensity, age, sex and history of WAD. Consistent with previous research, catastrophizing was also found to be predictive of future pain. The amount of unique variance explained by beliefs in the prediction of future disability was modest after controlling for baseline disability, age, sex and history of WAD.

DISCUSSION

These results suggest that expectancy beliefs are potentially important constructs to include in future explanatory prognosis studies. The Medical Cure and Permanence subscales of the SOPA and PBPI are tools that could be used to measure these expectancy constructs.

Psychological Care, Patient Education, Orthotics, Ergonomics and Prevention Strategies for Neck Pain: An Systematic Overview Update as Part of the ICON Project

OBJECTIVES

To conduct an overview on psychological interventions, orthoses, patient education, ergonomics, and 1⁰/2⁰ neck pain prevention for adults with acute-chronic neck pain.

SEARCH STRATEGY

Computerized databases and grey literature were searched (2006-2012).

SELECTION CRITERIA

Systematic reviews of randomized controlled trials (RCTs) on pain, function/disability, global perceived effect, quality-of-life and patient satisfaction were retrieved.

DATA COLLECTION & ANALYSIS

Two independent authors selected articles, assessed risk of bias using AMSTAR tool and extracted data. The GRADE tool was used to evaluate the body of evidence and an external panel to provide critical review.

MAIN RESULTS

We retrieved 30 reviews (5-9 AMSTAR score) reporting on 75 RCTs with the following moderate GRADE evidence. For acute whiplash associated disorder (WAD), an education video in emergency rooms (1RCT, 405participants] favoured pain reduction at long-term follow-up thus helping 1 in 23 people [Standard Mean Difference: -0.44(95%CI: -0.66 to -0.23)). Use of a soft collar (2RCTs, 1278participants) was not beneficial in the long-term. For chronic neck pain, a mind-body intervention (2RCTs, 1 meta-analysis, 191participants) improved short-term pain/function in 1 of 4 or 6 participants. In workers, 2-minutes of daily scapula-thoracic endurance training (1RCT, 127participants) over 10 weeks was beneficial in 1 of 4 participants. A number of psychosocial interventions, workplace interventions, collar use and self-management educational strategies were not beneficial.

REVIEWERS' CONCLUSIONS

Moderate evidence exists for quantifying beneficial and non-beneficial effects of a limited number of interventions for acute WAD and chronic neck pain. Larger trials with more rigorous controls need to target promising interventions.

Optimal designs for prediction studies of whiplash

STUDY DESIGN

Commentary.

OBJECTIVE

To provide guidance for the design and interpretation of predictive studies of whiplash associated disorders (WAD).

SUMMARY OF BACKGROUND DATA

Numerous studies have sought to define and explain the clinical course and response to treatment of people with WAD. Design of these studies is often suboptimal, which can lead to biased findings and issues with interpreting the results.

METHODS

Literature review and commentary.

RESULTS

Predictive studies can be grouped into four broad categories; studies of symptomatic course, studies that aim to identify factors that predict outcome, studies that aim to isolate variables that are causally responsible for outcome, and studies that aim to identify patients who respond best to particular treatments. Although the specific research question will determine the optimal methods, there are a number of generic features that should be incorporated into design of such studies. The aim of these features is to minimize bias, generate adequately precise prognostic estimates, and ensure generalizability of the findings.

CONCLUSION

This paper provides a summary of important considerations in the design, conduct, and reporting of prediction studies in the field of whiplash.

Catastrophizing and perceived injustice: risk factors for the transition to chronicity after whiplash injury

STUDY DESIGN

The article will summarize research that has supported the role of pain catastrophizing and perceived injustice as risk factors for problematic recovery after whiplash injury.

OBJECTIVE

This article focuses on two psychological variables that have been shown to impact on recovery trajectories after whiplash injury; namely pain catastrophizing and perceived injustice.

SUMMARY OF BACKGROUND DATA

Research has shown that psychological variables play a role in determining the trajectory of recovery after whiplash injury.

METHODS

This article will focus on two psychological variables that have been shown to impact on recovery trajectories after whiplash injury; namely pain catastrophizing and perceived injustice. The article will summarize research that has supported the role of pain catastrophizing and perceived injustice as risk factors for problematic recovery after whiplash injury.

RESULTS

Several investigations have shown that measures of catastrophizing and perceived injustice prospectively predict problematic trajectories of recovery after whiplash injury. Basic research points to the potential roles of expectancies, attention, coping and endogenous opioid dysregulation as possible avenues through which catastrophizing might heighten the probability of the persistence of pain after whiplash injury. Although research has yet to systematically address the mechanisms by which perceived injustice might contribute to prolonged disability in individuals with whiplash injuries, there are grounds for suggesting the potential contributions of catastrophizing, pain behavior and anger.

CONCLUSION

A challenge for future research will be the development and evaluation of risk factor-targeted interventions aimed at reducing catastrophizing and perceived injustice to improve recovery trajectories after whiplash injury.