Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art

The fear-avoidance model as an embodied prediction of threat

The fear-avoidance model is a well-established framework in the understanding of persistent pain. It proposes a dichotomous path: either the context is interpreted as safe; there is no fear reaction and, therefore, the individual engages in active (positive) coping; or the context is interpreted as threatening, leading to a self-reinforcing vicious circle of fear and (negative) avoidance. We propose an embodied interpretation of this phenomenon employing the joint framework of predictive coding and active inference. The key idea is that multisensory integration of exteroceptive, proprioceptive, and interoceptive sensory inputs can lead to dysfunctional experiences of threat in nonthreatening situations. Threat inference can promote fear responses, maladaptive strategies (i.e., avoidance) and self-provides evidence for threat in associated or future contexts, or both. Under this treatment, the prediction of nonrealized threat becomes self-evidencing and context-invariant, and hence self-perpetuating. Safety cues are unable to attenuate the interpretation of the negative context as the dominant inference of the context is threatful and gains more precision and becomes resistant over time. Our model provides an explanation for the emergence of a dysfunctional fear response in the clinical setting despite apparent safety based on modern concepts from theoretical (computational) neuroscience.

Psychoeducational Intervention for Pain, Psychological Distress, Hope, and Post-traumatic Growth Among Breast Cancer Patients During Chemotherapy: A Pilot Randomized Controlled Trial

BACKGROUND

Chemotherapy is associated with many side effects, including pain and psychological distress, which affect patients' physical and psychological health.

AIM

The aim of this study was to elucidate the efficacy of a pain management intervention (POLA) to promote pain, psychological distress, hope and post-traumatic growth in breast cancer patients, also, to undertake a preliminary evaluation of the intervention.

METHODS

A pilot randomized controlled trial was conducted in an Iranian hospital involving 42 breast cancer (BC) patients during chemotherapy. The intervention group received a 6-week group therapy (90 minutes per session) administered by a psychologist. Meanwhile, the comparison group received standard care. patients' Pain, psychological distress, hope and post-traumatic growth were measured at 3 time points (baseline, week 6, and 12 weeks postintervention).

RESULTS

The study design was found to be feasible, with a recruitment rate of 61.64% and an attrition rate of 6.66%. Compared to the control group, the intervention group showed a significant reduction in pain, psychological distress, depression, anxiety, and stress, as well as a notable improvement in hope and post-traumatic growth (p < .01). These differences remained significant at follow-up (p < 0.05). The study population found the intervention acceptable, as evidenced by a high attendance rate of 90% and adherence rate of 90.47%.

CONCLUSION

Psychoeducational intervention positively affects the pain, psychological distress, hope and post-traumatic growth of BC patients during chemotherapy.

Enhanced Muscle Endurance Through Self-regulated Dual-Task Exercises in Elbow Fracture Rehabilitation: A Cross-sectional Study

OBJECTIVE

The main objective of this study was to investigate the effect of a self-regulated dual task on muscle endurance within a single rehabilitation session in patients recovering from an elbow fracture.

DESIGN

This is a cross-sectional study of individuals recovering from elbow fractures ( N = 20). Muscle endurance was tested using elastic bands at Borg's CR10 intensity 3-during four conditions: single-task and dual-task for elbow flexion and extension.

RESULTS

The cognitive condition significantly influenced muscle endurance ( P < 0.001), while the type of elbow exercise (flexion or extension) did not show significant differences ( P = 0.592). The perceived difficulty of the tasks showed a significant interaction effect ( P = 0.032). The dual-task condition showed an average increase of about 15 repetitions. A moderate negative correlation was found between the differences in repetitions and the perceived difficulty of the flexion exercise ( r = 0.677, P = 0.001).

CONCLUSIONS

Dual-task with self-regulation enhances muscle endurance among patients recovering from an elbow fracture. However, the improvements seem to depend on the perceived difficulty of the cognitive task. Future randomized controlled trials are required to understand the therapeutic implications of dual-tasking.

Feasibility of a Virtual Adaptation of a Yoga Intervention for Veterans with Chronic Pain and Posttraumatic Stress Disorder

Purpose/Objective: This study assessed the feasibility and acceptability of a yoga intervention for veterans with comorbid posttraumatic stress disorder (PTSD) and chronic pain (CP) that was adapted for virtual implementation. Research Method/Design: This pilot feasibility study at a large, mid-Atlantic Veteran's Affairs (VA) Medical Center with veterans with both PTSD and CP examined the adaptation of an eight-session virtual yoga group intervention. Participants (n = 18, 11 completers) were primarily male (82.4%), African American (76.5%), with no prior yoga experience (70.6%). A measure of client satisfaction was administered at completion and attendance rates were examined. Self-reported symptom measures were also assessed. Results: There were no instances of injuries or other adverse effects related to the study. This study yielded a 39% attrition rate, consistent with in-person yoga interventions. Mean number of sessions attended was 5.53 (SD = 1.73). Participants rated overall satisfaction as high (M = 28.09; SD = 3.96; potential range 8-32). Conclusions/Implications: This study provides initial data on the acceptability of a virtual yoga intervention for veterans with comorbid PTSD and CP, with attrition and satisfaction rates in line with prior in-person iterations. Implications of virtual adaption and considerations for future efforts will be discussed. This study was not preregistered but has been registered subsequently on ClinicalTrials.gov [CTR #: NCT06123065].

Peer Support for Chronic Pain in Online Health Communities: Quantitative Study on the Dynamics of Social Interactions in a Chronic Pain Forum

BACKGROUND

Peer support for chronic pain is increasingly taking place on social media via social networking communities. Several theories on the development and maintenance of chronic pain highlight how rumination, catastrophizing, and negative social interactions can contribute to poor health outcomes. However, little is known regarding the role web-based health discussions play in the development of negative versus positive health attitudes relevant to chronic pain.

OBJECTIVE

This study aims to investigate how participation in online peer-to-peer support communities influenced pain expressions by examining how the sentiment of user language evolved in response to peer interactions.

METHODS

We collected the comment histories of 199 randomly sampled Reddit (Reddit, Inc) users who were active in a popular peer-to-peer chronic pain support community over 10 years. A total of 2 separate natural language processing methods were compared to calculate the sentiment of user comments on the forum (N=73,876). We then modeled the trajectories of users' language sentiment using mixed-effects growth curve modeling and measured the degree to which users affectively synchronized with their peers using bivariate wavelet analysis.

RESULTS

In comparison to a shuffled baseline, we found evidence that users entrained their language sentiment to match the language of community members they interacted with (t198=4.02; P<.001; Cohen d=0.40). This synchrony was most apparent in low-frequency sentiment changes unfolding over hundreds of interactions as opposed to reactionary changes occurring from comment to comment (F2,198=17.70; P<.001). We also observed a significant trend in sentiment across all users (β=-.02; P=.003), with users increasingly using more negative language as they continued to interact with the community. Notably, there was a significant interaction between affective synchrony and community tenure (β=.02; P=.02), such that greater affective synchrony was associated with negative sentiment trajectories among short-term users and positive sentiment trajectories among long-term users.

CONCLUSIONS

Our results are consistent with the social communication model of pain, which describes how social interactions can influence the expression of pain symptoms. The difference in long-term versus short-term affective synchrony observed between community members suggests a process of emotional coregulation and social learning. Participating in health discussions on Reddit appears to be associated with both negative and positive changes in sentiment depending on how individual users interacted with their peers. Thus, in addition to characterizing the sentiment dynamics existing within online chronic pain communities, our work provides insight into the potential benefits and drawbacks of relying on support communities organized on social media platforms.

The impact of fear of attacks on pain-related disability in cluster headache: Insights from the fear avoidance model

OBJECTIVE

This study utilized the theoretical framework of the "fear avoidance model" (FAM) and investigated the role of fear of attack in pain-related disability. To this end, a measurement specific to cluster headache (CH) was used to investigate whether fear of attacks, alongside attack frequency, is a significant predictor of pain-related disability in CH.

BACKGROUND

Cluster headache substantially impacts daily functioning, yet empirical research exploring specific contributing factors is limited.

METHODS

A cross-sectional online survey was undertaken in patients with CH, gathering sociodemographic, clinical data, and responses on the Cluster Headache Scale and the Depression, Anxiety and Stress Scale.

RESULTS

Analysis of data from 640 patients (chronic CH: 287/640 [44.8%]; female: 264/640 [41.3%]; male: 373/640 [58.3%]; gender diverse: three of 640 [0.5%]; age range: 18-86 years; mean [standard deviation] Cluster Headache Scales subscale disability score: 36.9 [9.8]; out of 869 respondents) revealed that both attack frequency and fear of attacks significantly predicted pain-related disability (p < 0.001, percentage of variance explained: R2 = 0.24). More variance was explained by fear of attacks (R2 = 0.22) than by attack frequency (R2 = 0.02). This relationship remained significant even when controlling for depression and anxiety, which were also identified as independent predictors of pain-related disability (p < 0.001, R2 = 0.44).

CONCLUSION

This study emphasizes the relevance of psychological factors in CH-related disability. Fear of attacks was found to be an independent predictor, while attack frequency was of minor relevance. Empirical investigation of the FAM in CH could improve the understanding of the mechanisms underlying disability and contribute to the development of CH-specific interventions.

Virtual Reality for Subacute Pain After Orthopedic Traumatic Musculoskeletal Injuries: A Mixed Methods Pilot Study

OBJECTIVES

Acute orthopedic traumatic musculoskeletal injuries are prevalent, costly, and often lead to persistent pain and functional limitations. Psychological risk factors (eg, pain catastrophizing and anxiety) exacerbate these outcomes but are often overlooked in acute orthopedic care. Addressing gaps in current treatment approaches, this mixed-methods pilot study explored the use of a therapeutic virtual reality (VR; RelieVRx ), integrating principles of mindfulness and cognitive-behavioral therapy, for pain self-management at home following orthopedic injury.

METHODS

We enrolled 10 adults with acute orthopedic injuries and elevated pain catastrophizing or pain anxiety from Level 1 Trauma Clinics within the Mass General Brigham health care system. Participants completed daily RelieVRx sessions at home for 8 weeks, which included pain education, relaxation, mindfulness, games, and dynamic breathing biofeedback. Primary outcomes were a priori feasibility, appropriateness, acceptability, satisfaction, and safety. Secondary outcomes were pre-post measures of pain, physical function, sleep, depression, and hypothesized mechanisms (pain self-efficacy, mindfulness, and coping).

RESULTS

The VR and study procedures met or exceeded all benchmarks. We observed preliminary improvements in pain, physical functioning, sleep, depression, and mechanisms. Qualitative exit interviews confirmed high satisfaction with RelieVRx and yielded recommendations for promoting VR-based trials with orthopedic patients.

DISCUSSION

The results support a larger randomized clinical trial of RelieVRx versus a sham placebo control to replicate the findings and explore mechanisms. There is potential for self-guided VR to promote evidence-based pain management strategies and address the critical mental health care gap for patients following acute orthopedic injuries.

Differences in dynamic balance control based on pain catastrophizing level in individuals with nonspecific chronic low back pain

BACKGROUND

Pain catastrophization (PC) is related to motor control changes in individuals with nonspecific chronic low back pain (NSCLBP). However, differences in dynamic balance control based on the level of PC still remain unclear in these individuals.

OBJECTIVE

The aim of this study was to compare the dynamic balance control between healthy controls and individuals with NSCLBP with high and low PC.

METHODS

Forty individuals with NSCLBP and 20 healthy participants were enrolled in this cross-sectional study. Individuals with NSCLBP were classified into two groups of high and low PC. Dynamic balance control was assessed using the Modified Star Excursion Balance Test (MSEBT), Five-Time Sit-to-Stand Test (FTSST), and Timed Up and Go Test (TUGT).

RESULTS

Statistical analyses showed that mean values of reach distances in the anterior, posteromedial, and posterolateral directions of the MSEBT were significantly lower in individuals with NSCLBP with high PC compared to low PC (p = .04, p = .01, and p = .04, respectively) and healthy controls (p < .001, p = .001, and p = .006, respectively). In addition, for both the FTSS and TUG tests, the mean time was significantly greater in individuals with NSCLBP with high PC compared to low PC (p < .001 and p = .004, respectively) and healthy controls (p < .001).

CONCLUSIONS

Our results showed poor dynamic balance control in individuals with NSCLBP with high PC. This suggests that PC could contribute to the impaired dynamic balance control in individuals with NSCLBP. Combining balance exercises and cognitive-behavioral treatments targeting PC may be useful for the improvement of dynamic balance control in individuals with NSCLBP with high PC.

A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: short-term outcomes of pain and disability

BACKGROUND

The evidence supporting the application of pain neuroscience education (PNE) in patients with chronic low back pain (LBP) remains some arguments.

OBJECTIVE

This review aims to investigate the effect of PNE alone and combined with physical therapy or exercise for chronic LBP.

METHODS

PubMed, Embase, Web of Science, and the Cochrane databases were searched from establishment to June 3, 2023. Randomized controlled trials (RCT) evaluating the effect of PNE in patients with chronic LBP were considered eligible. Data were analyzed using a random-effects model (I2 >50%) or a fixed-effects model (I2 <50%) and trials were appraised using the Cochrane ROB tool. Meta-regression was conducted to assess the moderator factors.

RESULTS

Seventeen studies (1078 participants) were included in this review. PNE plus exercise and PNE plus physiotherapy both showed a reduction of short-term pain (mean differences [MD] -1.14 [-1.55, -0.72]; MD -1.15 [-1.67, -0.64]) and disability (standardized mean difference [SMD] -0.80 [-1.13, -0.47]; SMD -0.85 [-1.29, -0.40]) than physiotherapy or exercise alone. Meta-regression showed that only single PNE session duration was associated with a greater reduction in pain (P < .05). Subgroup results showed that a single PNE session exceeding 60 minutes (MD -2.04), 4 to 8 sessions (MD -1.34), intervention for 7 to 12 weeks (MD -1.32), and a group-based approach (MD -1.76) may be more beneficial.

CONCLUSION

This review indicates that adding PNE to treatment programs would lead to more efficacious effects for chronic LBP. Additionally, we preliminarily extracted dose-effect relationships for PNE intervention, providing guidance for clinicians to design effective PNE sessions.

Fear avoidance, fear of falling, and pain disability in hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders

PURPOSE

Hypermobile Ehlers-Danlos Syndrome (hEDS) and Hypermobility Spectrum Disorders (HSD) are understudied conditions characterized by hallmark hypermobility and chronic pain. Disease manifestations lead to significant disability. Understanding predictors of disability, over and above the univariate construct of pain severity, is necessary to tailor treatment. Thus, the current study examined the impact of the Fear-Avoidance Model [FAM] on disability in hEDS/HSD. Fear of falling was included as a novel fear-avoidance factor impacting disability.

METHODS

A total of 168 individuals with hEDS/HSD answered a cross-sectional online survey regarding FAM constructs, fear of falling, disability, and clinical-demographic factors. A hierarchical regression analysis was used to assess whether FAM constructs and fear of falling significantly predicted disability, over and above pain severity and age.

RESULTS

Pain catastrophizing, anxiety, and fear of falling contributed significant unique predictive relations, above age and average pain severity. Pain severity and fear of falling were the strongest unique predictors of disability.

CONCLUSIONS

This is the first study to assess the relations among FAM constructs, pain severity, and disability in hEDS/HSD, and introduces fear of falling as a novel fear-avoidance factor specific to this population. Future research should apply these findings towards individualized interventions to improve disability in hEDS/HSD.

Gender differences on preoperative psychologic factors affecting acute postoperative pain in patients with lumbar spinal disorders

BACKGROUND

Psychosexual factors are one of the preoperative factors influencing acute postoperative pain. Because of gender differences in pain, the preoperative factors that influence acute postoperative pain may also differ between males and females. However, there have been no reports on such factors in patients with spinal disorders that focused on gender differences. Therefore, the purpose of this study was to examine the preoperative factors that influence acute postoperative pain, focusing on gender differences.

METHODS

The subjects were 75 males and 60 females admitted for surgery for lumbar spinal disorders. Preoperatively, the following were assessed: low back pain using the Numeric Rating Scale (NRS); anxiety and depression using the Japanese version of the Hospital Anxiety and Depression Scale (HADS); catastrophic thinking using the Pain Catastrophizing Scale (PCS); psychiatric problems using the Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP); and neurological assessments. Acute postoperative pain was also assessed using the NRS within 48 h, postoperatively. Based on these data, we analyzed gender differences in preoperative factors affecting acute postoperative pain in patients with lumbar spinal disorders.

RESULTS

Postoperative NRS and preoperative PCS scores were higher in females compared to males. In the males, the coefficient of determination of the multiple regression equation was 0.088, and PCS (β = 0.323, p = 0.015) was extracted as a significant factor. In the females, the coefficient of determination of the multiple regression equation was 0.075, and BS-POP (β = 0.300, p = 0.019) was extracted as a significant factor.

CONCLUSION

Preoperative factors influencing acute postoperative pain for patients with lumbar spinal disorders vary by gender. It was suggested that males should be screened using PCS. In females, on the other hand, PCS alone is not sufficient for evaluation. It was suggested that evaluation using BS-POP should be considered in addition to PCS.

The Hope and Reality of Pain Relief Using Psychological Manipulations

ABSTRACT

Many patients suffer from chronic pain despite the absence of injury or sufficient biomedical disease to explain their pain. These pains are highly resistant to treatment. Psychological therapies designed to help patients undermine the negative thought and behavioral patterns that maintain pain provide only modest pain relief, leading to suspicion that such pain might be maintained by unconscious processes. An article in this issue of Psychosomatic Medicine provides the first experimental evidence that unconscious negative memories can increase pain unpleasantness. These findings are exciting, but the effect sizes are small, which is consistent with the small effects of psychological therapy. It seems that pain stubbornly resists psychological manipulation, but this work provides some hope that psychological therapy for pain can be improved to provide more effective pain relief.

Relationship between Kinesiophobia and Dynamic Postural Stability after Anterior Cruciate Ligament Reconstruction: A Prospective Cohort Study

Anterior cruciate ligament (ACL) injuries in young, active patients generally require ACL reconstruction (ACLR) to restore mechanical and postural stability. The fear of movement or reinjury (kinesiophobia) has become increasingly recognized in the post-ACLR population; however, the association between restoration of postural stability and kinesiophobia remains largely unknown. The purpose of this study was to investigate changes in mean Tampa Scale of Kinesiophobia-11 (TSK-11), dynamic motion analysis (DMA) scores, and time on the testing platform, as well as any correlation between TSK-11 and mean overall and individual translational and rotational DMA scores during the first 12 months following ACLR. Cohort study. Patients undergoing ACLR were prospectively enrolled and dynamic postural stability and kinesiophobia based on the TSK-11 were collected within 2 days prior to surgery and at 6 and 12 months following ACLR. Dynamic postural stability was quantified by calculating a DMA score, with score calculated in three translational (anterior/posterior [AP], up/down [UD], medial/lateral [ML]) and three rotational (left/right [LR], flexion/extension, and internal/external rotation) independent planes of motions. Correlations between DMA and TSK-11 scores at each time point were analyzed. A total of 25 patients meeting inclusion criteria were analyzed. Mean overall DMA and TSK-11 scores increased with each successive testing interval. At 6-month follow-up, a weakly positive association between TSK-11 and DMA scores was appreciated based on overall DMA, AP, UD, ML, and LR. At 12 months, a moderately positive correlation was appreciated between TSK-11 and the translational, but not rotational, planes of motion. Following ACLR, lower level of kinesiophobia were found to be moderately associated with improved dynamic stability, especially in the translation planes of motion.

Avoidance and Rumination as Predictors of Substance Use, Mental Health, and Pain Outcomes Among People Living With HIV

Pain, substance use, and mental health conditions are common among people living with HIV (PLWH), and avoidance and rumination may influence the co-occurrence of these conditions. The present study examined longitudinal associations between avoidance/rumination and pain outcomes, anxiety, anger, and substance use among PLWH. Participants (N = 187) with chronic pain and depressive symptoms completed self-report assessments over a 1-year period. Greater avoidance/rumination was positively associated with mental health outcomes (anxiety, anger), pain interference, and alcohol use across participants after controlling for depression severity. At time points with greater avoidance/rumination than average, participants also reported increased pain severity and interference, anxiety and anger symptoms, and alcohol use. No associations were found between avoidance/rumination and cannabis use. Results suggest a mechanistic effect of avoidance/rumination, such that increases in avoidance/rumination correspond with poorer health outcomes among PLWH over time. Targeting avoidance/rumination through intervention approaches may be beneficial for addressing comorbid health conditions among PLWH. Additional research is necessary to investigate this possibility and further characterize the effects of avoidance/rumination on health outcomes for PLWH.

The relationship between fatigue, exercise self-efficacy, fear of movement, and quality of life in patients with heart failure: A moderated mediation model

This study was aimed to examine the moderated mediating effects of exercise self-efficacy and fear of movement on the relationship between fatigue and quality of life in patients with heart failure. A total of 305 patients with heart failure were enrolled in this cross-sectional study. The results showed that fear of movement significantly mediated the relationship between fatigue and quality of life, indicating that relieving fear of movement may be beneficial to improve quality of life. Furthermore, exercise self-efficacy negatively moderated the mediating effect of fear of movement on the relationship between fatigue and physical health-related quality of life. It is suggesting that improving exercise self-efficacy may provide opportunities to buffer the negative effect of fear of movement on physical health-related quality of life in patients with heart failure, especially for those with fatigue. The findings provide additional strategies to optimize quality of life management in patients with heart failure.

Trends in Physiotherapy of Chronic Low Back Pain Research: Knowledge Synthesis Based on Bibliometric Analysis

BACKGROUND

Physiotherapy and chronic low back pain (CLBP) form a broad and quickly developing research area. The aim of this article was to holistically, thematically and chronologically analyze and synthesize the literature production in this research area and identify the most prolific research entities and research themes.

METHODS

This article quantitatively and qualitatively analyzed research literature production harvested from the Scopus bibliometric database, using a triangulation of bibliometric and thematic analysis. For this, Excel 2024, Bibliometrix Biblioshiny 4.1 and VOSviewer version 1.6.20 softwares were used.

RESULTS

In the Scopus database, 2843 data sources were found, which were published between 1974 and 26 February 2024. The growth trend has been linearly positive since the beginning of publication, and after 2018 exponential growth began. A review of the most prolific entities showed that the most literature was published in America, Europe and Australasia. The thematic analysis of the information sources identified six main themes (pathophysiology of CLBP and the quantification assessment tools, diagnostics and CLBP treatment, CLBP questionnaires and surveys, quality of life, complementary methods in physiotherapy and psychosocioeconomic aspects), while the chronological analysis revealed three main areas of development: assessment tools, CLBP processing and study methodology.

CONCLUSIONS

The results of this bibliometric study present a good starting point for further research, providing taxonomy and research landscapes as a holistic framework offering multidisciplinary knowledge about CLBP, while chronological analysis provides a basis for identifying prospective research trends. This article offers an interdisciplinary view of the current issue of public health. The results of this study provide a basis for the development of both the physiotherapy and epidemiological fields.

Integrating Chiropractic Care and Tai Chi Training for the Treatment of Chronic Nonspecific Neck Pain in Nurses: A Single-Arm Mixed-Methods Pilot Trial

Objectives: Chronic nonspecific neck pain (CNNP) is prevalent among health care workers, with particularly high rates among nurses. Nurses experiencing CNNP often report decreased job satisfaction, increased absenteeism, and reduced productivity. In recent years, nonpharmacologic approaches have gained attention as effective treatments for the management of CNNP, with exercise and manual therapies representing two of the most common. Early evidence shows that multimodal treatments may be more effective than unimodal strategies. The purpose of this current study was to assess the feasibility and observe the clinical outcomes of combined multimodal chiropractic care (MCC) and Tai Chi (TC) for CNNP in nurses. Methods: A single-arm mixed-methods pilot trial was conducted including 16 weeks of MCC and TC in nurses with self-reported CNNP. Feasibility outcomes were recruitment, retention, and adherence to the interventions. Clinical outcomes of interest included neck pain and related disabilities. Secondary outcomes of interest were functional, affective, and work-related performance. Qualitative interviews were also conducted. Results: Of the 59 screened, 36 met the eligibility criteria, and 21 were enrolled. The retention rate was 71.4%, and adherence rates were 85.3% for MCC and 62.5% for TC classes. Multiple pain and disability-related outcomes exhibited modest improvement from baseline to 16-week follow-up. Qualitative analysis identified six emergent themes: (1) neck pain being an inherent part of nursing, (2) nurses push through their pain, (3) MCC relieves pain and is instructive for preventing pain, (4) TC provides overall relaxation, (5) both interventions increased body awareness and improved posture, and (6) scheduling difficulties were a key obstacle for participating. Conclusions: Observed reductions in neck pain and disability suggest the potential utility of combined MCC and TC interventions for managing CNNP. Along with qualitative feedback regarding facilitators and barriers to participation, the findings support and inform a future randomized trial evaluating the combined benefits of MCC and TC for CNNP in nurses. Clinical Trial Registration #NCT06523036.

Germ aversion is a risk factor for chronic low back pain and shoulder pain under the COVID-19 pandemic: an internet-based panel study

The COVID-19 pandemic has increased germ aversion, an aversive affective response to a high likelihood of pathogen transmission. While psychological factors are associated with chronic pain, the relationship between germ aversion and chronic pain remains unexplored. This study aimed to examine the relationship between germ aversion and new-onset and prognosis of chronic pain using longitudinal data collected during the COVID-19 pandemic. We conducted web-based surveys of full-time workers at baseline and after three months. Data were collected on demographic characteristics, psychological factors, and chronic pain. Germ aversion was assessed using a modified Perceived Vulnerability to Disease scale. We analyzed responses from 1265 panelists who completed the survey twice. The prevalence of chronic low back pain (CLBP) and chronic neck and shoulder pain (CNSP) was associated with sex, short sleep duration, psychological distress, loneliness, and germ aversion. Stratified analyses showed that germ aversion was a risk factor for CLBP at three months in both individuals with and without CLBP at baseline, and for CNSP at three months in those with CNSP at baseline, even after adjustment for confounders. In conclusion, this preliminary study suggests that high germ aversion is a risk factor for CLBP and CNSP in young and middle-aged workers.

Psychological Risk Factors for Delayed Recovery Among Active Duty Service Members Seeking Treatment for Musculoskeletal Complaints at a Navy Shore-Based Military Medical Treatment Facility

INTRODUCTION

Musculoskeletal injuries (MSIs) are a leading cause of separation from the U.S. Navy. Data have shown that several psychological responses to MSI are associated with treatment outcomes. Yellow flags are maladaptive psychological responses to injury and predict delayed recovery, whereas pink flags indicate resilience after MSI and are associated with good treatment outcomes. Identifying these factors in patients with MSI would permit early targeted care to address factors that may delay their readiness for deployment and enhance factors that support recovery.

MATERIALS AND METHODS

Active duty service members with MSI who reported to physical therapy outpatient services at a naval hospital were recruited for the study. Yellow flags were assessed at baseline as part of a larger study. Participants completed the Fear Avoidance Beliefs Questionnaire (with two subscales, physical activity and work), the Pain Catastrophizing Scale, and the Hospital Anxiety and Depression Scale. Clinically relevant cut-off scores were used to indicate risk factors of delayed recovery. Pink flags were assessed with the Pain Self-Efficacy Questionnaire and a measure of positive outcome expectations for recovery.

RESULTS

Two hundred and ninety participants responded to some or all of the questionnaires. Of these, 82% exceeded the cut-off scores on the physical activity subscale of the Fear Avoidance Beliefs Questionnaire, and 39% did so on the work subscale. Pain catastrophizing exceeded the cut-off in only 4.9% of the sample. Forty-three percent of these exceeded the cut-off for the anxiety subscale of the Hospital Anxiety and Depression Scale; 27% exceeded the cut-off on the depression subscale of the Hospital Anxiety and Depression Scale. Additionally, 54% endorsed scores greater than 40 on the Pain Self-Efficacy Questionnaire, and 53% endorsed a high score on the positive outcome expectations.

CONCLUSIONS

A substantial portion of the sample endorsed elevated scores on one or more indicators of delayed recovery from MSI. Most participants showed a fear of physical activity, and approximately half reported pain-related distress (anxiety and depression). In addition, feelings of self-efficacy and positive outcome expectations of treatment were endorsed by only about half of the participants, indicating that the remaining half did not report adaptive responses to MSI. Early identification of these risk factors will allow for targeted treatment approaches that incorporate these yellow flags into treatment and support a psychologically informed approach to physical therapy. This approach is likely to reduce delayed recovery and improve deployment readiness.

Changes in isokinetic trunk muscle strength and endurance after two different restoration programs in people with chronic low back pain: A longitudinal retrospective study

Background

Multidisciplinary functional restoration programs (FRPs) aim to improve pain and function in people with chronic low back pain (CLBP). The intensity and content of FRPs varies; the benefits of one program over another are unclear.

Objective

To assess changes in trunk muscle strength and endurance after an intensive (IFRP) (for people on sick leave for >6 months with high levels of fear-avoidance beliefs about physical activity and work) or semi-intensive (SIFRP) (for people working) FRP in people with CLBP.

Methods

Longitudinal retrospective study from March 2016 to December 2019. Setting: rehabilitation department of a tertiary care center. Trunk flexor and extensor muscle strength (60°.s-1) and endurance (120°.s-1) were measured with the Humac NORM isokinetic dynamometer at pre and post FRP. Change in isokinetic variables (peak torque, total work and flexor/extensor ratio) after each program was assessed with a paired t-test (p < 0.05). Pearson's rho and multiple linear regression assessed associations between changes in isokinetic and clinical variables and demographic characteristics.

Results

125 individuals, 63.2 % female, age 43.5 (10.3) years, were included. Mean low back pain intensity was 49.8 (24.9) and 37.2 (25.8)/100 and mean activity limitation (QBPDS) was 38.8 (16.4) and 32.0 (14.6)/100 in the IFRP and SFRP groups, respectively. Trunk extensor peak torque, flexor total work, extensor total work and flexor/extensor peak ratio improved significantly in both FRPs, p < 0.001. The flexor/extensor total work ratio improved in the IFRP group only, p = 0.003. Trunk extensor endurance increased more in the IFRP than the SIFRP group, the absolute pre-post differences for extensor total work [95%CI] N.m were 611.7 [495.2; 728.3] in the IFRP group and 380.0 [300.8; 459.3] in the SIFRP group. No variables were correlated and none predicted improvement in extensor total work in either group.

Conclusion

This study highlights the short-term independence of clinical and trunk muscle strength and endurance changes.

Who develops chronic pain after an acute lower limb injury? A longitudinal study of children and adolescents

ABSTRACT

Prevention of chronic pain is a major challenge in this area of clinical practice. To do this, we must be able to understand who is most at risk of developing chronic pain after an injury. In this study, we aimed to identify risk factors of chronic pain onset, disability, and pain interference after a lower limb musculoskeletal injury in children and adolescents between 8 to 16 years of age. We assessed biopsychosocial factors including age, sex, pubertal status, anxiety, depression, fear of pain, pain worry, adverse life events, and sleep in children. We also assessed risk factors in parents including parent anxiety, depression, parent pain catastrophising, and protective behaviours. Logistic and hierarchical linear regressions identified risk factors assessed immediately postinjury for outcomes assessed at 3 months postinjury. Fourteen percent (17/118 children) reported chronic pain 3 months after injury. There were significant between-group differences in children with and without chronic pain at baseline. Children with chronic pain reported higher pain intensity, disability, pain interference, child depression, fear of pain, and catastrophic thinking about their pain. Regressions showed child depression and fear of pain at baseline independently predicted chronic pain onset at 3 months, parent protectiveness predicted child pain interference at 3 months, and child depression, poor sleep, parent anxiety and pain catastrophising predicted disability. Most children recover after a lower limb injury, but a minority develop chronic pain predicted by important psychosocial risk factors, which could be addressed to prevent the onset of treatment-resistant chronic pain and disability.

Prevalence and influencing factors of kinesiophobia in patients with heart disease: a meta-analysis and systematic review

This study aims to assess the global prevalence of kinesiophobia and the potential influencing factors among patients with heart disease. A comprehensive search was conducted in PubMed, Embase, Web of Science, PsycINFO, and Scopus databases to identify studies reporting on the prevalence of kinesiophobia and its influencing factors in heart disease patients up to January 2024. A random-effects model was employed to aggregate prevalence rates. Heterogeneity sources were investigated through subgroup analysis, while differences in the prevalence of kinesiophobia across regions, types of heart disease, and gender were evaluated. Additionally, a qualitative analysis of the factors influencing kinesiophobia was performed. This research incorporated 15 studies from six countries, with 14 providing data on the prevalence of kinesiophobia and nine exploring its potential influencing factors. The findings indicated that the overall prevalence of kinesiophobia among heart disease patients was 61.0% (95% CI 49.4-72.6%). Subgroup analysis revealed that the prevalence in upper-middle-income countries was 71.8% (95% CI 66.2-77.4%), while it stands at 49.9% (95% CI 30.2-69.5%) in high-income countries. The prevalence rates among patients with coronary artery disease, heart failure, and atrial fibrillation were 63.2% (95% CI 45.2-81.3%), 69.2% (95% CI 57.6-80.8%), and 71.6% (95% CI 67.1-76.1%), respectively. Gender-wise, no significant difference was observed in the prevalence of kinesiophobia between men and women (52.2% vs. 51.8%). A total of 24 potential influencing factors of kinesiophobia were identified, with education level, monthly income, anxiety, and exercise self-efficacy being the most recognized. The prevalence of kinesiophobia in patients with heart disease is notably high and is influenced by a multitude of factors. Early implementation of targeted preventive measures is imperative to mitigate the incidence of kinesiophobia in this population.

Prevalence and predictors of persistent cognitive and psychological symptoms in non-hospitalized post-COVID-19 patients seeking care at an outpatient post-COVID-19 clinic

Introduction

There is still much uncertainty about why some people develop persistent cognitive and mental health problems after SARS-CoV-2 infection and require additional care while others do not. In this study, we investigated the cognitive and psychological outcomes of non-hospitalized post-COVID-19 patients referred to an outpatient post-COVID-19 clinic for persistent symptoms more than 3 months after infection. Additionally, we aimed to explore the influence of demographic, physical, and personal factors on these outcomes.

Methods

This cross-sectional study was conducted at an outpatient post-COVID-19 clinic located at a prominent clinical teaching hospital in the Netherlands. Participants included non-hospitalized patients referred between 2020 and 2022, more than 3 months after SARS-CoV-2 infection, experiencing persistent symptoms. Main outcome measures included levels of anxiety and depression (Hospital Anxiety and Depression Scale), post-traumatic stress symptoms (PTSS) (Post-traumatic Stress Symptoms Checklist 14), and cognitive symptoms (Checklist for Cognitive and Emotional Consequences). Data analysis employed Spearman correlation and hierarchical multiple regression analyses.

Results

A total of 265 patients (61% female; mean age of 51.7 ± 13.7 years) were included in the study, with an average of 7.6 ± 4.5 months following SARS-CoV-2 infection. Among them, 104 patients (40%) reported high levels of anxiety, 111 patients (43%) showed high levels depressive symptoms, and 71 patients (31%) demonstrated high levels of PTSS. Additionally, 200 patients (79%) reported experiencing more than 2 cognitive symptoms. Bivariate analyses indicated associations between psychiatric history and increased cognitive and psychological symptoms. Multivariate analyses revealed positive associations between physical symptoms and cognitive and psychological symptoms, and catastrophizing thoughts were associated with higher anxiety levels (β = 0.217, p < 0.001). Conversely, positive refocusing was associated with lower depressive symptoms (β = -0.325, p < 0.001), PTSS (β = -0.290, p < 0.001), and cognitive symptoms (β = -0.220, p < 0.001).

Discussion

Among non-hospitalized COVID-19 patients seeking care for persistent symptoms, approximately one-third reported high levels of psychological symptoms, and more than three-quarter experienced cognitive symptoms. Physical symptoms, psychiatric history, and a tendency to catastrophize were identified as potential risk factors for persistent psychological and cognitive symptoms. Conversely, positive refocusing demonstrated a protective effect. These findings contribute to the understanding of long-term COVID-19 outcomes and emphasize the importance of integrating a biopsychosocial perspective into treatment approaches.

Identifying pain profiles in employees including work-related factors and pain perceptions: a cross-sectional study in Belgian companies

OBJECTIVES

Studies usually investigate a limited number or a predefined combinations of risk factors for sickness absence in employees with pain. We examined frequently occurring combinations across a wide range of work-related factors and pain perceptions.

DESIGN

Cross-sectional study.

SETTING

Belgian companies that are under supervision of IDEWE, an external service for prevention and protection at work.

PARTICIPANTS

In total, 249 employees experiencing pain for at least 6 weeks were included and filled out an online survey.

OUTCOMES

Latent profile analysis was used to differentiate profiles of work-related factors (physical demands, workload, social support and autonomy) and pain perceptions (catastrophising, fear-avoidance beliefs and pain acceptance). Subsequently, profiles were compared on sociodemographics (age, gender, level of education, work arrangement, duration of complaints, multisite pain and sickness absence in the previous year) and predictors of sickness absence (behavioural intention and perceived behavioural control).

RESULTS

Four profiles were identified. Profile 1 (38.2%) had favourable scores and profile 4 (14.9%) unfavourable scores across all indicators. Profile 2 (33.3%) had relatively high physical demands, moderate autonomy levels and favourable scores on the other indicators. Profile 3 (13.7%) showed relatively low physical demands, moderate autonomy levels, but unfavourable scores on the other indicators. Predictors of profiles were age (OR 0.93 and 95% CI (0.89 to 0.98)), level of education (OR 0.28 and 95% CI (0.1 to 0.79)) and duration of sickness absence in the previous year (OR 2.29 and 95% CI (0.89 to 5.88)). Significant differences were observed in behavioural intention (χ2=8.92, p=0.030) and perceived behavioural control (χ2=12.37, p=0.006) across the four profiles.

CONCLUSION

This study highlights the significance of considering the interplay between work-related factors and pain perceptions in employees. Unfavourable scores on a single work factor might not translate into maladaptive pain perceptions or subsequent sickness absence, if mitigating factors are in place. Special attention must be devoted to employees dealing with unfavourable working conditions along with maladaptive pain perceptions. In this context, social support emerges as an important factor influencing sickness absence.

Insomnia among patients with chronic pain: A retrospective study

Insomnia can coexist with chronic pain and is a major cause of rapidly increasing medical expenses. However, insomnia has not been fully evaluated in patients with chronic pain. This retrospective study aimed to identify the risk factors for insomnia in patients with chronic non-cancer pain. A total of 301 patients with chronic non-cancer pain were enrolled. Patients with the Athens insomnia scale scores ≥ 6 and < 6 were classified into insomnia (+) and insomnia (-) groups, respectively. All patients completed self-report questionnaires as part of their chronic pain treatment approach. Univariate and multivariate analyses were performed to predict insomnia. We found that 219 of 301 (72.8%) patients met the AIS criteria for insomnia. Significant differences were depicted between patients with and without insomnia in terms of body mass index, numeric rating scale, pain catastrophizing scale, hospital anxiety, and depression scale (HADS), pain disability assessment scale, EuroQol 5 dimension (EQ5D), and pain self-efficacy questionnaire. Multiple regression analysis identified the numeric rating scale, HADS, and EQ5D scores as factors related to insomnia in patients with chronic non-cancer pain. Anxiety, depression, and disability were associated with a greater tendency toward insomnia. HADS and EQ5D scores are useful screening tools for preventing insomnia in patients with chronic non-cancer pain.

A functional intervention within a cognitive approach to chronic cervical radiculopathy : Description of the non-surgical treatment arm in a randomised controlled trial evaluating the effectiveness of surgery

BACKGROUND

Most patients with cervical radiculopathy improve within the first months without treatment or with non-surgical treatment. A systematic review concluded that these patients improve, regardless of their intervention. Still, many patients are offered surgery, despite limited evidence regarding the indications for surgical treatments. The aim of this article is to describe the intervention that is going to be followed in the non-surgical treatment arm of a randomised controlled trial (RCT) comparing the effectiveness of surgical and non-surgical treatment for patients with cervical radiculopathy.

METHODS

The non-surgical intervention is a functional intervention within a cognitive approach founded on previous experiences, and current recommendations for best practice care of musculoskeletal pain and cervical radiculopathy. It is based on the biopsychosocial rather than a biomedical perspective, comprises an interdisciplinary approach (physicians, physiotherapy specialists), and includes brief intervention and graded activities. The intervention consists of 6 sessions over 12 weeks. The primary goals are first, to validate the patients´ symptoms and build a therapeutic alliance, second, to explore the understanding and promote alternatives, and third, to explore problems and opportunities based on patients´ symptoms and function. Motivational factors toward self-management are challenging. We will attempt shared decision-making in planning progress for the individual patient and emphasise learning of practical self-help strategies and encouragement to stay active (reinforcing the positive natural course). General physical activities such as walking will be promoted along with simple functional exercises for the neck- and shoulder region. We will also explore social activity, comorbidities, pain location, sleep, and work-related factors. The health providers will set individualised goals together with each patient.

DISCUSSION

The aim of the intervention is to describe a functional intervention within a cognitive approach for patients with chronic cervical radiculopathy. The effectiveness of the present program will be compared to surgery in a randomised controlled trial.

Expectation of pain and relief: A dynamical model of the neural basis for pain-trauma co-morbidity

Posttraumatic Stress Disorder (PTSD) is highly co-morbid with chronic pain conditions. When present, PTSD significantly worsens chronic pain outcomes. Likewise, pain contributes to a more severe PTSD as evidenced by greater disability, more frequent use of harmful opioid analgesics and increased pain severity. The biomechanism behind this comorbidity is incompletely understood, however recent work strongly supports the widely-accepted role of expectation, in the entanglement of chronic pain and trauma symptoms. This work has shown that those with trauma have a maladaptive brain response while expecting stress and pain, whereas those with chronic pain may have a notable impairment in brain response while expecting pain relief. This dynamical expectation model of the interaction between neural systems underlying expectation of pain onset (traumatic stress) and pain offset (chronic pain) is biologically viable and may provide a biomechanistic insight into pain-trauma comorbidity. These predictive mechanisms work through interoceptive pathways in the brain critically the insula cortex. Here we highlight how the neural expectation-related mechanisms augment the existing models of pain and trauma to better understand the dynamics of pain and trauma comorbidity. These ideas will point to targeted complementary clinical approaches, based on mechanistically separable neural biophenotypes for the entanglement of chronic pain and trauma symptoms.

A systematic review with meta-analyses of the association between stigma and chronic pain outcomes

ABSTRACT

Stigma is common in people experiencing chronic pain and there are indications that it may adversely affect pain outcomes. However, to date, there is no systematic review exploring the impact of stigma on chronic pain-related outcomes. This systematic review and meta-analysis aimed to examine the association between stigma and key chronic pain outcomes and differences in stigma between pain conditions. Seven databases were searched for studies reporting a measure of association between stigma and at least one pain outcome in adults with chronic pain. Studies were screened by 2 independent researchers. Nineteen studies met eligibility criteria and data were extracted, quality-assessed, and narratively synthesised and meta-analysed where possible. Meta-analyses of bivariate cross-sectional correlations demonstrated significant positive correlations between stigma and pain intensity, disability, and depression, with small to moderate effects. Data from 2 prospective studies and those only reporting multivariate analyses that were not included in meta-analyses further supported these findings. There was some evidence that individuals who experience pain conditions with less clear pathophysiology may report greater stigma, although more research is needed. The review highlights that there is a growing number of studies on stigma in the pain field showing an adverse association between stigma and chronic pain outcomes.

Pain Education and Virtual Reality Improves Pain, Pain-related Fear of Movement, and Trunk Kinematics in Individuals With Persistent Low Back Pain

OBJECTIVES

To evaluate the effect of combining pain education and virtual reality (VR) exposure therapy using a cognitive-behavioral therapy-informed approach (virtual reality-based cognitive behavioral therapy [VR-CBT]) on pain intensity, fear of movement, and trunk movement in individuals with persistent low back pain.

MATERIALS AND METHODS

Thirty-seven participants were recruited in a single cohort repeated measures study, attending 3 sessions 1 week apart. The VR-CBT intervention included standardized pain education (session 1) and virtual reality-based exposure therapy (VRET; session 2) incorporating gameplay with mixed reality video capture and reflective feedback of performance. Outcome measures (pain intensity, pain-related fear of movement (Tampa Scale of Kinesiophobia), and trunk kinematics during functional movements (maximum amplitude and peak velocity) were collected at baseline (session 1) and 1 week after education (session 2) and VRET (session 3). One-way repeated measures analysis of variances evaluated change in outcomes from baseline to completion. Post hoc contrasts evaluated effect sizes for the education and VR components of VR-CBT.

RESULTS

Thirty-four participants completed all sessions. Significant ( P < 0.001) reductions were observed in mean (SD) pain (baseline 5.9 [1.5]; completion 4.3 [2.1]) and fear of movement (baseline 42.6 [6.4]; completion 34.3 [7.4]). Large effect sizes (Cohen d ) were observed for education (pain intensity: 0.85; fear of movement: 1.28), whereas the addition of VRET demonstrated very small insignificant effect sizes (pain intensity: 0.10; fear of movement: 0.18). Peak trunk velocity, but not amplitude, increased significantly ( P < 0.05) across trunk movement tasks.

CONCLUSION

A VR-CBT intervention improved pain, pain-related fear of movement, and trunk kinematics. Further research should explore increased VR-CBT dosage and mechanisms underlying improvement.

Neural mechanisms underlying attentional bias modification in fibromyalgia patients: a double-blind ERP study

There is a growing interest in the potential benefits of attentional bias modification (ABM) training in chronic pain patients. However, studies examining the effectiveness of ABM programs in fibromyalgia patients have demonstrated inconclusive effects on both behavioral indices and clinical symptoms. Additionally, underlying neural dynamics of ABM effects could yield new insights but remain yet unexplored. Current study, therefore, aims to investigate the effects of ABM training on known neural electrophysiological indicators of attentional bias to pain (P2, N2a). Thirty-two fibromyalgia patients were enrolled and randomly assigned to an ABM training (N = 16) or control (N = 16) condition (2 weeks duration). Within the ABM training condition participants performed five sessions consisting of a modified version of the dot-probe task in which patients were trained to avoid facial pain expressions, whereas in the control group participants performed five sessions consisting of a standard version of the dot-probe task. Potential ABM training effects were evaluated by comparing a single pre- and post-treatment session, in which event-related potentials (ERPs) were recorded in response to both facial expressions and target stimuli. Furthermore, patients filled out a series of self-report questionnaires assessing anxiety, depression, pain-related worrying, fear of pain, fatigue and pain status. After training, results indicated an overall reduction of the amplitude of the P2 component followed by an enhancement of N2a amplitude for the ABM condition compared to control condition. In addition, scores on anxiety and depression decreased in patients assigned to the training condition. However, we found no effects derived from the training on pain-related and fatigue status. Present study offers new insights related to the possible neural mechanisms underlying the effect of ABM training in fibromyalgia. Clinical trial (TRN: NCT05905159) retrospectively registered (30/05/2023).

Pain Intensity After Cardiac Surgery and its Association With Kinesiophobia: A Descriptive Study

PURPOSE

Severe pain and fear of pain may decrease physical activity and restrict movements after cardiac surgery. This study aimed to determine pain intensity after cardiac surgery and its association with kinesiophobia.

DESIGN

This was a descriptive and correlational study.

METHODS

The study was conducted with cardiac surgery patients (n = 170). The sample size was calculated by using the G*POWER 3.1 program. According to the power analysis, the sample size was calculated as 170, taking into account the dependent variable with the largest sample size (kinesiophobia) and 20% loss. The outcome measures were pain and kinesiophobia collected using the Visual Analog Scale and Tampa Kinesiophobia Scale.

FINDINGS

Married patients were at the greatest risk for kinesiophobia, higher than that for single patients (β = -3.765, β = -3.609; P < .05). Obese patients were at the greatest risk for kinesiophobia higher when compared to patients of normal weight (β = -2.907, P < .05). No statistically significant correlation was found between the pain intensity and kinesiophobia scores (P > 0.05).

CONCLUSIONS

Kinesiophobia was higher in patients after cardiac surgery. Married and obese patients were predictors of kinesiophobia; however, pain was not associated with kinesiophobia.

Path Analysis Between Family Functioning and Mental Health in People With Neuropathic Pain: Roles of Pain Intensity, Self-Perceived Burden, Pain Catastrophizing, and Functional Status

PURPOSE

This study aimed to explore the pathways between family functioning and mental health in people with neuropathic pain, as well as to discuss the mediating role of pain intensity, self-perceived burden, pain catastrophizing, and functional status.

DESIGN

Cross-sectional design reported using the STROBE guidelines.

METHODS

A total of 277 people with neuropathic pain completed face-to-face questionnaires to evaluate family functioning, pain intensity, pain catastrophizing, self-perceived burden, functional status, and mental health. Structural equation modeling (SEM) was constructed to analyze the pathways between these variables.

RESULTS

The positive total effect between family functioning and mental health was significant and partially mediated by self-perceived burden, pain catastrophizing, and functional status. In addition, better family functioning was associated with higher pain intensity, which worsens self-perceived burden, pain catastrophizing, and functional status, masking 23.68% of the positive effects between family functioning and mental health.

CONCLUSIONS

Better family functioning was associated with better mental health, as explained by reduced self-perceived burden, reduced pain catastrophizing, and improved functional status. However, this benefit may be partially masked by the relationship that better family functioning explains higher pain intensity.

CLINICAL IMPLICATIONS

Nurses' comprehensive assessment and management of neuropathic pain from both the family and individual levels, such as family functioning, pain intensity, self-perceived burden, pain catastrophizing, and functional status, may be beneficial in promoting patients' mental health. In addition, it is necessary to identify why good family functioning is associated with higher pain intensity and intervene in this regard.

The Mediating Role of Pain Cognitions and Pain Sensitivity in the Treatment Effect of Perioperative Pain Neuroscience Education in People Undergoing Surgery for Lumbar Radiculopathy

Though perioperative pain neuroscience education (PPNE) positively influences patients' surgical outcomes, little is known about the mechanisms behind this treatment's success. Therefore, this study aims to evaluate the potential mediating role of pain cognitions and pain sensitivity in the treatment effect of PPNE on postoperative quality of life in people undergoing surgery for lumbar radiculopathy. This secondary analysis uses data from 120 participants of a randomized controlled trial who were randomized to receive either PPNE or perioperative biomedical education before undergoing surgery for lumbar radiculopathy. Quality of life was assessed 1-year postsurgery using the short form 36-item health survey (SF36) physical and mental component scores. Potential mediators included pain cognitions (ie, kinesiophobia, pain catastrophizing, and hypervigilance) and pain sensitivity (ie, endogenous nociceptive modulation), assessed 6 weeks postsurgery. Mediation models were constructed using structural equation modeling, and 95% confidence intervals (CIs) were calculated using 10,000 bootstrap samples. Analyses show a significant total effect for PPNE (estimate = .464, 95% CI [.105, .825]) and a significant indirect effect via pain catastrophizing on the SF36 physical component (estimate = .124, 95% CI [.001, .293]). No mediating effect was found through the remaining pain cognitions or pain sensitivity measures. Also, no potential mediators were identified for the treatment effect of PPNE on the SF36 mental component. Our findings suggest that pain catastrophizing mediates the treatment effect of PPNE on physical health-related quality of life in people undergoing surgery for lumbar radiculopathy. PERSPECTIVE: This secondary analysis identified pain catastrophizing as a mediator for PPNE in people undergoing surgery for lumbar radiculopathy. More so, its findings indicate that this educational intervention can enhance the postoperative physical health-related quality of life of these patients by addressing their catastrophizing thoughts. TRIAL REGISTRATION: Clinicaltrials.gov (NCT02630732).

Pain From a Distance: Can Third-Person Self-Talk Mitigate Pain Sensitivity and Pain Related Distress During Experimentally Induced Pain?

Pain is self-immersive, leading to a narrow, egocentric focus on the self in the here and now. Preliminary evidence suggests that distancing oneself from the pain can reduce experimentally induced pain. The primary aim of this experimental study was to examine whether a hitherto unexplored, simple self-distancing strategy - "third-person self-talk" - has an analgesic effect on physiological and psychological pain variables. Participants (N = 292) were randomly assigned to one of four conditions (third-person self-talk, first-person self-talk, and two control conditions). Pain was induced with a cold pressor apparatus and pain tolerance, pain intensity, negative affect and blood pressure were measured for each group. While in pain, participants engaged in strategic self-talk aided by cue-cards. Data were analyzed with univariate planned comparisons. Few significant differences emerged for the third-person self-talk versus the other conditions. It is concluded that third-person self-talk does not seem to have a meaningful effect on physiological and psychological pain variables, although a small effect size could not be ruled out. Practical implications are discussed.The study was registered at ClinicalTrials.gov with the ClinicalTrials.gov ID NCT05511857.

Assessment of kinesiophobia levels in patients with musculoskeletal pathologies: A demographic, physical, and clinical perspective

INTRODUCTION

Kinesiophobia is a crucial factor influencing the rehabilitation process for individuals with musculoskeletal pathologies. Assessing kinesiophobia levels is crucial for personalized interventions.

AIM

The aim of this study is to investigate the level of kinesiophobia in individuals with musculoskeletal pathology based on the pathology areas, demographic, physical, and clinical characteristics.

METHODS

A total of 210 participants with musculoskeletal pathologies were included in the study. All participants were assessed using a sociodemographic information form for demographic and physical characteristics, the Tampa Kinesiophobia Scale for kinesiophobia level, and the McGill-Melzack Pain Questionnaire for pain location and intensity.

RESULTS

There was no statistically significant difference observed in kinesiophobia level between patients in terms of pathology location and sex. However, a significant difference in kinesiophobia levels was found among patients based on the acute and chronic duration of the disease (p = 0.00), previous treatment history (p = 0.04), and exercise engagement (p = 0.00). When kinesiophobia levels were examined according to educational status, a significant difference was found between the primary education group and the undergraduate and above group (p = 0.00).

CONCLUSIONS

According to the results of this study, kinesiophobia levels appear to be independent of pathology location and sex, but vary based on educational level, exercise habits, pain duration and history of previous treatment. Considering these findings, it is essential to take into account these factors in treatment programs in clinical practice and to provide support in exercise and physical activity training to individuals who have previously received treatment and individuals with low education levels.

Unraveling pain experience and catastrophizing after cognitive behavioral therapy

Pain experiences are often complex with catastrophic cognitions, emotions, and behaviors. Cognitive behavioral therapists share the work of unraveling these complex experiences with their patients. However, the change process underlying the unraveling of the pain experience have not yet been quantified. We used an interrelationship-focused network model to examine the way an undifferentiated conceptualization between cognition and pain experience changed via group cognitive-behavioral therapy (CBT). Overall, 65 participants (77.4% of all patients who entered the intervention) were included in the analysis; they attended the total of 12 weekly group CBT and filled the Short-Form McGill Pain Questionnaire and the pain catastrophizing questionnaire. Before treatment, there were no edges in the partial correlation-based network because of large covariation across items. After treatment, many edges appeared and, particularly strong couplings were found between items within the same subscale. The formative shift from a non-edged pre-treatment network to a mature post-treatment network may indicate that patients were able to conceptualize these symbolic constructs better. These results are probably of interest to clinicians and would be consistent with the fundamental monitoring process of CBT.

Marked differences between continuous long-term and clinical snapshot examinations: is the current standard of back pain diagnostics outdated?

Current clinical examination of low back pain (LBP) patients primarily relies on static clinical examinations, which rarely represent the dynamic postures patients adopt during daily activities. To gain an overview on the dynamic kinematics-kinetics changes over a day, the lumbar back kinematics of asymptomatic individuals and LBP patients were measured over 24 h, and the passively resisted bending and torsional moments were estimated. 208 asymptomatic subjects (115 females) and 116 LBP patients (71 females) were analysed. Compared to static upright standing, the mean lumbar lordosis of asymptomatic subjects drops significantly by 21° during everyday life (p < 0.01). Maximum bending moments of 44.0-50.6 Nm were estimated at the L2-L3. LBP patients showed significantly lower (p < 0.01) lumbar flattening during daily life of about 16°. Maximum bending moments of 27-52 Nm were found at the L3-L4. The initial static upright lumbar lordosis was significantly lower in LBP population (by 6°) resulting in almost similar average lumbar shapes during daily activities in both groups. The torsional movements were with 2.2° greatest in L1-L2 independent of sex (p = 0.19) and LBP (p = 0.54) with moments of 6-16 Nm. The lumbar profile and associated internal moments during daily life differ substantially from those recorded during clinical examinations. LBP patients demonstrates significantly lower lordosis at the snapshot assessment and significantly lower movement variations and internal moments during daily life. Only the dynamic long-term assessments unravelled a less flexed posture in LBP population. Apparently, such a reduced dynamic flexed posture indicates a compensatory habit for pain relief.

Avoidance and Endurance Responses to Pain Before and with Advanced Chronification: Preliminary Results from a Questionnaire Survey in Adult Patients with Non-Cancer Pain Conditions

Purpose

The Avoidance-Endurance Model postulates fear-avoidance responses and endurance responses as important psychological mechanisms in the development and maintenance of chronic pain. The present study aims to investigate potential differences in avoidance and endurance responses to pain before and with advanced chronification.

Patients and Methods

Two samples of adults with non-cancer pain at two different stages of chronicity were compared: One with pain and risk factors for chronicity (n=26, part of the PAIN2020 project) and one with chronic pain (n=33 from a pain day care clinic). The German Pain Questionnaire, the Graded Chronic Pain Scale (GCPS) and medical reports were used to measure duration and severity of pain. Responses to pain were assessed with the Avoidance-Endurance Questionnaire (AEQ) and psychological strain with the Depression, Anxiety and Stress Scales (DASS).

Results

Both groups were primarily affected by musculoskeletal pain. Although not yet chronified, the risk group reported comparable GCPS levels of pain intensity and disability. Depression and stress ratings were also similar, except for anxiety, which was significantly elevated in the chronic pain sample (p<.001). The AEQ scales did not differ between groups, neither on any of the fear-avoidance- nor endurance-related dimensions. A post-hoc regression analysis revealed a significant prediction of fear-avoidance by pain-related disability (p<.001). The regression model for endurance responses was not significant.

Conclusion

Patients with risk factors of chronification experience substantial pain-related burden. Responses to pain in the realm of the Avoidance-Endurance model do not appear to vary as a function of chronification. While fear-avoidance and pain-related disability correlate positively, endurance could not be associated to any of our variables.

Clinical relevance of combined treatment with exercise in patients with chronic low back pain: a randomized controlled trial

Low back pain is a widespread public health concern owing to its high prevalence rates according to the Global Burden of Diseases. This study aimed to investigate the effect of exercise alone or in combination with manual therapy and kinesiotherapy on pain sensitivity, disability, kinesiophobia, self-efficacy, and catastrophizing in patients with chronic low back pain (CLBP). A total of 55 participants were enrolled and randomly allocated to one of three groups: (1) exercise alone group (ET; n = 19), (2) exercise + manual therapy group (ETManual therapy; n = 18), and (3) exercise + kinesio tape group (ETkinesiotape; n = 18). The interventions consisted of core stabilization exercises (ET group), prior spinal manipulation with core exercises (ETManual therapy group), and combined application of kinesiotape plus core stabilization exercises (ETkinesiotape group). The primary outcome was disability. The secondary outcomes were pain sensitization, kinesiophobia, catastrophizing, and self-efficacy. Assessments were performed at baseline and at weeks 3, 6, and 12. All therapies applied achieved significant improvements over time after 12 weeks in all parameters analyzed. ETmanualtherapy showed the greatest changes in all variables, with significant differences from the rest of the interventions in Oswestry (ODI) (3 and 6 weeks, respectively). A clinically significant cutoff point was achieved for the ETmanualtherapy group in the ODI parameter (-54.71%, -63.16% and -87.70% at 3, 6, and 12 weeks, respectively). Manual therapy prior to the core exercise technique was the most effective approach to improve health-related functionality compared with exercise alone or exercise combined with kinesiotape in patients with CLBP.Clinical Trial Registration Number: NCT05544890.

How to Promote Walking in Women with Fibromyalgia: A Look at Catastrophizing, Goal Conflict, and Avoidance from a Self-Emotional Regulatory Perspective

The aim of this study was twofold: to explore the concordance between two measures of physical activity (accelerometer and IPAQ) among female fibromyalgia (FM) patients, as well as to examine the impact of psychosocial variables (catastrophism, activity avoidance) on walking among these patients. Helplessness, activity avoidance, and commitment to physical activity were evaluated in 132 FM women. After the first assessment, an accelerometer was placed by a psychologist on each participant for seven consecutive days. Eight days later, accelerometers were collected, and participants were evaluated again using the IPAQ. Two models were tested to analyze mediation and a moderated mediation effect. The mediating role of activity avoidance between helplessness and minutes walked was corroborated regarding the objective measure of walking. The effect of helplessness on minutes walked during a week was mediated by activity avoidance and assessed by accelerometers. Cognitive variables played a contextual role when trying to promote exercise. Activity avoidance must be understood as a key variable in physical activity promotion, specifically in the promotion of walking with the aim to do exercise in individuals with FM.

Psychophysiologic symptom relief therapy for chronic back pain: hypothesis and trial rationale

Chronic pain syndromes affect over one-third of the US adult population and often lead to significant disability and a reduced quality of life. Despite their high prevalence, causal links between chronic pain syndromes and anatomic abnormalities are often not apparent. Most current chronic pain treatments provide modest, if any, relief. Thus, there is a pressing need to understand the causal mechanisms implicated in chronic pain as a means to develop more targeted interventions for improvement in clinical outcomes and reduction in morbidity and financial burden. In the present manuscript, we summarize the current literature on treatment for chronic pain, and hypothesize that non-specific chronic back pain (without a clear organic etiology, such as tumors, infections or fractures) is of psychophysiologic origin. Based on this hypothesis, we developed Psychophysiologic Symptom Relief Therapy (PSRT), a novel pain reduction intervention for understanding and treating chronic pain. In this manuscript, we provide the rationale for PSRT, which we have tested in a pilot trial with a subsequent larger randomized trial underway. In the proposed trial, we will evaluate whether non-specific chronic back pain can be treated by addressing the underlying stressors and psychological underpinnings without specific physical interventions.

Systematic review and tools appraisal of prognostic factors of return to work in workers on sick leave due to musculoskeletal and common mental disorders

With the overall objective of providing implication for clinical and research practices regarding the identification and measurement of modifiable predicting factors for return to work (RTW) in people with musculoskeletal disorders (MSDs) and common mental disorders (CMDs), this study 1) systematically examined and synthetized the research evidence available in the literature on the topic, and 2) critically evaluated the tools used to measure each identified factor. A systematic search of prognostic studies was conducted, considering four groups of keywords: 1) population (i.e., MSDs or CMDs), 2) study design (prospective), 3) modifiable factors, 4) outcomes of interest (i.e., RTW). Studies showing high risk of bias were eliminated. Tools used to measure prognostic factors were assessed using psychometric and usability criteria. From the 78 studies that met inclusion criteria, 19 (for MSDs) and 5 (for CMDs) factors reaching moderate or strong evidence were extracted. These factors included work accommodations, RTW expectations, job demands (physical), job demands (psychological), job strain, work ability, RTW self-efficacy, expectations of recovery, locus of control, referred pain (back pain), activities as assessed with disability questionnaires, pain catastrophizing, coping strategies, fears, illness behaviours, mental vitality, a positive health change, sleep quality, and participation. Measurement tools ranged from single-item tools to multi-item standardized questionnaires or subscales. The former generally showed low psychometric properties but excellent usability, whereas the later showed good to excellent psychometric properties and variable usability. The rigorous approach to the selection of eligible studies allowed the identification of a relatively small set of prognostic factors, but with a higher level of certainty. For each factor, the present tool assessment allows an informed choice to balance psychometric and usability criteria.

Resting-state brain activity as a biomarker of chronic pain impairment and a mediator of its association with pain resilience

Past cross-sectional chronic pain studies have revealed aberrant resting-state brain activity in regions involved in pain processing and affect regulation. However, there is a paucity of longitudinal research examining links of resting-state activity and pain resilience with changes in chronic pain outcomes over time. In this prospective study, we assessed the status of baseline (T1) resting-state brain activity as a biomarker of later impairment from chronic pain and a mediator of the relation between pain resilience and impairment at follow-up. One hundred forty-two adults with chronic musculoskeletal pain completed a T1 assessment comprising a resting-state functional magnetic resonance imaging scan based on regional homogeneity (ReHo) and self-report measures of demographics, pain characteristics, psychological status, pain resilience, pain severity, and pain impairment. Subsequently, pain impairment was reassessed at a 6-month follow-up (T2). Hierarchical multiple regression and mediation analyses assessed relations of T1 ReHo and pain resilience scores with changes in pain impairment. Higher T1 ReHo values in the right caudate nucleus were associated with increased pain impairment at T2, after controlling for all other statistically significant self-report measures. ReHo also partially mediated associations of T1 pain resilience dimensions with T2 pain impairment. T1 right caudate nucleus ReHo emerged as a possible biomarker of later impairment from chronic musculoskeletal pain and a neural mechanism that may help to explain why pain resilience is related to lower levels of later chronic pain impairment. Findings provide empirical foundations for prospective extensions that assess the status of ReHo activity and self-reported pain resilience as markers for later impairment from chronic pain and targets for interventions to reduce impairment. PRACTITIONER POINTS: Resting-state markers of impairment: Higher baseline (T1) regional homogeneity (ReHo) values, localized in the right caudate nucleus, were associated with exacerbations in impairment from chronic musculoskeletal pain at a 6-month follow-up, independent of T1 demographics, pain experiences, and psychological factors. Mediating role of ReHo values: ReHo values in the right caudate nucleus also mediated the relationship between baseline pain resilience levels and later pain impairment among participants. Therapeutic implications: Findings provide empirical foundations for research extensions that evaluate (1) the use of resting-state activity in assessment to identify people at risk for later impairment from pain and (2) changes in resting-state activity as biomarkers for the efficacy of treatments designed to improve resilience and reduce impairment among those in need.

The persian version of the fear-avoidance beliefs questionnaire among iranian post-surgery patients: a translation and psychometrics

INTRODUCTION

Fear-avoidance beliefs (FAB) play a crucial role in the treatment outcomes of post-surgery patients. These beliefs can lead to activity avoidance, increased pain, and decreased quality of life. Therefore, accurately measuring these beliefs in Iranian patients is of significant importance. The Fear-Avoidance Belief Questionnaire (FABQ) is a patient-reported questionnaire that evaluates individuals' FAB. Since the validity and reliability of the Persian version of FABQ (FABQ-P) have not been assessed based on the Iranian population and sociocultural contexts, the current study has been implemented to determine the reliability and validity of the FABQ-P among Iranian post-operative patients by translation and psychometric properties.

METHODS

This methodological study conducted in 2023, a sample of 400 patients who had undergone surgery were selected using a convenience sampling method. The scale used in the study was translated and its psychometric properties were evaluated through network analysis and assessments of construct validity (including exploratory and confirmatory factor analysis), convergent validity, and discriminant validity. Additionally, the study assessed the internal consistency of the scale.

RESULTS

The MLEFA results with Promax and Kaiser Normalization rotation yielded two factors explaining 57.91% of the variance, encompassing 13 items. Also, the model was approved by CFA. Convergent and discriminant validity have been confirmed through the following criteria: Average Variance Extracted (AVE) exceeding 0.5, Composite Reliability (CR) surpassing 0.7, and Heterotrait-Monotrait Ratio of Correlations (HTMT) equating to 0.597. As for reliability, Cronbach's alpha, composite reliability (CR), and MaxR for all constructs were greater than 0.7, demonstrating good internal consistency.

CONCLUSION

As demonstrated by the results, the FABQ-P has a satisfactory level of reliability along with authentic validity according to the sociocultural contexts of Iranian post-operative patients.

Beyond the chronic pain stage: default mode network perturbation depends on years lived with back pain

ABSTRACT

Research has indicated that the default mode network (DMN) is perturbated in patients with chronic pain when compared with healthy controls, and this perturbation is correlated with the duration of pain during the chronic pain stage. It remains unclear whether DMN adaptations manifest during the subacute pain stage and progress over time because of the duration of pain experience, rather than being a specific correlate of the chronic pain stage. Furthermore, information regarding whether these adaptations are related to cognitive processes of adaptation is lacking. To this end, we examined the DMN in 31 patients with chronic back pain (CBP), 77 patients with subacute back pain (SBP), as well as 39 healthy pain-free controls (HC) applying a graph-theoretic network approach on functional resting-state magnetic resonance imaging. Beyond the comparison between groups, we used a linear analysis considering the years lived with pain (YLP) across all patients with back pain and additionally performed a mediation analysis of the role of cognitive pain coping. In line with previous studies, we found significant DMN perturbation in CBP compared with HC. However, this did not apply to the comparison of CBP with SBP. Instead, we observed a positive correlation between DMN perturbation and YLP. This was significantly mediated by coping attitudes towards pain. Default mode network perturbation may thus reflect neural adaptation processes to pain experience rather than a single correlate of the chronic pain stage and be modulated by cognitive adaption. This points to potentially underinvestigated significant adaptation processes that could enable more fine-grained patient stratification.

The Relationship Between Pain and Interoception: A Systematic Review and Meta-Analysis

Interoception refers to the ability to sense internal bodily sensations. Research suggests that dysfunctions in interoception may be implicated in the transition to chronic pain, however, little work has examined interoceptive ability in pain states. Therefore, this systematic review aimed to assess whether interoception is altered in individuals experiencing pain. Following a systematic search of 4 electronic databases from inception to February 2023, 28 studies were included. Outcomes of interoceptive accuracy, interoceptive sensibility, and interoceptive awareness were meta-analysed. The risk of bias was assessed, and the certainty of the evidence was evaluated. Meta-analyses indicated that those with chronic pain display reduced interoceptive accuracy and increased interoceptive sensibility. Subgroup analyses indicated that the change in interoceptive sensibility is dependent on the measure used, with those with chronic pain scoring higher on measures focusing on attention to bodily sensations, while also scoring lower on emotional reactivity. No difference in interoceptive awareness was observed between individuals with chronic pain and pain-free controls. Only one study was found that measured interoception in those experiencing acute pain, while another study recruited those experiencing recurrent pain. These findings suggest that while those with chronic pain self-report as more interoceptively aware, they are less accurate at detecting internal bodily signals. Further research investigating domains of interoception in those experiencing acute and recurrent pain is needed. Data should be interpreted with caution as the certainty of evidence was very low for all completed analyses. This review was registered on the PROSPERO International Prospective Register of Systematic Reviews (Registration ID = CRD42022318843). PERSPECTIVE: This review considered the relationship between interoception and pain and found that an individual's ability to accurately sense internal signals is decreased in those with chronic pain, despite them reporting being more aware of internal sensations. However, there remains little research examining interoception in non-chronic pain states.

Shared and distinct effect mediators in exposure-based and traditional cognitive behavior therapy for fibromyalgia: Secondary analysis of a randomized controlled trial

Fibromyalgia is a chronic pain condition associated with substantial suffering and societal costs. Traditional cognitive behavior therapy (T-CBT) is the most evaluated psychological treatment, but exposure therapy (Exp-CBT) has shown promise with a pronounced focus on the reduction of pain-related avoidance behaviors. In a recent randomized controlled trial (N = 274), we found that Exp-CBT was not superior to T-CBT (d = -0.10) in reducing overall fibromyalgia severity. This study investigated pain-related avoidance behaviors, pain catastrophizing, hypervigilance, pacing, overdoing and physical activity as potential mediators of the treatment effect. Mediation analyses were based on parallel process growth models fitted on 11 weekly measurement points, and week-by-week time-lagged effects were tested using random intercepts cross-lagged panel models. Results indicated that a reduction in avoidance behaviors, pain catastrophizing, and hypervigilance were significant mediators of change in both treatments. An increase in pacing and a reduction in overdoing were significant mediators in T-CBT only. Physical activity was not a mediator. In the time-lagged analyses, an unequivocal effect on subsequent fibromyalgia severity was seen of avoidance and catastrophizing in Exp-CBT, and of overdoing in T-CBT. Exposure-based and traditional CBT for fibromyalgia appear to share common treatment mediators, namely pain-related avoidance behavior, catastrophizing and hypervigilance.

The autobiographical memory system and chronic pain: A neurocognitive framework for the initiation and maintenance of chronic pain

Chronic pain affects approximately 20% of the world's population, exerting a substantial burden on the affected individual, their families, and healthcare systems globally. Deficits in autobiographical memory have been identified among individuals living with chronic pain, and even found to pose a risk for the transition to chronicity. Recent neuroimaging studies have simultaneously implicated common brain regions central to autobiographical memory processing in the maintenance of and susceptibility to chronic pain. The present review proposes a novel neurocognitive framework for chronic pain explained by mechanisms underlying the autobiographical memory system. Here, we 1) summarize the current literature on autobiographical memory in pain, 2) discuss the role of the hippocampus and cortical brain regions including the ventromedial prefrontal cortex, anterior temporal lobe, and amygdala in relation to autobiographical memory, memory schemas, emotional processing, and pain, 3) synthesize these findings in a neurocognitive framework that explains these relationships and their implications for patients' pain outcomes, and 4) propose translational directions for the prevention, management, and treatment of chronic pain.

The impact of perceived injustice on pain and psychological outcomes after traumatic injury: a longitudinal analysis

ABSTRACT

Individuals' appraisals regarding the injustice of their pain or physical injury have emerged as a significant risk factor for worse physical and psychological outcomes. Injustice appraisals are defined by perceptions of external blame for pain or injury and viewing pain or injury as a source of irreparable loss. To date, research on the impact of injustice appraisal has been primarily cross sectional, and existing longitudinal studies have examined injustice appraisals at only 2 time points in the context of rehabilitation treatment. This study examined the trajectory of injustice appraisals in 171 patients admitted for traumatic injury at admission, as well as 3, 6, and 12 months after discharge and examined injustice appraisals as a potential moderator of recovery after injury. Findings can be summarized as follows: First, injustice perception was largely stable in the 12 months after hospital discharge. Second, elevated injustice perception was associated with decreased recovery in pain intensity and depressive symptomatology over the study period but did not moderate changes in pain catastrophizing or posttraumatic stress symptomatology over time. This study is the first naturalistic prospective analysis of injustice appraisal following trauma admission within the American healthcare system. Findings indicate that injustice appraisals do not naturally decrease in the aftermath of traumatic injury and may be a risk factor for poorer physical and psychological recovery. Future research should examine additional sociodemographic and psychosocial factors that may contribute to elevated injustice appraisal, as well as ways of addressing the potential deleterious impact of injustice appraisals in treatment settings.