Psychosocial factors appear to predict postoperative pain: Interesting, but how can such information be used to reduce risk?

The role of catastrophizing and basic psychological needs satisfaction on health-related quality of life and pain in patients with lumbar disc herniation

Introduction

Lumbar disc herniation (LDH) is one of the most common conditions associated with functional disability, affecting patients' quality of life (QOL). Disability can be affected by cognitive factors, such as pain catastrophizing. Similarly, unfulfilled basic psychological needs (i.e., autonomy, competence, relatedness) are associated with biases in pain perception and QOL. Using the fear-avoidance model and the self-determination theory, this study investigates: (1) the separate contribution of pain-related variables and basic psychological needs satisfaction in predicting QOL in patients proposed for LDH surgery; (2) pre- and post-surgical differences in pain catastrophizing and basic psychological needs satisfaction.

Methods

First, we used hierarchical regression on 193 patients (M_age = 46.10, SD_age = 11.40) to identify predictors of QOL. Second, we performed paired t-tests on 55 patients to investigate pre- and post-surgical differences in pain catastrophizing and basic psychological needs satisfaction.

Results

Hierarchical regression showed that the model predicts 27% of the variance in QOL; medium pain level, age, pain catastrophizing, and basic psychological needs satisfaction were significant predictors. Also, pain catastrophizing significantly decreased after surgery [t (54) = 6.07, p < 0.001, Cohen's d = 0.81], but basic psychological needs satisfaction did not modify significantly.

Discussion

This research confirms the importance of pain perception and pain catastrophizing for LDH patients' QOL and broadens the applicability of the self-determination theory for spinal patients.

Can perioperative psychological interventions reduce chronic pain after surgery?

Chronic post-surgical pain is a relatively common adverse effect following surgery. Several prognostic factors for chronic post-surgical pain have been identified, including psychological states and traits. Psychological factors are modifiable, and perioperative psychological interventions may reduce the incidence of chronic post-surgical pain. A meta-analysis showed preliminary evidence for the benefits of such interventions for the prevention of chronic post-surgical pain. Further research must be conducted to better understand the specific type, intensity, duration and timing of interventions that are most effective. The number of studies in this area has recently increased, with additional randomised controlled trials currently being carried out, which may allow for the development of more robust conclusions in the coming years. In order to implement perioperative psychological care alongside routine surgical interventions, efficient and accessible interventions should be available. In addition, demonstration of cost-effectiveness may be a prerequisite for wider adoption of perioperative psychological interventions in regular healthcare. Offering psychological interventions selectively to patients at risk of chronic post-surgical pain could be a means to increase cost-effectiveness. Stepped-care approaches should also be considered, where the intensity of psychological support is adapted to the needs of the patient.

AMAZONE: prevention of persistent pain after breast cancer treatment by online cognitive behavioral therapy-study protocol of a randomized controlled multicenter trial

Background

Surviving breast cancer does not necessarily mean complete recovery to a premorbid state of health. Among the multiple psychological and somatic symptoms that reduce the quality of life of breast cancer survivors, persistent pain after breast cancer treatment (PPBCT) with a prevalence of 15–65% is probably the most invalidating. Once chronic, PPBCT is difficult to treat and requires an individualized multidisciplinary approach. In the past decades, several somatic and psychological risk factors for PPBCT have been identified. Studies aiming to prevent PPBCT by reducing perioperative pain intensity have not yet shown a significant reduction of PPBCT prevalence. Only few studies have been performed to modify psychological distress around breast cancer surgery. The AMAZONE study aims to investigate the effect of online cognitive behavioral therapy (e-CBT) on the prevalence of PPBCT.

Methods

The AMAZONE study is a multicenter randomized controlled trial, with an additional control arm. Patients (n=138) scheduled for unilateral breast cancer surgery scoring high for surgical or cancer-related fears, general anxiety or pain catastrophizing are randomized to receive either five sessions of e-CBT or online education consisting of information about surgery and a healthy lifestyle (EDU). The first session is scheduled before surgery. In addition to the online sessions, patients have three online appointments with a psychotherapist. Patients with low anxiety or catastrophizing scores (n=322) receive treatment as usual (TAU, additional control arm).

Primary endpoint is PPBCT prevalence 6 months after surgery.

Secondary endpoints are PPBCT intensity, the intensity of acute postoperative pain during the first week after surgery, cessation of postoperative opioid use, PPBCT prevalence at 12 months, pain interference, the sensitivity of the nociceptive and non-nociceptive somatosensory system as measured by quantitative sensory testing (QST), the efficiency of endogenous pain modulation assessed by conditioned pain modulation (CPM) and quality of life, anxiety, depression, catastrophizing, and fear of recurrence until 12 months post-surgery.

Discussion

With perioperative e-CBT targeting preoperative anxiety and pain catastrophizing, we expect to reduce the prevalence and intensity of PPBCT. By means of QST and CPM, we aim to unravel underlying pathophysiological mechanisms. The online application facilitates accessibility and feasibility in a for breast cancer patients emotionally and physically burdened time period.

Trial registration

NTR NL9132, registered December 16 2020.

Emotional Changes and Functional Progressions during Post-Operative Rehabilitation in Collegiate Student-Athletes: A Preliminary Study

An interrelationship between psychological and physical health is generally accepted in the field of sports medicine. This preliminary study explored the association between emotional changes and functional outcomes and aimed to describe how each aspect progresses during postoperative rehabilitation. Four collegiate student-athletes (1 female and 3 males) who underwent supervised postoperative rehabilitation due to a lower-extremity injury volunteered for participation in the study. Emotion was quantified using a visual analogue scale prior to and after each session while self-reported function using the Lower-extremity Functional Scale was assessed every eight sessions throughout rehabilitation. There was a moderate correlation between emotional changes and functional outcomes (r = 0.58, p < 0.0001). After the first emotional improvement, patients experienced six emotional deteriorations (28% of the entire rehabilitation period; F49,297 = 2.25, p < 0.0001), while their function consistently increased (F49,147 = 17.39, p < 0.0001). Clinicians should be aware of the relationship between emotional changes and functional progression as well as the occurrence of emotional fluctuations when supervising and consulting patients during postoperative rehabilitation. A larger study is warranted to generalize the results.

A randomized controlled TRIal of cognitive BEhavioral therapy for high Catastrophizing in patients undergoing lumbar fusion surgery: the TRIBECA study

Background

Around 20% of patients undergoing spinal fusion surgery have persistent back or leg pain despite surgery. Pain catastrophizing is the strongest psychological predictor for chronic postsurgical pain. Psychological variables are modifiable and could be target for intervention. However, randomized controlled trials evaluating the effectiveness of psychological interventions to reduce chronic pain and disability after spinal fusion in a population of patients with high preoperative pain catastrophizing scores are missing. The aim of our study is to examine whether an intervention targeting pain catastrophizing mitigates the risk of chronic postsurgical pain and disability. Our primary hypothesis is that targeted perioperative cognitive behavioral therapy decreases the risk of chronic postsurgical pain and disability after spinal fusion surgery in high catastrophizing patients.

Methods

We will perform a two-center prospective, single-blind, randomized, controlled study comparing lumbar spinal fusion surgery outcome between 2 cohorts. Adult patients selected for lumbar spinal fusion with decompression surgery and a minimum score of 24 on the pain catastrophizing scale will be randomized with 1:1 allocation for either perioperative cognitive behavioral therapy (intervention group) or a perioperative education plus progressive exercise program (control group). Patients randomized to the intervention group will receive six individual sessions of cognitive behavioral therapy, two sessions before the operation and four after. Primary outcome is the Core Outcome Measures Index at 12 months. Secondary outcomes include pain, disability, depression and quality of life.

Discussion

This is the first trial that evaluates the effectiveness of cognitive behavioral therapy as a perioperative tool to improve pain and disability after spinal fusion surgery in comparison with an educational/exercise control intervention, in patients with high levels of pain catastrophizing. If perioperative cognitive behavioral therapy proves to be effective, this might have important clinical implications, reducing the incidence of chronic postsurgical pain and improving outcome after spinal fusion surgery.

Trial registration

Clinicaltrials (NCT03969602). Registered 31 May 2019,

Psychological factors predict an unfavorable pain trajectory after hysterectomy: a prospective cohort study on chronic postsurgical pain

Chronic postsurgical pain (CPSP) is a well-recognized potential complication with negative personal, social, and health care consequences. However, limited data exist on CPSP and on the course of pain over time after hysterectomy. Using data from a prospective cohort study on a consecutive sample assessed at 4 time points, presurgery (T1), 48 hours (T2), 4 months (T3), and 5 years postsurgery (T4), we sought to examine women's PSP trajectories using assessments of pain at T3 and T4. In addition, this study aimed to investigate presurgical and postsurgical risk factors associated with an unfavourable pain trajectory (PT). Based on pain data collected at T3 and T4, 3 distinct trajectories of PSP emerged: no CPSP (PT1; n = 88), prolonged PSP (PT2; n = 53), and CPSP (PT3; n = 29). Moreover, reported CPSP prevalence at 5 years was 17.1%. Multinomial logistic regression models controlling for age, presurgical pain, and type of hysterectomy tested for baseline and acute postsurgical predictive variables. Membership in PT2 and PT3 was predicted by presurgical anxiety (odds ratio [OR] = 1.131, P = 0.015; OR = 1.175, P = 0.009, respectively), emotional representation of the surgical disease (OR = 1.155, P = 0.034; OR = 1.213, P = 0.020, respectively), and pain catastrophizing (OR = 1.079, P = 0.043; OR = 1.143, P = 0.001, respectively). Furthermore, acute PSP intensity and frequency determined membership of women in PT3 (OR = 1.211, P = 0.033; OR = 3.000, P = 0.029, respectively), and postsurgical anxiety (OR = 1.182, P = 0.026) also played a key predictive role. This study identified factors that can be easily screened before and after surgery and are amenable to change through carefully designed timely and tailored interventions for women at risk of an unfavorable PSP trajectory posthysterectomy.

PRERECORDED HYPNOTIC PERI-SURGICAL INTERVENTION TO ALLEVIATE RISK OF CHRONIC POSTSURGICAL PAIN IN TOTAL KNEE REPLACEMENT: A RANDOMIZED CONTROLLED PILOT STUDY

This pilot study evaluated the effect sizes associated with prerecorded hypnotic interventions provided during the perisurgical period for reducing risk factors associated with chronic postsurgical pain, including acute postsurgical pain, anxiety, depression, and pain catastrophizing. A total of 25 participants (N = -25) were randomly assigned to receive a hypnotic intervention (n = 8), minimal-effect treatment (n = 8), or treatment as usual (n = 9) during their hospital stay for total knee replacement (TKR). Participants were followed for 6 months after hospital discharge. Results indicate that prerecorded hypnotic intervention exerted medium effects for reducing acute postsurgical pain and large effects for reducing perisurgical anxiety and pain catastrophizing. The findings indicate that a fully powered clinical trial to evaluate the beneficial effects of prerecorded hypnosis to manage pain and psychological distress in patients undergoing TKR is warranted.

Psychophysical and psychological predictors of acute pain after breast surgery differ in patients with and without pre-existing chronic pain

The prediction of acute postoperative pain would be of great clinical advantage, but results of studies investigating possible predictors are inconsistent. Here, we studied the role of a wide variety of previously suggested predictors in 74 patients undergoing breast surgery. Preoperatively, patients filled out the Pain Sensitivity Questionnaire (PSQ) and a set of psychological questionnaires (the Beck Depression Inventory [BDI], State-Trait Anxiety Inventory [STAI], and Pain Catastrophizing Scale [PCS]) and participated in an experimental pain testing session, including assessment of conditioned pain modulation (CPM), temporal summation, and responses to heat, pinprick, and pressure pain. Postoperatively, patients reported pain intensity. Stepwise linear regression analysis was used to test for prediction of maximal pain on postoperative day 1 in the whole cohort and in the subgroups of patients with and without pre-existing chronic pain. In the total group, linear regression identified only the expectation of postoperative pain intensity as significant predictor (F[1,65] = 6.5, P < 0.05), explaining 9% of the variance. In patients without pre-existing chronic pain, a smaller CPM effect predicted more postoperative pain, explaining 17% of the variance (F[1,48] = 9.9, P < 0.01). In patients with pre-existing chronic pain, higher PSQ and PCS scores predicted more postoperative pain, together explaining 54% of the variance (F[2,19] = 11.1, P < 0.001). In conclusion, prediction of acute postoperative pain in the whole group was limited. This might be due to differing predictors in specific subgroups of patients. Although CPM predicted pain in patients without pre-existing chronic pain, PSQ and PCS predicted pain in patients with pre-existing chronic pain.

Interdisciplinary Cognitive-Behavioral Therapy as Part of Lumbar Spinal Fusion Surgery Rehabilitation: Experience of Patients With Chronic Low Back Pain

Supplemental Digital Content is Available in the Text.

BACKGROUND:

Patients receiving lumbar spinal fusion surgery often have persisting postoperative pain negatively affecting their daily life. These patients may be helped by interdisciplinary cognitive-behavioral therapy which is recognized as an effective intervention for improving beneficial pain coping behavior, thereby facilitating the rehabilitation process of patients with chronic pain.

PURPOSE:

The purpose of this study was to describe the lived experience of patients recovering from lumbar spinal fusion surgery and to explore potential similarities and disparities in pain coping behavior between receivers and nonreceivers of interdisciplinary cognitive-behavioral group therapy.

METHODS:

We conducted semistructured interviews with 10 patients; 5 receiving cognitive-behavioral therapy in connection with their lumbar spinal fusion surgery and 5 receiving usual care. We conducted a phenomenological analysis to reach our first aim and then conducted a comparative content analysis to reach our second aim.

RESULTS:

Patients' postoperative experience was characterized by the need to adapt to the limitations imposed by back discomfort (coexisting with the back), need for recognition and support from others regarding their pain, a relatively long rehabilitation period during which they “awaited the result of surgery”, and ambivalence toward analgesics. The patients in both groups had similar negative perception of analgesics and tended to abstain from them to avoid addiction. Coping behavior apparently differed among receivers and nonreceivers of interdisciplinary cognitive-behavioral group therapy. Receivers prevented or minimized pain by resting before pain onset, whereas nonreceivers awaited pain onset before resting.

CONCLUSION:

The postoperative experience entailed ambivalence, causing uncertainty, worry and insecurity. This ambivalence was relieved when others recognized the patient's pain and offered support. Cognitive-behavioral therapy as part of rehabilitation may have encouraged beneficial pain coping behavior by altering patients' pain perception and coping behavior, thereby reducing adverse effects of pain.

Herbal medications for surgical patients: a systematic review protocol

INTRODUCTION

Postoperative nausea and vomiting (PONV) affect approximately 80% of surgical patients and is associated with increased length of hospital stay and systemic costs. Preoperative and postoperative pain, anxiety and depression are also commonly reported. Recent evidence regarding their safety and effectiveness has not been synthesised. The aim of this systematic review is to evaluate the efficacy and safety of herbal medications for the treatment and prevention of anxiety, depression, pain and PONV in patients undergoing laparoscopic, obstetrical/gynaecological and cardiovascular surgical procedures.

METHODS AND ANALYSIS

The following electronic databases will be searched up to 1 October 2016 without language or publication status restrictions: CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science and LILACS. Randomised clinical trials enrolling adult surgical patients undergoing laparoscopic, obstetrical/gynaecological and cardiovascular surgeries and managed with herbal medication versus a control group (placebo, no intervention or active control) prophylactically or therapeutically will be considered eligible. Outcomes of interest will include the following: anxiety, depression, pain, nausea and vomiting. A team of reviewers will complete title and abstract screening and full-text screening for identified hits independently and in duplicate. Data extraction, risk of bias assessments and evaluation of the overall quality of evidence for each relevant outcome reported will be conducted independently and in duplicate using the Grading of Recommendations Assessment Development and Evaluation classification system. Dichotomous data will be summarised as risk ratios; continuous data will be summarised as standard average differences with 95% CIs.

ETHICS AND DISSEMINATION

This is one of the first efforts to systematically summarise existing evidence evaluating the use of herbal medications in laparoscopic, obstetrical/gynaecological and cardiovascular surgical patients. The findings of this review will be disseminated through peer-reviewed publications and conference presentations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016042838.

Predictors of Acute Postsurgical Pain After Inguinal Hernioplasty

Acute postsurgical pain (APSP) is a common and anticipated problem after surgery with detrimental consequences if not appropriately managed. This study examined the independent and joint contribution of presurgical demographic, clinical, and psychological variables as predictors of APSP intensity, evaluated using an 11-point numeric rating scale, after inguinal hernioplasty, one of the most performed surgeries worldwide. In a prospective observational cohort study, a consecutive sample of 135 men undergoing hernioplasty was assessed before and 48 hours after surgery. When adjusted for depression, helplessness, and magnification scores, a multiple hierarchical regression analysis revealed that younger age (β = -.247, P < .005), previous chronic pain (β = .175, P < .05), presurgical anxiety (β = .235, P < .05), and the rumination component of pain catastrophizing (β = .222, P < .05) were significant predictors of APSP intensity. The integrative predictive model found in this study revealed the simultaneous influence that demographic, clinical, and psychological factors have on APSP after inguinal hernioplasty. Therefore, these results improve knowledge on APSP predictors after inguinal hernioplasty and highlight potential modifiable intervention targets, such as anxiety and pain catastrophizing (rumination), for the design of interventions focused on APSP prevention and management. Hence, taken together, these findings lend support for the inclusion of presurgical screening and psychological interventions among surgical patients at risk for higher APSP intensity.

PERSPECTIVE

This study found that, when adjusted for depression, helplessness, and magnification scores, the variables younger age, previous chronic pain, presurgical anxiety, and the rumination component of pain catastrophizing are significant predictors of APSP intensity after inguinal hernioplasty. These findings improve knowledge on APSP and highlight potential modifiable intervention targets for the design of interventions focused on APSP prevention and management.

Influence of depression, catastrophizing, anxiety, and resilience on postoperative pain at the first day after otolaryngological surgery: A prospective single center cohort observational study

The aim was to assess the association between objectified preoperative psychological factors and postoperative pain at the first day after otolaryngological surgery in accordance with other predictors of postoperative pain. Eighty-two (82) patients (59% male, median age 56 years) were included between January and May 2015. The psychological assessment the day before surgery included the Patient Health Questionnaire (PHQ-9), pain catastrophizing scale (PCS), State-Trait Operation Anxiety (STOA) inventory, and the resilience scale (RS-13). On first postoperative day, patients were rated their pain using the questionnaires of the German-wide project Quality Improvement in Postoperative Pain Treatment (QUIPS) including a numeric rating scale (NRS, 0-10) for determination of patient's maximal pain. QUIPS allowed standardized assessment of patients' characteristics, pain parameters, and outcome. The influence of preoperative and postoperative parameters on patients' maximal postoperative pain was estimated by univariate and multivariate statistical analysis. The mean maximal pain was 3.2 ± 2.9. In univariate analysis, higher PHQ-9 score more than 4 (P = 0.010), higher STOA trait anxiety (P = 0.044), and higher STOA total score (P = 0.043) were associated to more postoperative pain. In multivariate analysis higher PHQ-9 score remained an independent predictor for severe pain (beta = 0.302; 95% confidence interval [CI]: 0.054-0.473; P = 0.014). When all parameters were included into multivariate analysis, 2 of all somatic, psychological, and treatment factors were associated with severe maximal pain: more depression (PHQ-9; beta = 0.256; 95% CI: 0.042-0.404; P = 0.017), and use of opioids in the recovery room (beta = 0.371; 95% CI: 0.108-0.481; P = 0.002). Otolaryngological surgery covers the spectrum from low to severe postoperative pain and is therefore a good model for pain management studies. A set of somatic and psychological parameters seems to allow the identification of patients with higher risk for more postoperative pain. This should help to individualize and improve the perioperative pain management.

Recovery 3 and 12 months after hysterectomy: epidemiology and predictors of chronic pain, physical functioning, and global surgical recovery

Chronic postsurgical pain (CPSP) is 1 important aspect of surgical recovery. To improve perioperative care and postoperative recovery knowledge on predictors of impaired recovery is essential. The aim of this study is to assess predictors and epidemiological data of CPSP, physical functioning (SF-36PF, 0-100), and global surgical recovery (global surgical recovery index, 0-100%) 3 and 12 months after hysterectomy for benign indication.A prospective multicenter cohort study was performed. Sociodemographic, somatic, and psychosocial data were assessed in the week before surgery, postoperatively up to day 4, and at 3- and 12-month follow-up. Generalized linear model (CPSP) and linear-mixed model analyses (SF-36PF and global surgical recovery index) were used. Baseline data of 468 patients were collected, 412 (88%) patients provided data for 3-month evaluation and 376 (80%) patients for 12-month evaluation.After 3 and 12 months, prevalence of CPSP (numeric rating scale ≥ 4, scale 0-10) was 10.2% and 9.0%, respectively, SF-36PF means (SD) were 83.5 (20.0) and 85.9 (20.2), global surgical recovery index 88.1% (15.6) and 93.3% (13.4). Neuropathic pain was reported by 20 (5.0%) patients at 3 months and 14 (3.9%) patients at 12 months. Preoperative pain, surgery-related worries, acute postsurgical pain on day 4, and surgery-related infection were significant predictors of CPSP. Baseline level, participating center, general psychological robustness, indication, acute postsurgical pain, and surgery-related infection were significant predictors of SF-36PF. Predictors of global surgical recovery were baseline expectations, surgery-related worries, American Society of Anesthesiologists classification, type of anesthesia, acute postsurgical pain, and surgery-related infection.Several predictors were identified for CPSP, physical functioning, and global surgical recovery. Some of the identified factors are modifiable and optimization of patients' preoperative pain status and psychological condition as well as reduction of acute postsurgical pain and surgery-related infection may lead to improvement of outcome.

Differential predictors of acute post-surgical pain intensity after abdominal hysterectomy and major joint arthroplasty

BACKGROUND

Psychological factors have a significant role in post-surgical pain, and their study can inform pain management.

PURPOSE

The aims of this study are to identify psychological predictors of post-surgical pain following abdominal hysterectomy (AH) and major joint arthroplasty (MJA) and to investigate differential predictors by type of surgery.

METHOD

One hundred forty-two women undergoing AH and 110 patients undergoing MJA were assessed 24 h before (T1) and 48 h after (T2) surgery.

RESULTS

A predictive post-surgical pain model was found for AH and MJA yielding pre-surgical pain experience and pain catastrophizing as significant predictors and a significant interaction of pre-surgical optimism and surgery type. Separate regression models by surgery type showed that pre-surgical optimism was the best predictor of post-surgical pain after MJA, but not after AH.

CONCLUSIONS

Findings highlight the relevance of psychological predictors for both surgeries and the value of targeting specific psychological factors by surgery type in order to effectively manage acute post-surgical pain.

Pain Sensitivity and Pain Catastrophizing Are Associated With Persistent Pain and Disability After Lumbar Spine Surgery

OBJECTIVE

To examine whether pain sensitivity and pain catastrophizing are associated with persistent pain and disability after lumbar spine surgery.

DESIGN

Prospective observational cohort study.

SETTING

Academic medical center.

PARTICIPANTS

Patients (N=68; mean age, 57.9±13.1y; 40 women [58.8%]) undergoing spine surgery for a degenerative condition from March 1, 2012 to April 30, 2013 were assessed 6 weeks, 3 months, and 6 months after surgery.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The main outcome measures were persistent back pain intensity, pain interference, and disability. Patients with persistent back pain intensity, pain interference, or disability were identified as those patients reporting Brief Pain Inventory scores ≥4 and Oswestry Disability Index scores ≥21 at all postoperative time points.

RESULTS

From 6 weeks to 6 months after surgery, approximately 12.9%, 24.2%, and 46.8% of patients reported persistent back pain intensity, pain interference, or disability, respectively. Increased pain sensitivity at 6 weeks was associated with having persistent back pain intensity (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.0-4.1) after surgery. Increased pain catastrophizing at 6 weeks was associated with having persistent back pain intensity (OR, 1.1; 95% CI, 1.0-1.2), pain interference (OR, 1.1; 95% CI, 1.0-1.2), and disability (OR, 1.3; 95% CI, 1.1-1.4). An interaction effect was not found between pain sensitivity and pain catastrophizing on persistent outcomes (P>.05).

CONCLUSIONS

The findings suggest the importance of early postoperative screening for pain sensitivity and pain catastrophizing to identify patients at risk for poor postoperative pain intensity, pain interference, and/or disability outcomes. Future research should consider the benefit of targeted therapeutic strategies for patients with these postoperative prognostic factors.