Widespread pain is a risk factor for cardiovascular mortality: results from the Framingham Heart Study

A historical perspective and recent advances on the evolution of the relationship between acute and chronic pain and cardiovascular disease

The relationship between acute pain and the cardiovascular system was recognized approximately 50 years ago following the initial observation, along with several subsequent experimental studies, that hypertension can result in decreases in the perception of pain. These studies provided a strong impetus to study potential mechanisms to clarify commonalities between the regulatory pathways associated with pain and the cardiovascular system. Attention subsequently shifted to an emphasis on the impact of chronic pain on cardiovascular diseases and mortality with several large meta-analyses of longitudinal studies providing clear evidence that chronic widespread pain increases the risk for developing cardiovascular disease and is associated with excess morbidity and mortality. Cardiovascular associated mortality from myocardial infarction and stroke appears to be directly related to the duration and severity of chronic pain, a result often characterized as a 'dose-response' relationship. The availability and reproducibility of extensive large-scale observational and retrospective studies have emphasized the critical need for more research, including prospective studies, along with the need for the development of preclinical animal models, to better understand the relationship(s) and underlying mechanisms between chronic pain, associated comorbidities, and cardiovascular disease. Elucidation and a deeper understanding of these relationships, including a focus on the link between chronic pain, cardiovascular disease, and depression, could provide valuable information to guide the development of potential treatment interventions to aid in attenuating pain while preventing pain-associated cardiovascular disease, comorbidities, and mortality.

Group eye movement desensitization and reprocessing (EMDR) in chronic pain patients

The prevalence of chronic pain is increasing, and conventional pain therapies often have limited efficacy in individuals with high levels of psychological distress and a history of trauma. In this context, the use of Eye Movement Desensitization and Reprocessing (EMDR), an evidence-based psychotherapy approach for the treatment of posttraumatic stress disorder, is becoming increasingly important. EMDR shows promising results, particularly for patients with pain and high levels of emotional distress. Although group therapy is becoming increasingly popular in pain management, EMDR has mainly been studied as an individual treatment. However, a systematic review suggests that group therapy can be an effective tool for improving mental health outcomes, especially when trauma is addressed together. Based on these findings, an outpatient EMDR group program was developed for patients with chronic pain. The program consists of a total of four treatment days with 5-5.5 h therapy sessions each day and provides patients with a supportive environment in which they can learn effective pain management strategies and interact with other patients with similar experiences. Initial pilot evaluations indicate high efficacy and adequate safety for patients with chronic pain.

Prevalence of chronic pain and chronic widespread pain among subjects with heart failure in the general population: The HUNT study

BACKGROUND

Pain in chronic heart failure (HF) is a significant but often unrecognized symptom. Characteristics of pain in subjects with HF are largely undescribed. The study aimed to address a knowledge gap in the relationship between HF and pain by investigating the prevalence of chronic pain and chronic widespread pain (CWP) among subjects with HF.

METHODS

Population data from the HUNT3 study in Norway (2006-2008, n = 50,802) was used. HF was measured by self-report. CWP was defined as having pain in both sides of the body, pain in the upper and lower limbs, and axial pain for at least 3 months in the last year. Associations between HF and CWP and HF and moderate to high pain intensity were analysed with logistic regression.

RESULTS

Among subjects with HF in the general population, the prevalence of chronic pain was 67.8%, 20.7% had CWP, and 58.8% had moderate to high intensity pain. Compared to participants with cardiovascular disease but not HF, the odds of both CWP (OR = 1.6; 95% CI: 1.3-2.0) and moderate to high intensity pain (OR = 1.3; 95% CI: 1.3-1.8) were higher among participants with HF-controlled for age, sex, body mass index, and comorbidity.

CONCLUSIONS

Our study confirmed the high prevalence of pain among HF subjects. This pain could not be explained by comorbidity or sociodemographic factors, which are relevant for clinical and research purposes. Pain management should not be restricted to cardiac-related pain but to chronic pain in general.

SIGNIFICANCE

This epidemiological study corroborates previous studies reporting a high prevalence of pain in the HF-population. We found that the relationship between HF, CWP, and pain intensity could not be explained by comorbidity or sociodemographic factors, illustrating the burden of chronic pain related to HF. Our results expand the understanding of pain in HF and highlight the need to identify and manage chronic pain among individuals with HF, as widespread pain adds to the symptom burden in individuals with HF.

Genetic insights into associations of multisite chronic pain with common diseases and biomarkers using data from the UK Biobank

BACKGROUND

Chronic pain is a common, complex, and challenging condition, for which specialised healthcare is required. We investigated the relationship between multisite chronic pain (MCP) and different disease traits identify safe biomarker interventions that can prevent MCP.

METHODS

Univariable and multivariable Mendelian randomisation (MR) analysis were conducted to investigate associations between MCP and 36 common diseases in the UK Biobank. Subsequently, we estimated the potential effect of expression of 4774 proteins on MCP utilising existing plasma protein quantitative trait locus data. For the significant biomarkers, we performed phenome-wide MR (Phe-MR) with 1658 outcomes to predict potential safety profiles linked to biomarker intervention.

RESULTS

Multisite chronic pain had a substantial impact on psychiatric and neurodevelopmental traits (major depression and attention deficit hyperactivity disorder), cardiovascular diseases (myocardial infarction, coronary artery disease, and heart failure), respiratory outcomes (asthma, chronic obstructive pulmonary disease, and sleep apnoea), arthropathies, type 2 diabetes mellitus, and cholelithiasis. Higher genetically predicted levels of S100A6, DOCK9, ferritin, and ferritin light chain were associated with a risk of MCP, whereas PTN9 and NEUG were linked to decreased MCP risk. Phe-MR results suggested that genetic inhibition of DOCK9 increased the risk of 21 types of disease, whereas the other biomarker interventions were relatively safe.

CONCLUSIONS

We established that MCP has an effect on health conditions covering various physiological systems and identified six novel biomarkers for intervention. In particular, S100A6, PTN9, NEUG, and ferritin light chain represent promising targets for MCP prevention, as no significant side-effects were predicted in our study.

Continuous visualization and validation of pain in critically ill patients using artificial intelligence: a retrospective observational study

Machine learning tools have demonstrated viability in visualizing pain accurately using vital sign data; however, it remains uncertain whether incorporating individual patient baselines could enhance accuracy. This study aimed to investigate improving the accuracy by incorporating deviations from baseline patient vital signs and the concurrence of the predicted artificial intelligence values with the probability of critical care pain observation tool (CPOT) ≥ 3 after fentanyl administration. The study included adult patients in intensive care who underwent multiple pain-related assessments. We employed a random forest model, utilizing arterial pressure, heart rate, respiratory rate, gender, age, and Richmond Agitation-Sedation Scale score as explanatory variables. Pain was measured as the probability of CPOT scores of ≥ 3, and subsequently adjusted based on each patient's baseline. The study included 10,299 patients with 117,190 CPOT assessments. Of these, 3.3% had CPOT scores of ≥ 3. The random forest model demonstrated strong accuracy with an area under the receiver operating characteristic curve of 0.903. Patients treated with fentanyl were grouped based on CPOT score improvement. Those with ≥ 1-h of improvement after fentanyl administration had a significantly lower pain index (P = 0.020). Therefore, incorporating deviations from baseline patient vital signs improved the accuracy of pain visualization using machine learning techniques.

High Self-Reported Levels of Pain 1 Year After a Myocardial Infarction Are Related to Long-Term All-Cause Mortality: A SWEDEHEART Study Including 18 376 Patients

Background Pain increases the risk for cardiovascular diseases, including myocardial infarction (MI). However, the impact of pain on mortality after MI has not yet been investigated in large studies with long-term follow-up periods. Thus, we aimed to examine various levels of pain severity 1 year after an MI as a potential risk for all-cause mortality. Methods and Results We collected data from 18 376 patients, aged <75 years, who had a registered MI event during the period from 2004 to 2013 and with measurements of potential cardiovascular risk indicators at hospital discharge from the Swedish quality register SWEDEHEART (Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies). Self-reported levels of experienced pain according to EuroQol-5 dimension instrument were recorded in secondary prevention clinics 1 year after hospital discharge. We collected all-cause mortality data up to 8.5 years (median, 3.4 years) after the 1-year visit. The Cox proportional hazard regression was used to estimate hazard ratio (HR) and 95% CI. Moderate pain and extreme pain were reported by 38.2% and 4.5%, respectively, of included patients. There were 1067 deaths. Adjusted HR was 1.35 (95% CI, 1.18-1.55) and 2.06 (95% CI, 1.63-2.60) for moderate and extreme pain, respectively. Pain was a stronger mortality predictor than smoking. Conclusions Pain 1 year after MI is highly prevalent, and its effect on mortality 1 year after MI was found to be more pronounced than smoking. Clinicians managing patients after MI should recognize the need to consider experienced pain when making prognosis or treatment decisions.

Stress biomarkers in individuals with fibromyalgia syndrome: a systematic review with meta-analysis

ABSTRACT

Evidence suggests an involvement of hypothalamic-pituitary-adrenal (HPA) axis dysregulation in the development and maintenance of fibromyalgia syndrome (FMS). However, studies on the stress response via the HPA-axis in individuals with FMS show conflicting results. To better understand the relationship between FMS and HPA-axis dysregulation, we (1) systematically summarized the current level of evidence on HPA biomarkers in individuals with FMS compared with individuals without and (2) evaluated whether FMS is associated with a specific pattern of HPA dysregulation. The main outcome measures were cortisol, adrenocorticotropic hormone (ACTH), corticotropin-releasing hormone (CRH), epinephrine, and norepinephrine. A systematic search of MEDLINE, EMBASE, and PsychMed yielded 47 studies eligible for meta-analysis, including 1465 individuals with FMS and 1192 FMS-free controls. No main effect of FMS was found on altered levels of blood cortisol, ACTH, CRH, and epinephrine. Compared with controls, salivary and urinary cortisol levels were decreased in individuals with FMS, whereas blood levels of norepinephrine were increased. However, heterogeneity of data was high with significant evidence for publication bias. Overall, the data are compatible with association of FMS with adrenocortical hypofunction in the presence of increased sympathetic tone. However, the data are partially contradictory, so it must be assumed that the data are highly dependent on the respective study designs, patient samples, and analytical methods and do not necessarily demonstrate an abnormal HPA-axis function in FMS.

Multisite Pain and Myocardial Infarction and Stroke: A Prospective Cohort and Mendelian Randomization Analysis

Background

Whether individuals with multisite pain had a higher risk of cardiovascular diseases is unclear.

Objectives

The purpose of this study was to investigate the longitudinal association of pain in multiple sites with incident myocardial infarction (MI) and stroke, and to disentangle the genetic causality of these associations.

Methods

A total of 281,760 participants (mean age: 56.3 years) who had no MI and stroke at baseline from UK Biobank study were included. Data on pain in the hip, knee, back and neck/shoulder, or 'all over the body' were collected. Chronic pain was defined if pain had lasted for ≥3 months. MI and stroke events were determined from hospital admission records and death registries. Cox regression and 2-sample Mendelian randomization were used for the analyses.

Results

During a median follow-up of 11.9 years, 4,854 had a first MI and 2,827 had a first stroke. In multivariable analyses, greater number of painful sites was dose-responsively associated with higher risks of incident MI and stroke, with a higher risk among participants with pain 'all over the body' (MI: HR: 1.65, 95% CI: 1.32-2.07; stroke: HR: 1.44, 95% CI: 1.13-1.85). Similar trends and associations were observed in those with chronic pain. Two-sample Mendelian randomization results supported a causal effect of multisite pain on MI risk, but not vice versa. No causal association was found between multisite pain and stroke risk.

Conclusions

Pain in multiple sites causally increases the risk of MI, highlighting that pain should be considered when assessing individuals' MI risk, and pain treatment and management may prevent MI risk.

Increasing pain prevalence and intensity among middle-aged and older adults: Evidence from the German Ageing Survey

OBJECTIVE

Pain is a very common chronic condition in late life that is associated with poorer quality of life and greater functional restrictions. Little is known regarding temporal trends in pain prevalence and pain intensity. Therefore, we estimated trends in pain prevalence and intensity over time among German middle-aged and older adults.

METHODS

We used two independent samples drawn in different years from the German Ageing Survey, which is a nationwide population-representative study with a cohort-sequential design. Specifically, a sample of individuals aged 40-85 years who were assessed in 2008 (n = 5961) was compared with a sample of individuals with the same age range who were assessed in 2014 (n = 5809). Individuals were asked if and to what extent they had experienced constant or recurrent pain within the past four weeks. χ² tests and regression analyses were computed.

RESULTS

In 2008, about 44% of all individuals reported suffering from at least very mild pain. In 2014, this proportion was higher by about 7%. Controlling for chronological age, gender, education, region of residence (West vs. East Germany), depressive symptoms, chronic diseases, BMI, and physical activity, the difference in pain prevalence and pain intensity between the samples remained statistically significant.

CONCLUSION

Our data suggest an increase in the prevalence and intensity of pain among middle-aged and older German adults between 2008 and 2014, which remained statistically significant when controlling for socio-demographic and health-related indicators. Further research is needed to identify the factors underlying this increasing pain prevalence and pain intensity in order to counteract this negative temporal trend.

Chronic Pain-Associated Cardiovascular Disease: The Role of Sympathetic Nerve Activity

Chronic pain affects many people world-wide, and this number is continuously increasing. There is a clear link between chronic pain and the development of cardiovascular disease through activation of the sympathetic nervous system. The purpose of this review is to provide evidence from the literature that highlights the direct relationship between sympathetic nervous system dysfunction and chronic pain. We hypothesize that maladaptive changes within a common neural network regulating the sympathetic nervous system and pain perception contribute to sympathetic overactivation and cardiovascular disease in the setting of chronic pain. We review clinical evidence and highlight the basic neurocircuitry linking the sympathetic and nociceptive networks and the overlap between the neural networks controlling the two.

A Shared Genetic Signature for Common Chronic Pain Conditions and its Impact on Biopsychosocial Traits

The multiple comorbidities & dimensions of chronic pain present a formidable challenge in disentangling its aetiology. Here, we performed genome-wide association studies of 8 chronic pain types using UK Biobank data (N =4,037-79,089 cases; N = 239,125 controls), followed by bivariate linkage disequilibrium-score regression and latent causal variable analyses to determine (respectively) their genetic correlations and genetic causal proportion (GCP) parameters with 1,492 other complex traits. We report evidence of a shared genetic signature across chronic pain types as their genetic correlations and GCP directions were broadly consistent across an array of biopsychosocial traits. Across 5,942 significant genetic correlations, 570 trait pairs could be explained by a causal association (|GCP| >0.6; 5% false discovery rate), including 82 traits affected by pain while 410 contributed to an increased risk of chronic pain (cf. 78 with a decreased risk) such as certain somatic pathologies (eg, musculoskeletal), psychiatric traits (eg, depression), socioeconomic factors (eg, occupation) and medical comorbidities (eg, cardiovascular disease). This data-driven phenome-wide association analysis has demonstrated a novel and efficient strategy for identifying genetically supported risk & protective traits to enhance the design of interventional trials targeting underlying causal factors and accelerate the development of more effective treatments with broader clinical utility. PERSPECTIVE: Through large-scale phenome-wide association analyses of >1,400 biopsychosocial traits, this article provides evidence for a shared genetic signature across 8 common chronic pain types. It lays the foundation for further translational studies focused on identifying causal genetic variants and pathophysiological pathways to develop novel diagnostic & therapeutic technologies and strategies.

Sex-specific effects of neuropathic pain on long-term pain behavior and mortality in mice

ABSTRACT

Human epidemiological studies suggest that chronic pain can increase mortality risk. We investigated whether this was true in mice so that underlying mechanisms might be identified. At 10 weeks of age, C57BL/6 mice of both sexes received sham or spared nerve injury (SNI) surgery producing neuropathic pain. Mice were weighed monthly, tested behaviorally for mechanical and cold sensitivity and guarding behavior every 3 months postsurgery, and otherwise left undisturbed in their cages until death by natural causes. Evidence of pain over the lifespan displayed a strikingly sex-specific pattern. Male mice displayed largely stable mechanical and cold hypersensitivity and guarding at 6 to 30 months post-SNI. By contrast, female mice displayed a biphasic temporal pattern of mechanical hypersensitivity and guarding behavior, with a complete resolution of SNI-induced pain behavior at 6 to 9 months post-SNI followed by the return of pain thereafter. Mouse lifespan was not significantly altered by SNI in either sex nor was frailty as assessed by cage inspection in the last 6 months of life. However, in male mice with SNI, we observe a significant correlation between average lifetime mechanical hypersensitivity and lifespan, such that death occurred sooner in male mice exhibiting more evidence of chronic pain. This relationship was not observed in female SNI mice nor in sham-operated mice of either sex. This experiment is the first to investigate pain behavior over an entire adult lifetime and suggests that biology of relevance to human chronic pain is being ignored by the very short timespans of most extant preclinical pain research.

[Influence of chronic pain in osteoarthritis on the risk of cardiovascular diseases and modern methods of drug prevention]

The purpose of the review of scientific medical literature was to evaluate the data of the epidemiology of osteoarthritis (OA) and cardiovascular diseases (CVD) with the analysis of risk factors, pathophysiological and pathobiochemical mechanisms of the relationship between OA and the risk of developing CVD in the presence of chronic pain, modern strategies for screening and management of this cohort of patients, the mechanism of action and pharmacological effects of chondroitin sulfate (CS). Conclusions were drawn about the need for additional clinical and observational studies of the efficacy and safety of the parenteral form of CS (Chondroguard) in patients with chronic pain in OA and CVD, improvement of clinical recommendations for the treatment of chronic pain in patients with OA and cardiovascular risk, with special attention to interventions that eliminate mobility restrictions in patients and the inclusion of basic and adjuvant therapy with DMOADs to achieve the goals of multipurpose monotherapy in patients with contraindications to standard therapy drugs.

The PerPAIN trial: a pilot randomized controlled trial of personalized treatment allocation for chronic musculoskeletal pain-a protocol

BACKGROUND

The therapy of chronic musculoskeletal pain (CMSP) is complex and the treatment results are often insufficient despite numerous therapeutic options. While individual patients respond very well to specific interventions, other patients show no improvement. Personalized treatment assignment offers a promising approach to improve response rates; however, there are no validated cross-disease allocation algorithms available for the treatment of chronic pain in validated personalized pain interventions. This trial aims to test the feasibility and safety of a personalized pain psychotherapy allocation with three different treatment modules and estimate initial signals of efficacy and utility of such an approach compared to non-personalized allocation.

METHODS

This is a randomized, controlled assessor-blinded pilot trial with a multifactorial parallel arm design. CMSP patients (n = 105) will be randomly assigned 1:1 to personalized or non-personalized treatment based on a cluster assignment of the West Haven-Yale Multidimensional Pain Inventory (MPI). In the personalized assignment condition, patients with high levels of distress receive an emotional distress-tailored intervention, patients with pain-related interference receive an exposure/extinction-tailored treatment intervention and patients who adapt relatively well to the pain receive a low-level smartphone-based activity diary intervention. In the control arm, patients receive one of the two non-matching interventions. Effect sizes will be calculated for change in core pain outcome domains (pain intensity, physical and emotional functioning, stress experience, participant ratings of improvement and satisfaction) after intervention and at follow-up. Feasibility and safety outcomes will assess rates of recruitment, retention, adherence and adverse events. Additional data on neurobiological and psychological characteristics of the patients are collected to improve treatment allocation in future studies.

CONCLUSION

Although the call for personalized treatment approaches is widely discussed, randomized controlled trials are lacking. As the personalization of treatment approaches is challenging, both allocation and intervention need to be dynamically coordinated. This study will test the feasibility and safety of a novel study design in order to provide a methodological framework for future multicentre RCTs for personalized pain psychotherapy.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00022792 ( https://www.drks.de ). Prospectively registered on 04/06/2021.

The association between short-term, chronic localized and chronic widespread pain and risk for cardiovascular disease in the UK Biobank

AIMS

The interplay between pain of different chronicity and cardiovascular disease (CVD) is incompletely understood. We aimed to investigate the association between different levels of chronic or nonchronic pain and risk of CVD.

METHODS AND RESULTS

Participants in the UK Biobank who reported pain at baseline were divided into three groups according to pain duration and widespreadness. Participants reporting no pain were controls. Multivariable Cox regression was used to investigate the association between pain and incidence of myocardial infarction, heart failure, stroke, cardiovascular mortality, and composite CVD (defined as any of the before-mentioned cardiovascular events). Of 475 171 participants, 189 289 reported no pain, 87 830 reported short-term pain, 191 716 chronic localized pain, and 6336 chronic widespread pain (CWP). During a median of 7.0 years' follow-up, participants with chronic localized pain and CWP had, after adjustment for age, sex, established cardiovascular risk factors, physical activity, anxiety, depression, cancer, chronic inflammatory/painful disease, pain/anti-inflammatory medication, socioeconomic status, a significantly increased risk for composite CVD [hazard ratio (HR) 1.14, confidence interval (CI) 1.08-1.21, P < 0.001; and HR 1.48, CI 1.28-1.73, P < 0.001, respectively] compared with controls, with similar results when using the different specific CVDs as outcomes. Population attributable risk proportion for chronic pain as a risk factor for composite CVD was comparable with that of diabetes (8.6 vs. 7.3%, respectively).

CONCLUSION

Chronic pain is associated with an increased risk for myocardial infarction, stroke, heart failure, and cardiovascular death independent of established cardiovascular risk factors, socioeconomic factors, comorbidities and medication. Our study, the largest to date, confirms and extends our understanding of chronic pain as an underestimated cardiovascular risk factor with important public health implications.

Opportunities and challenges of pain-related myocardial ischemia-reperfusion injury

Pain is one of the most serious problems plaguing human health today. Pain is not an independent pathophysiological condition and is associated with a high impact on elevated disability and organ dysfunction. Several lines of evidence suggested the associations of pain with cardiovascular diseases, especially myocardial ischemia-reperfusion (I/R) injury, while the role of pain in I/R injury and related mechanisms are not yet comprehensively assessed. In this review, we attempted to explore the role of pain in myocardial I/R injury, and we concluded that acute pain protects myocardial ischemia-reperfusion injury and chronic pain aggravates cardiac ischemia-reperfusion injury. In addition, the construction of different pain models and animal models commonly used to study the role of pain in myocardial I/R injury were discussed in detail, and the potential mechanism of pain-related myocardial I/R injury was summarized. Finally, the future research direction was prospected. That is, the remote regulation of pain to cardiac function requires peripheral pain signals to be transmitted from the peripheral to the cardiac autonomic nervous system, which then affects autonomic innervation during cardiac ischemia-reperfusion injury and finally affects the cardiac function.

Genetic risk for chronic pain is associated with lower antidepressant effectiveness: Converging evidence for a depression subtype

INTRODUCTION

Chronic pain and depression are highly comorbid and difficult-to-treat disorders. We previously showed this comorbidity is associated with higher depression severity, lower antidepressant treatment effectiveness and poorer prognosis in the Australian Genetics of Depression Study.

OBJECTIVE

The current study aimed to assess whether a genetic liability to chronic pain is associated with antidepressant effectiveness over and above the effect of genetic factors for depression in a sample of 12,863 Australian Genetics of Depression Study participants.

METHODS

Polygenic risk scores were calculated using summary statistics from genome-wide association studies of multisite chronic pain and major depression. Cumulative linked regressions were employed to assess the association between polygenic risk scores and antidepressant treatment effectiveness across 10 different medications.

RESULTS

Mixed-effects logistic regressions showed that individual genetic propensity for chronic pain, but not major depression, was significantly associated with patient-reported chronic pain (Pain^PRS OR = 1.17 [1.12, 1.22]; MD^PRS OR = 1.01 [0.98, 1.06]). Significant associations were also found between lower antidepressant effectiveness and genetic risk for chronic pain or for major depression. However, a fully adjusted model showed the effect of Pain^PRS (adjOR = 0.93 [0.90, 0.96]) was independent of MD^PRS (adjOR = 0.96 [0.93, 0.99]). Sensitivity analyses were performed to assess the robustness of these results. After adjusting for depression severity measures (i.e. age of onset; number of depressive episodes; interval between age at study participation and at depression onset), the associations between Pain^PRS and patient-reported chronic pain with lower antidepressant effectiveness remained significant (0.95 [0.92, 0.98] and 0.84 [0.78, 0.90], respectively).

CONCLUSION

These results suggest genetic risk for chronic pain accounted for poorer antidepressant effectiveness, independent of the genetic risk for major depression. Our results, along with independent converging evidence from other studies, point towards a difficult-to-treat depression subtype characterised by comorbid chronic pain. This finding warrants further investigation into the implications for biologically based nosology frameworks in pain medicine and psychiatry.

Association between chronic pain and physical activity in a Swiss population-based cohort: a cross-sectional study

OBJECTIVE

To assess the bidirectional association between chronic pain and both subjectively and objectively measured physical activity (PA).

DESIGN

Cross-sectional study.

SETTING

Population-based sample in Lausanne, Switzerland, May 2014 to April 2017.

PARTICIPANTS

Non-stratified, representative sample of the population of Lausanne (Switzerland) aged 35-75 years. Participants were excluded if they had missing data for the pain or the PA questionnaires, for accelerometry (defined as >20% of non-wear time or duration <7 days) or for covariates.

PRIMARY OUTCOMES

Primary outcomes were association between chronic pain and previous, subjectively assessed PA (questionnaire), and subsequent, objectively assessed PA (accelerometry). Daily pain, pain duration, number of painful sites and pain intensity were assessed by questionnaire. PA was assessed by questionnaire 2 weeks prior and by accelerometry 2 weeks after completion of the pain questionnaire. PA was further categorised as sedentary (SED), light and moderate-to-vigorous PA.

RESULTS

2598 participants (52.9% women, mean age 60.5 years) had subjectively assessed PA. Multivariable analysis showed time spent in SED to be negatively associated with the number of painful sites: adjusted mean±SE 528±5, 522±7 and 502±7 min/day for 0, 1-2 and 3+ painful sites, respectively, p for trend <0.005. No other association was found between chronic pain and subjectively assessed PA categories. 2205 participants (52.8% women, mean age 61.7 years) had accelerometry-derived PA. No significant association between chronic pain and subsequent objectively assessed PA was found after multivariable analyses.

CONCLUSION

In this Swiss population-based cohort, no consistent association was found between chronic pain and PA. Hence, in the general population, chronic pain does not significantly impact time spent in PA.

The association between myofascial orofacial pain with and without referral and widespread pain

OBJECTIVES

Pain referral on palpation has been suggested to be a clinical sign of central sensitization potentially associated with widespread pain conditions. Our aim was to evaluate if myofascial pain with referral is a better predictor for widespread pain when compared to no pain or local myofascial pain.

MATERIALS AND METHODS

Individuals at the Public Dental services in Västerbotten, Sweden, were randomly invited based on their answers to three screening questions for temporomandibular disorders (TMD). In total, 300 individuals (202 women, 20-69 yrs) were recruited, and examined according to the Diagnostic Criteria for TMD (DC/TMD) after completion of a body pain drawing. Widespread pain was considered present when seven or more pain sites were reported on the widespread pain index. A binary logistic regression model, adjusted for the effect of age and gender were used to evaluate the association between myofascial orofacial pain and widespread pain.

RESULTS

Widespread pain was reported by 31.3% of the study sample. There was a 57.3% overlap with myofascial pain. Widespread pain was associated to myofascial orofacial pain with and myofascial orofacial pain (OR 4.83 95% CI 2.62-9.05 and OR 11.62 95% CI 5.18-27.88, respectively).

CONCLUSION

These findings reinforce the existing knowledge on the overlap between painful TMD and other chronic pain conditions.

[Psychosocial factors in pain and pain management : A statement]

Although psychosocial factors have a profound impact on the experience of pain and pain recovery, the transfer to clinical application has so far been insufficient. With this article, a task force of the special interest group "Psychosocial Aspects of Pain" of the German Pain Society (Deutsche Schmerzgesellschaft e. V.) would like to draw attention to the considerable discrepancy between existing scientific evidence on the importance of psychosocial factors in the development of chronic pain disorders and the translation of these findings into the care of pain patients. Our objective is a stronger integration of psychological and psychosomatic expertise in pain treatment and research, as well as the improvement of structural and institutional conditions, to achieve an increased consideration of psychosocial aspects. In this way, modern, integrative and complex pain concepts can reach the patient. Based on these fundamental findings on the importance of psychosocial factors in pain and pain treatment, implications for the transfer to clinic and further research will be shown.

Trajectories of Pain in Very Old Age: The Role of Eudaimonic Wellbeing and Personality

Pain is common in very old age and in the last years prior to death. However, little is known regarding longitudinal trajectories of pain in very old age and at the end of life. Moreover, whereas medical and morbidity-related factors contributing to pain are established, the role of psychosocial factors, such as eudaimonic wellbeing or personality as potential determinants of late-life pain trajectories has so far not been sufficiently investigated. We used data from the LateLine project. The sample consisted of n = 118 very old adults (M = 90.5 years, SD = 2.8 years) who were living alone at baseline and who had died between 2009 and 2021. They took part in up to 16 measurement occasions (M = 5.2, SD = 4.7, range 1–16) within an observational interval of 7 years. Assessment of pain was based on the SF-36 bodily pain subscale. Key indicators of eudaimonic wellbeing (autonomy, environmental mastery, and purpose in life) as well two of the Big Five personality traits (neuroticism and extraversion) were included as predictors. We controlled in all analyses for gender, education, subjective health, and depressive symptoms. Contrasting pain trajectories over chronological age (time since birth) vs. time to death, a time-to-death-related model resulted in a better model fit and accounted for a larger amount of pain variability than the age-related model. Mean-level change in pain, both over age and time to death, was not significant, but there was substantial interindividual variability in intraindividual trajectories. Age-related change in pain was significantly predicted by autonomy and neuroticism, with increasing pain among those who had lower initial autonomy scores and higher initial neuroticism scores. With regard to time-to-death-related trajectories of pain, higher purpose in life as well as lower extraversion at baseline predicted less increase or even steeper decrease in pain with approaching death. Our findings suggest that, despite overall mean-level stability in pain both over age and time to death, there is a substantial proportion of individuals who reveal deterioration in pain over time. Regarding the role of psychosocial predictors, personality traits and eudaimonic wellbeing are related with late-life pain trajectories both over age and time-to-death.

Genetic basis to structural grey matter associations with chronic pain

Structural neuroimaging studies of individuals with chronic pain conditions have often observed decreased regional grey matter at a phenotypic level. However, it is not known if this association can be attributed to genetic factors. Here we employed a novel integrative data-driven and hypothesis-testing approach to determine whether there is a genetic basis to grey matter morphology differences in chronic pain. Using publicly available genome-wide association study summary statistics for regional chronic pain conditions (n = 196 963) and structural neuroimaging measures (n = 19 629-34 000), we applied bivariate linkage disequilibrium-score regression and latent causal variable analyses to determine the genetic correlations (rG) and genetic causal proportion (GCP) between these complex traits, respectively. Five a priori brain regions (i.e. prefrontal cortex, cingulate cortex, insula, thalamus and superior temporal gyrus) were selected based on systematic reviews of grey matter morphology studies in chronic pain. Across this evidence-based selection of five brain regions, 10 significant negative genetic correlations (out of 369) were found (false discovery rate < 5%), suggesting a shared genetic basis to both reduced regional grey matter morphology and the presence of chronic pain. Specifically, negative genetic correlations were observed between reduced insula grey matter morphology and chronic pain in the abdomen (mean insula cortical thickness), hips (left insula volume) and neck/shoulders (left and right insula volume). Similarly, a shared genetic basis was found for reduced posterior cingulate cortex volume in chronic pain of the hip (left and right posterior cingulate), neck/shoulder (left posterior cingulate) and chronic pain at any site (left posterior cingulate); and for reduced pars triangularis volume in chronic neck/shoulder (left pars triangularis) and widespread pain (right pars triangularis). Across these negative genetic correlations, a significant genetic causal proportion was only found between mean insula thickness and chronic abdominal pain [rG (standard error, SE) = -0.25 (0.08), P = 1.06 × 10-3; GCP (SE) = -0.69 (0.20), P = 4.96 × 10-4]. This finding suggests that the genes underlying reduced cortical thickness of the insula causally contribute to an increased risk of chronic abdominal pain. Altogether, these results provide independent corroborating evidence for observational reports of decreased grey matter of particular brain regions in chronic pain. Further, we show for the first time that this association is mediated (in part) by genetic factors. These novel findings warrant further investigation into the neurogenetic pathways that underlie the development and prolongation of chronic pain conditions.

Association of Arthritis and Antihypertensive Medication Use Among Individuals With Hypertension: A Cross-Sectional Analysis of the 2017 Behavioral Risk Factor Surveillance System

BACKGROUND

The aim of this study was to assess whether arthritis is associated with lower antihypertensive medication (AHM) use among those with hypertension and whether this relationship differs by age or cardiovascular (CV) comorbidity.

METHODS

The data were from the 2017 Behavioral Risk Factor Surveillance System. We employed survey weights to account for the complex sampling design and nonresponse bias. We used generalized linear models to estimate unadjusted and adjusted prevalence ratios (PRs) and 95% confidence intervals comparing AHM use among those with severe or mild arthritis to those without arthritis, stratified by age, sex, and CV comorbidity.

RESULTS

Among 173,098 adults with hypertension, 26.0% had severe arthritis and 22.3% had mild arthritis. Compared with those without arthritis, individuals with mild or severe arthritis were older, predominantly female, with lower income and more comorbidities. After adjustment for sex, race, inability to afford medications, and CV comorbidity, the prevalence ratios for AHM use were stronger for younger versus older age groups. Associations did not differ significantly by sex or CV comorbidity. Associations were similar for mild and severe arthritis, compared with no arthritis.

CONCLUSIONS

Among individuals with hypertension, those with arthritis had significantly higher prevalences of AHM use compared with those without arthritis. Higher prevalences of AHM use were seen with older age categories, although a stronger association of arthritis and AHM use was found in younger age groups. Future studies on hypertension management in arthritis should examine these relationships more closely.

Low Pain Tolerance Is Associated With Coronary Angiography, Coronary Artery Disease, and Mortality: The Tromsø Study

Background

The initial presentation to coronary angiography and extent of coronary artery disease (CAD) vary greatly among patients, from ischemia with no obstructive CAD to myocardial infarction with 3‐vessel disease. Pain tolerance has been suggested as a potential mechanism for the variation in presentation of CAD. We aimed to investigate the association between pain tolerance, coronary angiography, CAD, and death.

Methods and Results

We identified 9576 participants in the Tromsø Study (2007–2008) who completed the cold‐pressor pain test, and had no prior history of CAD. The median follow‐up time was 10.4 years. We applied Cox‐regression models with age as time‐scale to calculate hazard ratios (HR). More women than men aborted the cold pressor test (39% versus 23%). Participants with low pain tolerance had 19% increased risk of coronary angiography (HR, 1.19 [95% CI, 1.03–1.38]) and 22% increased risk of obstructive CAD (HR, 1.22 [95% CI, 1.01–1.47]) adjusted by age as time‐scale and sex. Among women who underwent coronary angiography, low pain tolerance was associated with 54% increased risk of obstructive CAD (HR, 1.54 [95% CI, 1.09–2.18]) compared with high pain tolerance. There was no association between pain tolerance and nonobstructive CAD or clinical presentation to coronary angiography (ie, stable angina, unstable angina, and myocardial infarction). Participants with low pain tolerance had increased risk of mortality after adjustment for CAD and cardiovascular risk factors (HR, 1.40 [95% CI, 1.19–1.64]).

Conclusions

Low cold pressor pain tolerance is associated with a higher risk of coronary angiography and death.

Association of Back Pain with Mortality: a Systematic Review and Meta-analysis of Cohort Studies

BACKGROUND

Back pain is the most common cause of disability worldwide. While disability generally is associated with greater mortality, the association between back pain and mortality is unclear. Our objective was to examine whether back pain is associated with increased mortality risk and whether this association varies by age, sex, and back pain severity.

METHODS

A systematic search of published literature was conducted using PubMed, Web of Science, and Embase databases from inception through March 2019. We included English-language prospective cohort studies evaluating the association of back pain with all-cause mortality with follow-up periods >5 years. Three reviewers independently screened studies, abstracted data, and appraised risk of bias using the Quality in Prognosis Studies (QUIPS) tool. A random-effects meta-analysis estimated combined odds ratios (OR) and 95% confidence intervals (CI), using the most adjusted model from each study. Potential effect modification by a priori hypothesized factors (age, sex, and back pain severity) was evaluated with meta-regression and stratified estimates.

RESULTS

We identified eleven studies with 81,337 participants. Follow-up periods ranged from 5 to 23 years. The presence of any back pain, compared to none, was not associated with an increase in mortality (OR, 1.06; 95% CI, 0.97 to 1.16). However, back pain was associated with mortality in studies of women (OR, 1.22; 95% CI, 1.02 to 1.46) and among adults with more severe back pain (OR, 1.26; 95% CI, 1.14 to 1.40).

CONCLUSION

Back pain was associated with a modest increase in all-cause mortality among women and those with more severe back pain.

Pain and mortality among older adults in Korea

OBJECTIVES

With the increasing elderly population with chronic disease, understanding pain and designing appropriate policy interventions to it have become crucial. While pain is a noted mortality risk factor, limited studies exist due to the various causes of pain and the subjectivity of pain expression. This study aimed to examine the relationship between pain and mortality, controlling for other diseases and socio-cultural factors.

METHODS

We analyzed 6,258 individuals aged 45 years or older, the population with the highest prevalence of pain, using the Korean Longitudinal Study of Aging (2006-2016) data and the Cox proportional-hazards model. Further subgroup analyses were conducted by sex and education level to examine differences in the relationship between pain and mortality.

RESULTS

The adjusted hazard ratios of mortality were 1.16 (95% confidence interval [CI], 1.00 to 1.34, model 1) and 1.12 (95% CI, 0.97 to 1.29, model 2) for the individuals in pain depending on the models used, where additional socio-cultural factors were accounted for in model 2. For individuals in severe pain, ratios were significantly higher with 1.23 (95% CI, 1.08 to 1.41, model 1) and 1.16 (95% CI, 1.02 to 1.32, model 2). Further subgroup analyses showed that severe pain was more associated with mortality for males and more educated individuals, with adjusted hazard ratios of 1.29 (95% CI, 1.08 to 1.55, model 2) and 1.62 (95% CI, 1.15 to 2.28, model 2), respectively.

CONCLUSIONS

Pain showed a statistically significant relationship with mortality risk. Family members or medical staff should pay proper attention to pain, particularly severe pain in males and highly educated individuals.

Association between widespread pain and dementia, Alzheimer's disease and stroke: a cohort study from the Framingham Heart Study

BACKGROUND AND OBJECTIVE

Chronic pain may be an early indicator of cognitive decline, but previous studies have not systematically examined the population-level associations between widespread pain and adverse cognitive outcomes and stroke. This study was designed to determine the association between widespread pain, a common subtype of chronic pain, and subsequent dementia, Alzheimer's disease dementia and stroke.

METHODS

This retrospective cohort study used data from the US community-based Framingham Heart Study. Pain status was assessed at a single time point between 1990 and 1994. Widespread pain was determined based on the Framingham Heart Study pain homunculus. Dementia follow-up occurred across a median of 10 years (IQR, 6-13 years) for persons who were dementia free at baseline. Proportional hazard models examined associations between widespread pain and incident dementia, Alzheimer's disease dementia and stroke.

RESULTS

A total of 347 (14.1%) subjects fulfilled the criteria for widespread pain, whereas 2117 (85.9%) subjects did not. Of 188 cases of incident all-cause dementia, 128 were Alzheimer's disease dementia. In addition, 139 patients suffered stroke during the follow-up period. After multivariate adjustment including age and sex, widespread pain was associated with 43% increase in all-cause dementia risk (HR: 1.43; 95% CI 1.06 to 1.92), 47% increase in Alzheimer's disease dementia risk (HR: 1.47; 95% CI 1.13 to 2.20) and 29% increase in stroke risk (HR: 1.29; 95% CI 1.08 to 2.54). Comparable results were shown in the subgroup of individuals over 65 years old.

CONCLUSION

Widespread pain was associated with an increased incidence of all-cause dementia, Alzheimer's disease dementia and stroke.

TRIAL REGISTRATION NUMBER

NCT00005121.

Supplementary Therapeutic Possibilities to Alleviate Myocardial Damage Due to Microvascular Dysfunction in Coronavirus Disease 2019 (COVID-19)

Myocardial damage with a consequent rise in cardio-specific troponin level is a frequent phenomenon in severe cases of coronavirus disease 2019 (COVID-19). Its causes are capillary endothelial cell dysfunction, associated carditis, low oxygenization, and increased sympathetic tone, which all worsen myocardial stiffness and microvascular dysfunction (MD). They lead to severe myocardial dysfunction, arrhythmia, acute congestive heart failure, and a significant rise in death cases. During COVID-19, no specific cardiological treatment is started. As adjuvant therapy, anxiolytics in COVID-19 are widely used, but not in all anxious patients who had been infected with coronavirus. Anxiolytics can be useful to moderate MD and immunosuppressive effect of anxiety. The favorable effects of trimetazidine (TMZ) and Coenzyme Q₁₀ (CoQ₁₀) in the treatment of myocardial ischemia and heart failure had previously been proven, and also their anti-inflammatory effects had been suspected; however, they have not yet been used in COVID-19 cases. TMZ promotes glucose-mediated ATP production, which requires less oxygen, which explains its advantageous cardiac effects. Since it lowers serum and myocardial tissue proinflammatory cytokine levels and inhibits myocardial macrophage infiltration, it was suspected that TMZ might represent a novel therapeutic agent to prevent and treat sepsis-induced myocardial dysfunction. CoQ₁₀ plays an important role in cellular ATP production; however, its concentration is decreased in cardiovascular diseases and in influenza patients. Due to its anti-inflammatory effect, CoQ₁₀ has been suspected to have a key therapeutic target in influenza infection. We suggest considering these medicines to alleviate myocardial damage and inflammation in COVID-19.

Pain Characteristics, Cardiovascular Risk Factors, and Cardiovascular Disease

BACKGROUND

There is unclear evidence that chronic pain may increase the risk of cardiovascular disease (CVD) incidence and mortality. This work evaluated the association between chronic pain, incidence of CVD and changes in CVD risk factors.

METHODS

Cohort of 1091 community-dwelling individuals ≥60years, free from CVD at baseline, followed up for 6 years. Data on psychosocial factors and CVD risk factors was obtained through validated questionnaires and laboratory measurements. A pain scale ranging from 0 (no pain) to 6 (worst pain) was created according to pain frequency, location and intensity.

RESULTS

The cumulative incidence of CVD was 4.2% at 3 years, and 7.7% at 5-years of follow-up. Compared to individuals without pain in the first 3 years (2012-2015), those with maintained scores ≥2 showed a mean reduction of 3.57 (-5.77,-1.37) METs-h/week in recreational physical activity; a 0.38-point (0.04,0.73) increase in psychological distress; and a 1.79 (1.03,3.11) higher odds of poor sleep. These associations held in the second follow-up period, when individuals with maintained pain also worsened their diet quality. A 1-point increase in the pain scale in 2012 was associated with a 1.21 (1.03,1.42) and 1.18 (0.97,1.44) increased CVD incidence in 2015 and 2017, respectively; none of the studied factors mediated this relationship.

CONCLUSIONS

Older adults with chronic pain show important reductions in recreational physical activity and deterioration in mental health, sleep and diet quality, which may well aggravate pain. Future studies should evaluate whether these factors mediate the increased risk of CVD observed in older adults with chronic pain.

Palliative Care for People Living With Heart Disease-Does Sex Make a Difference?

The distribution of individual heart disease differs among women and men and, parallel to this, among particular age groups. Women are usually affected by cardiovascular disease at an older age than men, and as the prevalence of comorbidities (like diabetes or chronic pain syndromes) grows with age, women suffer from a higher number of symptoms (such as pain and breathlessness) than men. Women live longer, and after a husband or partner's death, they suffer from a stronger sense of loneliness, are more dependent on institutionalized care and have more unaddressed needs than men. Heart failure (HF) is a common end-stage pathway of many cardiovascular diseases and causes substantial symptom burden and suffering despite optimal cardiologic treatment. Modern, personalized medicine makes every effort, including close cooperation between disciplines, to alleviate them as efficiently as possible. Palliative Care (PC) interventions include symptom management, psychosocial and spiritual support. In complex situations they are provided by a specialized multiprofessional team, but usually the application of PC principles by the healthcare team responsible for the person is sufficient. PC should be involved in usual care to improve the quality of life of patients and their relatives as soon as appropriate needs emerge. Even at less advanced stages of disease, PC is an additional layer of support added to disease modifying management, not only at the end-of-life. The relatively scarce data suggest sex-specific differences in symptom pathophysiology, distribution and the requisite management needed for their successful alleviation. This paper summarizes the sex-related differences in PC needs and in the wide range of interventions (from medical treatment to spiritual support) that can be considered to optimally address them.

Spreading of Pain in Patients with Chronic Pain is Related to Pain Duration and Clinical Presentation and Weakly Associated with Outcomes of Interdisciplinary Pain Rehabilitation: A Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP)

Introduction

The extent to which pain is distributed across the body (spreading of pain) differs largely among patients with chronic pain conditions and widespread pain has been linked to poor quality of life and work disability. A longer duration of pain is expected to be associated with more widespread pain, but studies are surprisingly scarce. Whether spreading of pain is associated with clinical presentation and treatment outcome in patients seen in interdisciplinary multimodal pain rehabilitation programs (IMMRPs) is unclear. The association between spreading of pain and (1) pain duration (2) clinical presentation (eg, pain intensity, pain-related cognitions, psychological distress, activity/participation aspects and quality of life) and (3) treatment outcome were examined.

Methods

Data from patients included in the Swedish Quality Registry for Pain Rehabilitation were used (n=39,916). A subset of patients that participated in IMMRPs (n=14,666) was used to examine whether spreading of pain at baseline predicted treatment outcome. Spreading of pain was registered using 36 predefined anatomical areas which were summarized and divided into four categories: 1–6 regions with pain (20.6% of patients), 7–12 regions (26.8%), 13–18 regions (22.0%) and 19–36 regions (30.6%).

Results

More widespread pain was associated with a longer pain duration and a more severe clinical picture at baseline with the strongest associations emerging in relation to health and pain aspects (pain intensity, pain interference and pain duration). Widespread pain was associated with a poorer overall treatment outcome following IMMRPs at both posttreatment and at a 12-month follow-up, but effect sizes were small.

Discussion

Spreading of pain is an indicator of the duration and severity of chronic pain and to a limited extent to outcomes of IMMRP. Longer pain duration in those with more widespread pain supports the concept of early intervention as clinically important and implies a need to develop and improve rehabilitation for patients with chronic widespread pain.

Emerging Clinical Technology: Application of Machine Learning to Chronic Pain Assessments Based on Emotional Body Maps

Depression and anxiety co-occur with chronic pain, and all three are thought to be caused by dysregulation of shared brain systems related to emotional processing associated with body sensations. Understanding the connection between emotional states, pain, and bodily sensations may help understand chronic pain conditions. We developed a mobile platform for measuring pain, emotions, and associated bodily feelings in chronic pain patients in their daily life conditions. Sixty-five chronic back pain patients reported the intensity of their pain, 11 emotional states, and the corresponding body locations. These variables were used to predict pain 2 weeks later. Applying machine learning, we developed two predictive models of future pain, emphasizing interpretability. One model excluded pain-related features as predictors of future pain, and the other included pain-related predictors. The best predictors of future pain were interactive effects of (a) body maps of fatigue with negative affect and (b) positive affect with past pain. Our findings emphasize the contribution of emotions, especially emotional experience felt in the body, to understanding chronic pain above and beyond the mere tracking of pain levels. The results may contribute to the generation of a novel artificial intelligence framework to help in the development of better diagnostic and therapeutic approaches to chronic pain.

A Systematic Review and Meta-Analysis on a Disease in TCM: Astragalus Injection for Gathering Qi Depression

Zong Qi depression is a disease recorded in the literature of Chinese traditional medicine for a long time. In recent years, the theory of Zong Qi depression has been more and more applied to the diagnosis and treatment of a variety of diseases. Astragalus is the most important drug used to treat the depression of Zong Qi. Meanwhile, Astragalus injection is also widely used in a variety of diseases in accordance with the manifestations of Zong Qi subsidence. However, there is a lack of systematic review or meta-analysis of the clinical effect of Astragalus injection in the treatment of Zong Qi subsidence. Therefore, we searched for diseases characterized by symptoms of Zong Qi subsidence (including heart failure, respiratory failure, acute respiratory distress syndrome, and acute lung injury) and evaluated the effect of Astragalus injection in these diseases with mortality and distance of a 6-minute walking test. The results showed that the mortality of patients with subsidence of Zong Qi decreased in 1 month (OR, 0.26 [0.12, 0.61], 95% CI, P=0.002) and 1 year (OR, 0.38 [0.20, 0.69], 95% CI, P=0.002) after using Astragalus injection. The distance of 6-minute walking test after 7 (MD, 91.60 [6.89, 176.31], 95% CI, P=0.03), 14 (MD, 22.62 [13.80, 31.43], 95% CI, P < 0.00001), and 28 days (MD, 108.31 [30.02, 186.59], 95% CI, P=0.007) of using Astragalus injection also increased. Therefore, we believe that Astragalus injection has a certain therapeutic effect on the depression of Zong Qi.