Educational achievement and chronic pain disability: mediating role of pain-related cognitions

Predictors of pain reduction following a program of manual therapies for patients with temporomandibular disorders: A prospective observational study

BACKGROUND

Clinical guidelines recommend conservative treatment for the management of temporomandibular disorders (TMD), and manual therapy (MT) is commonly applied to reduce pain and improve function.

OBJECTIVES

To identify predictors of pain reduction and functional improvement following a program of manual therapies (MTP) in patients with TMD and develop a first screening tool that could be used in clinical practice to facilitate decision-making.

DESIGN

A cohort of 102 adults with a diagnosis of TMD were treated with four weekly sessions within a MTP applied to craniomandibular structures. Candidate predictors were demographic variables, general health variables, psychosocial features, TMD characteristics and related clinical tests. A reduction of pain intensity by at least 30% after the MTP was considered a good outcome. Logistic regression was adopted to develop the predictive model and its performance was assessed considering the explained variance, calibration, and discrimination. Internal validation of the prediction models was further evaluated in 500 bootstrapped samples.

RESULTS

Patients experiencing pain intensity greater than 2/10 during mouth opening, positive expectations of outcome following a MTP, pain localized in the craniocervical region, and a low Central Sensitization Inventory score obtained a good outcome following the MTP. Predictive performance of the identified physical and psychological variables was characterized by high explained variance (R2 = 58%) and discrimination (AUC = 89%) after internal validation. A preliminary screening clinical tool was developed and presented as a nomogram.

CONCLUSIONS

The high discrimination of the prediction model revealed promising findings, although these need to be externally validated in future research.

TRIAL REGISTRATION NUMBER

NCT03990662.

Evaluating the validity of the Amharic Brief Pain Inventory among people with chronic primary musculoskeletal pain in Ethiopia

BACKGROUND

The Brief Pain Inventory (BPI) is a multidimensional pain assessment tool used to evaluate pain severity and pain interference. The BPI has been translated and validity estimated across multiple languages and patient populations for clinical and research settings. This study aimed to assess the reliability and validity of Amharic BPI test scores among patients with chronic primary musculoskeletal pain living in Ethiopia.

METHODS

This study had two parts: cognitive interviews and psychometric testing. An expert committee reviewed the Amharic BPI, and fifteen participants participated in the cognitive interviews. The results from the cognitive interviews were evaluated, and the committee approved recommendations for the tool prior to psychometric testing. Two hundred and sixty-nine patients were recruited from three sites for the psychometric testing. The results were summarised using descriptive statistics. Cronbach's alpha was calculated to estimate the internal consistency. To assess test-retest reliability, the intraclass coefficient was examined, and a Bland-Altman plot was created. Construct validity was determined using confirmatory factor analysis by testing BPI's previously suggested two or three-factor dimensionalities. Convergent validity was assessed by estimating the correlation between the Amharic BPI and SF-36 subscales.

RESULTS

The Amharic BPI scores showed a good internal consistency using a 2-factor model with α = 0.89 for pain severity and α = 0.91 for pain interference. Good internal consistency was also observed in the 3-factor model, with α = 0.89 for pain severity, α = 0.84 for activity interference, and α = 0.86 for affective interference items. The test-retest reliability testing resulted in an ICC = 0.82 for pain severity and ICC = 0.90 for the pain interference. The severity scale had the highest correlation with bodily pain subscale of the SF-36 at r = - 0.44, and the interference scale with Physical functioning scale of SF-36 at r = - 0.63. Confirmatory factor analysis support rating Amharic BPI using a two-factor approach.

CONCLUSIONS

Our findings showed that Amharic BPI scores demonstrate internal consistency, test-retest reliability, and construct validity among patients with chronic primary musculoskeletal pain in Ethiopia. Accordingly, the tool can be used in clinical practice or research in similar settings.

Impact of demographic factors on chronic pain among adults in the United States

Introduction

Chronic pain affects more than 1 in 5 American adults, and its effects are not evenly distributed throughout the population.

Methods

Using the National Health Interview Survey (NHIS), a household-based annual survey of self-reported health status of U.S. adults, this cross-sectional study describes differences in the prevalence of chronic pain and its effects across socioeconomic groups.

Results

In univariate analyses, chronic pain was more prevalent among female respondents, persons with lower educational attainment, non-Hispanic White individuals, and those who were insured as well as those who were married. After accounting for all other demographic factors, age, female sex, and lower educational attainment were associated with higher odds of having chronic pain, whereas Hispanic and non-Hispanic Black race were associated with lower odds. Despite lower odds of having chronic pain, Hispanic and non-Hispanic Black race were associated with greater odds of reporting more severe pain than White race. There were no significant differences across race in the effects of pain on life, work, or family, although female sex and lower educational attainment were associated with greater effects of pain on these domains. Educational attainment was the only characteristic associated with greater odds of ineffective pain management after accounting for all other demographic factors.

Conclusions

Implications for reducing disparities in the treatment of chronic pain are discussed.

Pain catastrophizing and associated factors in preoperative total knee arthroplasty in Lanzhou, China: a cross-sectional study

Background

Pain catastrophizing in preoperative total knee arthroplasty (TKA) patients is associated with several poorly characterised factors in the literature. This study investigated the current state and associated factors of preoperative pain catastrophizing in patients undergoing TKA.

Methods

This descriptive cross-sectional study was conducted at the orthopedics ward of two tertiary hospitals in Lanzhou, China. Pain catastrophizing was measured using the Chinese versions of the Pain Catastrophizing Scale, Short Form-36 (physical function domain), Numerical Rating Scale, Oxford Knee Score, Hospital Anxiety and Depression Scale, and Life Orientation Test-Revised.

Results

The study included 360 participants. Preoperative TKA pain catastrophizing in all patients was high, with a mean score of 24.92 (SD: 12.38). The stepwise multiple linear regression analysis revealed anxiety (β = 0.548, P < 0.01), education level (β =  − 0.179, P < 0.01), physical function (β =  − 0.156, P < 0.01), and pain intensity during activity (β = 0.105, P = 0.015) as associated factors for pain catastrophizing, possibly explaining 51.2% of the total variation (F = 95.149, P < 0.01).

Conclusion

Anxiety was the most relevant factor for pain catastrophizing in patients with preoperative TKA. Lower education levels, poor physical function, and stronger pain intensity during the activity were also associated with pain catastrophizing.

Finite Mixture Models Based on Pain Intensity, Functional Disability and Psychological Distress Composite Assessment Allow Identification of Two Distinct Classes of Persistent Spinal Pain Syndrome after Surgery Patients Related to Their Quality of Life

Persistent Spinal Pain Syndrome Type 2 (PSPS-T2), (Failed Back Surgery Syndrome), dramatically impacts on patient quality of life, as evidenced by Health-Related Quality of Life (HRQoL) assessment tools. However, the importance of functioning, pain perception and psychological status in HRQoL can substantially vary between subjects. Our goal was to extract patient profiles based on HRQoL dimensions in a sample of PSPS-T2 patients and to identify factors associated with these profiles. Two classes were clearly identified using a mixture of mixed effect models from a clinical data set of 200 patients enrolled in "PREDIBACK", a multicenter observational prospective study including PSPS-T2 patients with one-year follow-up. We observed that HRQoL was more impacted by functional disability for first class patients (n = 136), and by pain perception for second class patients (n = 62). Males that perceive their work as physical were more impacted by disability than pain intensity. Lower education level, lack of adaptive coping strategies and higher pain intensity were significantly associated with HRQoL being more impacted by pain perception. The identification of such classes allows for a better understanding of HRQoL dimensions and opens the gate towards optimized health-related quality of life evaluation and personalized pain management.

Thai Buddhism-Based Mindfulness for Pain Management in Thai Outpatients with Cancer: A Pilot Study

OBJECTIVE

This study aimed to evaluate Thai Buddhism-based Mindfulness (TBbM) feasibility based on recruitment and retention rates and to obtain preliminary data regarding changes (effect sizes) in pain severity and other outcomes when comparing control to intervention participants following TBbM use.

METHODS

A randomized controlled trial was conducted in the Outpatient Department at Sawanpracharak Hospital, Thailand, from April 2018 to February 2019. Seventeen participants completed the pretest and posttest. Both groups (control group [n = 10] and intervention group [n = 7]) received usual care and watched a 25-min educational video about cancer pain. The intervention group participated in a 3-day mindfulness training program at a Buddhist temple and continued practicing at home for 8 weeks. Data were collected at baseline and at 1 and 2 months postintervention.

RESULTS

One-hundred and thirty-five participants met the eligibility criteria; 112 (82%) declined to participate and 6 of 23 (26%) were lost to follow-up/dropped out. Control and intervention participants had an average age of 44 (± 8.77) and 56 years (± 7.41), respectively. When compared to the control group, the TBbM participants reported no statistically significant improvements in pain or other outcomes. While not statistically significant, the effect size indicated that pain did improve in the TBbM group (Cohen's d = 0.41).

CONCLUSIONS

Given the suboptimal recruitment and retention rates, modification of the intervention is warranted. Further, our findings suggest that the intervention had a moderate effect on pain. To evaluate efficacy, future adequately powered studies are needed to test a more feasible TBbM intervention.

Chronic Musculoskeletal Pain and Foot Reaction Time in Older Adults

This cross-sectional study examines the association between chronic musculoskeletal pain and foot reaction time (RT) among older community-living adults. Participants were 307 adults aged 71 years and older in the MOBILIZE Boston Study II. Pain severity, interference, and location were measured by the Brief Pain Inventory and a joint pain questionnaire. With participants seated, simple foot reaction time was measured as self-selected foot response time to an intermittent light, and choice foot reaction time was measured as response time to the light on the corresponding side of the sensored gait mat. We performed multivariable linear regression to determine associations of pain and foot RT, adjusted for sociodemographic and health characteristics, and serially adjusted for cognitive function (MMSE or Trail Making A). Pain severity and interference were associated with slower simple foot reaction time (P < .05). Pain severity and knee pain were associated with slower choice foot reaction time (P < .05). Adjustment for cognitive measures had little impact on the pain-RT relationship. This significant relationship was only observed among participants with less education. These results support the idea that chronic pain may lead to slower foot RT, thus could represent a fall hazard in older adults. Neuromotor mechanisms underlying the pain-fall relationship warrant further investigation. PERSPECTIVE: This study provides insights on the mechanisms underlying the pain-fall relationship. Chronic pain may contribute to slower foot RT thus increase fall risk in older adults. This may help inform interventions such as stepping training to reduce fall risk in older adults living with chronic pain.

Does the educational level of women influence hand grip and pinch strength in carpal tunnel syndrome?

BACKGROUND

Grip and pinch strength are relevant functional variables for various activities of daily life and are related to the quality of life of patients with carpal tunnel syndrome (CTS).

OBJECTIVE

The main aim was to analyze the relationship between grip and pinch strength and the educational level in women with CTS.

STUDY DESIGN

Cross-sectional study.

METHODS

Thirty-one female patients with CTS awaiting surgery were assigned to the low education group if they only had primary education level (completed or not) and the high education group for those having higher education level. The assessments included: grip strength, pinch strength, Visual Analogue Scale, Quick DASH Questionnaire, Pain Catastrophizing Scale and the Tampa scale of kinesiophobia.

RESULTS

A statistically significant difference was obtained for grip strength (p = 0.027), pinch strength (p = 0.002) and catastrophizing (p = 0.038) between the two groups. No significant differences were observed for the other variables studied (p < 0.05). Grip strength was not related to individual factors: type of work, age, body mass index.

CONCLUSION

CTS patients with a low educational level exhibited reduced grip and pinch strength and more catastrophic thinking. Future studies should investigate the mechanisms involved in the loss of strength in patients with lower educational levels.

Inequality in income change among cancer survivors five years after diagnosis: Evidence from a French national survey

Worldwide, around 18 million people receive a cancer diagnosis each year, most of whom survive long enough to face additional cancer-related costs. In France, most costs directly related to cancer are covered by the National Health Insurance Fund, and cancer patients can receive treatments without paying advance fees. In this context, the costs faced by cancer survivors are mostly social costs. Drawing on fundamental cause theory, this study aimed to explore the socially-differentiated evolution of cancer survivor’s income five years after diagnosis. Our study draws on the findings of VICAN5, a French national survey that was conducted in 2015/2016 in a representative sample of 4,174 cancer survivors to obtain information on living conditions five years after diagnosis, and that was restricted to 12 tumour sites accounting for 88% of global cancer incidence in France. We used the multiple imputation method and the Heckman selection model to identify the factors associated with a decrease in household income per consumption unit (HICU), while accounting for missing data. Among survivors still working five years after diagnosis, 17.6% reported lower income at survey than at diagnosis. After adjustment for socio-demographic and medical characteristics, the decrease in HICU was more frequent in women, singles, low educated survivors, and survivors with reduced working time. Finally, subjective measures of income variation and economic well-being were a useful complement to objective measures since 31.6% of cancer survivors still working five years after diagnosis reported a perceived decrease in household income. In conclusion, inequalities in economic well-being persist long after diagnosis in France, and this despite the fact that most cancer-related costs are covered by the French National Health Insurance Fund. Consequently, more attention should be paid to cancer patients with low socio-economic status to help reduce inequalities in post-diagnosis living conditions.

Socioeconomic factors, psychological factors, and function in adults with chronic musculoskeletal pain from rural Nepal

Background

Both socioeconomic and psychological factors have been shown to predict patient function in samples of individuals with chronic pain in Western countries. However, little is known about their role as predictors of function in individuals with chronic pain from developing countries.

Purpose

The purpose of this study was to examine the associations between measures of socioeconomic factors (income, education) and psychological factors (catastrophizing and resilience) and measures of function in a sample of individuals with chronic pain from rural Nepal. In addition, we sought to evaluate the moderating effects of socioeconomic factors on the associations between the psychological variables and function.

Methods

We interviewed 143 adults with chronic musculoskeletal pain from rural areas of Nepal to assess income, education level, pain intensity, catastrophizing, resilience, physical function, and depression. We performed two regression analyses to evaluate the direct and unique effects of the socioeconomic and psychological variables and pain intensity as predictors of patient function, as well as the moderating influence of income, education level, and pain intensity on the associations between the psychological variables and function.

Results

Education and income both predicted physical function, but only income predicted depression. In addition, pain catastrophizing, but not resilience, evidenced a direct and significant independent association with depression. Neither catastrophizing nor resilience made independent and significant direct contributions to the prediction of physical function. The association between resilience and physical function was moderated by pain intensity and income, and income (but not education or pain intensity) moderated the associations between both 1) resilience and depression and 2) catastrophizing and depression.

Conclusion

The results suggest the possibility that cultural differences may influence the role that psychosocial factors play in chronic pain adjustment. These findings have important implications regarding how psychosocial pain interventions should be adapted by individuals in developing countries.

Education level as a prognostic indicator at 12 months following decompression surgery for symptomatic lumbar spinal stenosis

OBJECTIVEThe goal of this study was to analyze the effect of patient education level on functional outcomes following decompression surgery for symptomatic lumbar spinal stenosis.METHODSPatients with surgically decompressed symptomatic lumbar stenosis were collected in a prospective observational registry at a single institution between 2012 and 2014. Patient education level was compared to surgical outcomes to elucidate any relationships. Outcomes were defined using the Oswestry Disability Index score, back and leg pain visual analog scale (VAS) score, and the EuroQol-5 Dimensions questionnaire score.RESULTSOf 101 patients with symptomatic lumbar spinal stenosis, 27 had no college education and 74 had a college education (i.e., 2-year, 4-year, or postgraduate degree). Preoperatively, patients with no college education had statistically significantly greater back and leg pain VAS scores when compared to patients with a college education. However, there was no statistically significant difference in quality of life or disability between those with no college education and those with a college education. Postoperatively, patients in both cohorts improved in all 4 patient-reported outcomes at 3 and 12 months after treatment for symptomatic lumbar spinal stenosis.CONCLUSIONSDespite their education level, both cohorts showed improvement in their functional outcomes at 3 and 12 months after decompression surgery for symptomatic lumbar spinal stenosis.

An Empirical Investigation of a Biopsychosocial Model of Pain in Multiple Sclerosis

OBJECTIVES

Pain is a significant problem for many individuals with multiple sclerosis (MS). Pain is often associated with other MS symptoms (eg, physical, sensorimotor, cognitive declines), and both pain and MS symptoms are hypothesized to contribute to psychosocial problems (eg, depression), other symptoms (eg, fatigue, sleep disturbance), and functional impairments (eg, pain interference). On the basis of a biopsychosocial model, we sought to: (1) examine the associations between pain, MS symptoms, depression, psychosocial, and functional variables and (2) identify possible risk and protective factors associated with pain in MS.

MATERIALS AND METHODS

A cross-sectional survey was completed by 424 individuals with MS. Pain, MS symptoms, demographics, MS diagnostic factors, and psychosocial and functional variables were assessed. Data were analyzed by structural equation models.

RESULTS

Participants were predominantly white (92%), middle-aged (mean=50.7 y), and female (80%). Results indicated that pain severity and depression accounted for >50% of the variance in pain interference. Although pain contributed minimally to fatigue and sleep quality, depression and MS symptoms predicted 49% of the variance in fatigue, and depression was largely responsible for the 40% of predicted variance in sleep quality. Identified risk factors for pain were low educational attainment and lack of a committed/marital relationship, even while controlling for diagnostic and other key demographic variables.

DISCUSSION

Results highlight the importance of targeting interventions toward improving coping skills and social support within the context of pain and MS. Research is needed to determine whether effectively targeting depression in MS results in improvements of other critical psychosocial and physical functioning domains.

The relationship between knowledge of pain neurophysiology and fear avoidance in people with chronic pain: A point in time, observational study

Chronic pain is prevalent in the western world; however fear of pain often has a greater impact than the degree of initial injury. The aim of this study was to explore the relationship between knowledge of the neurophysiology of pain and fear avoidance in individuals diagnosed with chronic pain. Twenty-nine people with chronic musculoskeletal pain were recruited and completed questionnaires to determine their understanding of pain neurophysiology and the degree of their fear avoidance beliefs. There was an inverse relationship between knowledge of pain neurophysiology and the level of fear avoidance. Patients with higher pain knowledge reported less fear avoidance and lower perceived disability due to pain. There was no relationship with the educational level or compensable status for either variable. The findings suggest that fear avoidance is positively influenced by neurophysiology of pain education, so that a higher level of pain knowledge is associated with less activity-related fear. The clinical implication is that reducing fear avoidance/kinesiophobia using neurophysiology of pain education in people with chronic pain may provide an effective strategy to help manage fear avoidance and related disability in the chronic pain population in order to improve treatment outcomes.

Influence of educational attainment on pain intensity and disability in patients with lumbar spinal stenosis: mediation effect of pain catastrophizing

STUDY DESIGN

Level IV, prospective case series.

OBJECTIVE

To investigate the influence of educational attainment on the level of pain intensity and disability in patients with lumbar spinal stenosis (LSS) and determine how coping behavior, such as catastrophizing, may mediate the association between educational attainment and clinical impairments.

SUMMARY OF BACKGROUND DATA

Educational attainment has been thought to influence disability caused by chronic painful disease, mediated by pain behavior or a coping strategy such as catastrophizing. Nevertheless, little is known about the role of educational attainment on pain intensity or disability related with LSS.

METHODS

A total of 155 patients who were diagnosed as degenerative LSS participated in the study. Data on detailed medical history, physical examination, and series of questionnaires were collected, including pain catastrophizing scale, Oswestry Disability Index, and visual analogue pain scale for back and leg pain. For measures of socioeconomic status, educational attainment and occupation were assessed. Radiological analysis was performed using magnetic resonance images and computed tomographic scans. After adjustment of covariates, multivariate regression analysis was used to assess each component of the proposed mediation models among visual analogue pain scale for back/leg pain, Oswestry Disability Index, the level of education, occupation and pain catastrophizing scale. Mediation was also assessed by the bootstrapping technique.

RESULTS

Educational attainment was negatively correlated with pain intensity, disability, and catastrophizing. Pain catastrophizing were also significantly correlated with disability and pain intensity for back/leg pain in the patients with LSS. In the relationship among variables, the mediation analysis with bootstrapping clearly showed the role of catastrophizing in the mediation between visual analogue pain scale for back pain/leg pain, Oswestry Disability Index, and the level of education.

CONCLUSION

This study demonstrated that lower educational attainment was associated with increased pain intensity and disability in patients with LSS, which was mediated by the coping mechanism, catastrophizing.

History of abuse and its relationship to pain experience and depression in women with chronic pelvic pain

OBJECTIVE

We sought to determine the relationship among a history of physical or sexual abuse, pain experience, and depressive symptoms among women with chronic pelvic pain (CPP).

STUDY DESIGN

This was a cross-sectional study of women who presented to a tertiary referral center for evaluation of CPP (N = 273). All participants completed standardized questionnaires to assess a history of physical or sexual abuse, pain severity, pain disability, and depressive symptoms. Subjects were grouped by abuse category and compared to CPP participants without history of abuse. Multinomial logistic regression models were used to determine the association between adolescent or adult and childhood physical or sexual abuse with pain intensity, pain-related disability, and depressive symptoms.

RESULTS

Logistic regression analyses indicated that, after controlling for age and education, none of the abuse categories was associated with pain severity. However, adolescent or adult sexual abuse predicted greater pain-related disability (odds ratio, 2.39; 95% confidence interval, 1.05-5.40), while both adolescent or adult physical and sexual abuse were associated with higher levels of depression (both P < .05). Level of education was significantly associated with pain intensity, pain disability, and depression.

CONCLUSION

For our sample of women with CPP, a history of abuse during childhood or adulthood was not associated with differences in pain intensity, but adolescent or adult sexual abuse was associated with greater pain-related disability. A history of physical abuse or sexual abuse appears to hold a stronger relationship with current depressive symptoms than pain experience for women with CPP. Educational achievement holds a robust relationship with pain morbidity and depression for this population.

Mental defeat predicts distress and disability in Hong Kong Chinese with chronic pain

OBJECTIVES

The concept of mental defeat (MD) has been applied to describe the deeper impact of pain on the person's sense of self. It describes an intense psychological reaction to pain, whereby people feel that pain has taken away their autonomy and identity. Although MD has been found to characterize Western individuals who are most distressed and disabled by CP, it is debatable whether the concept can be generalized to the experience of CP patients in other cultures. The present study examined whether MD contributed to the prediction of distress and disability among Hong Kong (HK) Chinese reporting CP.

METHODS

Using questionnaires, the present study assessed MD, pain, distress, and disability in a sample of HK Chinese, comprising CP patients seeking specialist treatment and community volunteers with chronic or acute pain but not seeking specialist treatment.

RESULTS

MD was found to be elevated in CP patients seeking specialist treatment but not in nontreatment-seeking volunteers with pain of comparable duration and severity. Hierarchical regression indicated that MD was a significant predictor of functioning and distress, over and above the effects of pain severity and other potential demographic confounds.

DISCUSSION

These findings provide further evidence that MD is a factor that differentiates treatment-seeking from nontreatment-seeking individuals with CP. They also highlight the potential value of applying this psychological concept to the understanding and treatment of CP in HK Chinese.

Demographic characteristics, psychosocial measures, and pain in a sample of patients with persistent pain referred to a new zealand tertiary pain medicine center

OBJECTIVE

Little is known on epidemiology of chronic pain in New Zealand. Its management has been based on data and models in North American/European studies. This project evaluated demographic and psychosocial correlates of pain severity, duration, and disability (PSDD) in chronic pain patients for assessment at a New Zealand tertiary care Pain Medicine Center.

DESIGN AND SETTING

This study was a retrospective, cross-sectional analysis on existing clinical assessment data (audit) collected over an 18-month period.

METHODS

Pre-admission data were collected on a consecutive series of 874 patients presenting for assessment.

ASSESSMENT TOOLS

This included demographic (gender, educational attainment, ethnicity) and psychosocial data. Pain severity was measured by numerical rating scale and present pain intensity using McGill Pain Questionnaire. Duration was measured in months. Disability was measured by using Pain Disability Index and depression using the Center for Epidemiological Studies Depression Scale. Distress was measured using the Kessler Psychological Distress Scale and self-efficacy using the Pain Self-Efficacy Questionnaire. Catastrophizing was measured by Coping Strategies Questionnaire and pain acceptance by the Pain Solutions Questionnaire.

RESULTS

No difference was found in mean values of all PSDD between genders and between ethnicities. Years of education did not form an important correlate of PSDD. Catastrophizers experienced more pain and were more disabled. Patients with severe pain experienced greater distress. Depressed patients were more disabled. Patients presenting with a high degree of self-efficacy were likely to have lower pain levels and to be less disabled. Level of acceptance of pain was positively associated with reported duration of pain and negatively associated with total disability.

CONCLUSION

Through this study, more is now known about effects of chronic pain on New Zealanders. The use of validated psychometric testing enables proper assessment and informs clinical management for chronic pain patients.

Pain among women: Associations with socio-economic factors over time and the mediating role of depressive symptoms

Background and aims

Lower socioeconomic status (SES), based on economic situation, education and occupation, has been associated with greater morbidity and mortality in a wide range of diseases, and socioeconomic inequalities have been found in several chronic pain populations. Since women are overrepresented in several clinical pain conditions, there is a need to understand the influence of SES among women with pain. In a previous cross-sectional study, socioeconomic-and work conditions were associated with pain among women from the general population of Sweden. In the present study, based on baseline and follow-up measures from 2300 of the same sample, we examined associations between pain variables, socioeconomic status and work conditions over time by means of multiple logistic/linear regression analyses. Additionally, a possible mediating role of depressive symptoms on the relationship between SES and pain was examined.

Methods

The study was a prospective panel survey with two measurements 12 months apart among 2300 women with and without pain from the general population in Stockholm (aged 18–64). Logistic and linear regression analyses were used to identify associations between SES and pain outcomes.

Results

Results revealed that pain is a rather stable condition with large impact on daily functioning among many women. Certain SES variables (educational level, financial strain, occupational level) were related to pain and pain related disability prospectively. Financial strain and to be a blue-collar worker were related to the incidence of pain among all women, while educational level was related to worse pain outcomes among women with pain in terms of pain intensity, pain frequency, number of pain locations and pain-related disability. Symptoms of depression were associated with pain incidence and with pain variables (intensity, number of pain locations and pain-related disability) and with lower SES.

Conclusions

Financial strain and occupational level were here identified as risk factors for the incidence of pain, and could be interpreted as increasing both physical and psychological stress and thereby work both as predisposing the individual to pain and to perpetuate the development of a pain condition. Educational level was associated with the course of pain in terms of pain duration and pain-related disability which may indicate that once affected by pain, lower educational level may be related to less functional coping strategies in the adaptation to the pain condition. Depressive symptoms could be understood as a mediator of the relationship between SES and pain among women in terms of limiting the individual’s strategies to handle pain in a functional manner by increasing passive behavior patterns such as avoidance.

Implications

The interplay between SES and symptoms of depression should be regarded in preventive interventions and in treatment of pain among women. An overall risk-profile in terms of psychosocial and biological factors needs to be assessed early on within pain treatment for women. Increased knowledge of socioeconomic risk factors for long term pain, e.g. low educational level, is needed on all levels among all professionals within the healthcare system in order to facilitate effective communication in the treatment of women with pain.

The coping flexibility questionnaire: development and initial validation in patients with chronic rheumatic diseases

Coping flexibility may be beneficial for the adjustment in the context of a progressive and unpredictable course of chronic rheumatic diseases. The aim of this study was to develop and initially validate a self-report measure that assesses coping flexibility. Study participants were 147 outpatients with chronic rheumatic diseases (73% women, mean age 59 (range 20-79) years). Principal axis factoring analysis with oblique rotation was applied and internal consistency was determined. To investigate the initial validity of the coping flexibility questionnaire (COFLEX), hypothesised correlations with psychological and physical adjustment outcomes, pain, and coping strategies were examined. Factor analysis yielded a two-factor model of coping flexibility with acceptable internal consistency: versatility, the capability of switching between assimilative and accommodative coping strategies according to personal goals and situational demands (α = .88) and reflective coping, the capability of generating and considering coping options, and appraising the suitability of a coping strategy in a given situation (α = .70). Versatility was correlated with adaptive ways of coping and psychological adjustment, but not with physical adjustment and pain. Reflective coping was correlated with both adaptive and maladaptive ways of coping, but it was not correlated with adjustment outcomes. In conclusion, the current study suggests acceptable internal consistency of the COFLEX. Preliminary evidence of the validity of the versatility dimension is indicated, while the validity of reflective coping could not be firmly established. The associations of versatility with favourable adjustment to the disease warrant future confirmatory and validity research in larger samples of patients with chronic rheumatic diseases.

The relationship of demographic and psychosocial variables to pain-related outcomes in a rural chronic pain population

Rural residency and low socioeconomic status (SES) are associated with increased likelihood of chronic pain. Other demographics are also differentially associated with the experience of pain. This study examines the relations between demographic and pain-related variables in a virtually unstudied population of rural Alabama chronic pain patients. One hundred and fifteen patients completed validated measures of pain catastrophizing, depression, pain intensity, pain interference, perceived disability, and life satisfaction. Average age of study participants was 52-years, 79% were female, 74% were African-American, 72% reported annual income between 00,000-12,999, and 61% were unemployed. Although average years of reported education was 12.26, reading level percentile (primary literacy indicant) was 17.33. Cross-sectional multivariate and univariate analyses were conducted to examine associations among demographic and psychosocial variables in relation to various pre-treatment pain-related variables. The mediating role of pain catastrophizing and depression was investigated. Results indicate that race was significantly associated with pain intensity and pain interference, such that African-Americans reported higher scores than White-Americans. Pain catastrophizing was uniquely associated with pain intensity, pain interference, and perceived disability; depression was uniquely associated with pain interference and life satisfaction. Pain catastrophizing mediated the relation between primary literacy and pain intensity; age effects were differentially mediated by either pain catastrophizing or depression. These analyses provide an insight into the specific demographic and psychosocial factors associated with chronic pain in a low-literacy, low-SES rural population.

Back pain in older male Italian-born immigrants in Australia: the importance of socioeconomic factors

Back pain is common in older people and is associated with functional disability and poor self-rated health. Older persons are under-represented in back pain research, and research on back pain in older persons from ethnic minorities is particularly sparse. We investigated differences in back pain characteristics, effects and medication use in a population-based sample of 335 Italian-born immigrants and 849 Australian-born men aged 70 years and over. There were 189 (62%) Italian-born men and 507 (63%) Australian-born men who reported experiencing back pain in the past 12 months. Despite no difference in the reported prevalence of back pain between the two groups of men, Italian-born men were more likely to report that their pain was frequent, severe and chronic. Italian-born men were also more likely to report having other sites of pain and that they had limited their activities in the past 12 months due to back pain. Despite these differences, the use of analgesic medication was the same in both groups. Multivariate analyses showed that differences in pain characteristics and effects between the two groups of men were explained by socioeconomic factors such as years of education and occupation history.

Moderators of the negative effects of catastrophizing in arthritis

OBJECTIVES

Pain is among the most frequently reported, bothersome, and disabling symptoms described by patients with rheumatoid arthritis (RA), and the experience of pain is partially shaped by catastrophizing, a set of cognitive and emotional pain-related processes. However, other variables may moderate catastrophizing's influence on the experience of pain. In this study, we investigated a variety of factors that might buffer or magnify catastrophizing's deleterious consequences among patients with RA.

METHODS

A total of 185 RA patients were surveyed to determine levels of catastrophizing, pain, general psychological distress, and physical functioning.

RESULTS

Catastrophizing was associated with increased pain severity and psychological distress, and with poorer physical functioning. Some of these relationships were significantly moderated by education and social functioning; among RA patients with above-average social functioning and a college education, minimal relationships of catastrophizing with pain and distress symptoms were observed, while these associations were highly significant (Ps < 0.001) among patients with lower levels of education or social functioning.

CONCLUSIONS

Collectively, educational achievement and positive social interactions may protect against some of the deleterious effects of catastrophizing. The design of future interventions to reduce catastrophizing or ameliorate its impact on pain outcomes may benefit from further study of these subgroups of patients.

A prospective study on educational level and adaptation to cancer, within one year after the diagnosis, in an older population

Socio-economic status (SES) has often been associated with health disparities and mortality in cancer patients, yet systematic research into the role of SES in the course of the disease is lacking. This prospective study intends to examine the role of SES (i.e. educational level in this study) in psychological and physical adaptation to cancer. Ninety-nine cancer patients were followed from a community-based survey. Pre- and post-morbid data on patients' quality of life (QoL) were available. Adaptation was defined by looking at the level and pattern of scores on QoL scales from pre- to post-disease assessments. Results show some non-significant trends that more high-educated patients managed to adapt completely to cancer in relation to role and physical functioning when compared with low-educated participants. Furthermore, the greater part of high-educated patients who completely adapted in physical functioning achieved this result more rapidly without an initial deterioration. Unexpectedly, these differences were not significant when tested in a regression model. Hence, although there are some indications for differences in adaptation to role and physical functioning between educational groups, we did not find any evidence that proved such a relation. For the group as a whole, it is very interesting to see that based on our operationalization of adaptation, only a small percentage of patients deteriorated from pre- to post-disease assessments.

Predictors and consequences of multiple persistent postmastectomy pains

Persistent postmastectomy pain is quite common and has been classified into several distinct types. Few studies, however, have investigated either the predictors or functional impact of multiple types of post mastectomy pain. In this investigation, 278 women, who were, on average, several years post mastectomy, completed questionnaires assessing pain, pain-related physical function, and psychosocial distress. We assessed three distinct categories of postmastectomy pain: phantom breast pain, scar pain, and other mastectomy-related pain. Each of the three types of postmastectomy pain was strongly related to one another (i.e., women reporting one type of pain were more likely to report the other types as well). In general, the more types of postmastectomy pain a woman reported, the greater the degree of disability and distress. Collectively, the presence of "other mastectomy-related pain" was a stronger unique predictor of disability and distress than were the other two categories of pain. Interestingly, demographic and surgical factors, including time since surgery, were not consistent predictors of pain or function. The findings suggest that the assessment of postmastectomy pain should include formal evaluation of multiple types of pain, with additional attention paid to the category of "other mastectomy-related pains," and that the number of types of pain reported by women after surgery may be important in predicting functional outcomes.

Coping, pain severity, interference, and disability: the potential mediating and moderating roles of race and education

Researchers have demonstrated that certain types of pain coping are correlated with less pain severity and disability and that there are differences between Caucasians and African-American pain patients in their use of specific coping strategies. However, the extent to which racial group differences exist in the associations between pain coping strategies and pain severity, interference, and disability is unclear. Furthermore, the role of education in these associations is uncertain. We recruited a diverse community sample of individuals with chronic pain and their spouses to examine this issue (N = 105). Participants completed the Coping Strategies Questionnaire, Multidimensional Pain Inventory, and Sickness Impact Profile. Results showed that African-American participants reported significantly more pain severity, interference, and disability and reported using diverting attention and prayer and hoping pain-coping strategies significantly more often than Caucasian participants; however, only the racial group difference in prayer and hoping remained when controlling for education. We also examined whether race and education interacted with coping strategies in relating to pain and disability. Significant three-way interactions were found for physical and psychosocial disability, suggesting that educational level should be included in analyses exploring racial group differences. The results suggest the need for pain treatments that take into account the educational and cultural context of pain.

PERSPECTIVE

This article demonstrates that demographic variables such as race and education should be considered together when evaluating the effectiveness of coping with pain. The findings have the potential to enhance research and clinical practice with diverse groups.

Catastrophizing, Pain, and Social Adjustment in Scleroderma: Relationships With Educational Level

OBJECTIVES

Low educational attainment is related to numerous adverse health outcomes, and some evidence suggests that psychosocial variables may mediate education's effects. Moreover, the relationship between psychosocial functioning and health-related outcomes may be moderated by educational level, with individuals lower in formal education being more susceptible to the deleterious effects of negative cognitive and affective states. The present study sought to characterize such interrelationships between educational level and pain-related catastrophizing.

METHODS

We investigated the association of self-reported educational level with pain and social disability, we evaluated catastrophizing's potential mediating role in those associations, and we also investigated education as a moderator of catastrophizing's effects on pain and social disability in a sample of patients with scleroderma, a frequently painful autoimmune disorder.

RESULTS

First, education-related differences in pain report were accounted for by catastrophizing and depression. Second, after controlling for demographic factors, disease severity, and depressive symptoms, education moderated the relationship between catastrophizing, pain affect, and social function. Specifically, catastrophizing was more highly associated with greater reporting of affective pain among those with less formal education. In addition, catastrophizing inversely correlated with social disruption among individuals with less formal education.

DISCUSSION

Collectively, study findings support multiple models of interaction between education and pain-related cognitive/affective functioning, though in both mediational and moderational analyses, lower levels of formal education act as a risk factor for adverse pain-related outcomes.

FUNCTIONING DESCRIPTION ACCORDING TO THE ICF MODEL IN CHRONIC BACK PAIN: DISABLEMENT APPEARS EVEN MORE COMPLEX WITH DECREASING SYMPTOM-SPECIFICITY

OBJECTIVE

To determine the significance of degree of symptom-specificity in the disablement condition in chronic back pain.

DESIGN

Cross-sectional design.

SUBJECTS

All inhabitants of a restricted geographical area of Norway, who had had 8 weeks of sick-leave due to back pain during a 2-year period, were included in this study. Following examination they were diagnosed as having "specific back pain" (n=34), "non-specific back pain" (n=113) or "widespread pain" (n=49).

METHODS

Functioning of the 3 diagnostic subgroups was described and compared. Functioning assessment was guided by the concepts of the International Classification of Functioning, Disability and Health (ICF): health condition, body function and structure, activity, participation and contextual factors.

RESULTS

Pain components and final participation restriction did not differ among the diagnostic subgroups. However, with increasing symptom-specificity, loss of physical body functions and structures and subsequent activity limitation tended to increase. On the other hand, with decreasing symptom-specificity, mental distress, unfavourable contextual factors and dissatisfaction with various factors of life tend to increase, which may raise the impact of pain on restricting participation in activities.

CONCLUSION

Functioning description according to the components of the ICF model indicated that the disablement condition in patients with back pain who had been on sick-leave for 8 weeks may appear more complex with decreasing symptom-specificity.

Self-Reported Treatments Used for Lower-Limb Phantom Pain: Descriptive Findings

OBJECTIVE

To examine the types and relative frequency of treatments used for lower-limb phantom limb pain (PLP), including both pharmacologic and rehabilitative interventions.

DESIGN

Cross-sectional survey.

SETTING

Community-based survey from clinical databases.

PARTICIPANTS

Community-based sample (N=255) of persons with lower-limb amputations.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Intensity of PLP and type and helpfulness of treatments (both past and present) used for PLP.

RESULTS

Although 72% of the sample (n=183) reported current PLP, 53% of the respondents with PLP (and 38% of those with severe PLP) had never used treatment for PLP. Those who had used treatment reported greater pain severity and interference. The most commonly used treatment modality was analgesic medication, including acetaminophen, opioids, and nonsteroidal anti-inflammatory drugs. Of the treatments surveyed, only opioids and chiropractic care were rated as moderately to extremely helpful by the majority of those who had tried them, and many pain interventions had been discontinued.

CONCLUSIONS

As hypothesized, a significant proportion of persons with PLP have not used treatment for this pain, and, among those who have used pain treatments, few treatments are perceived as substantially helpful. More research is needed to identify effective management strategies for PLP and to examine further patient perceptions of pain treatment.

The physician as disability advisor for patients with musculoskeletal complaints

STUDY DESIGN

Literature review.

OBJECTIVES

To review the literature about the performance of physicians as mediators of temporary and permanent disability for patients with chronic musculoskeletal complaints. To assess specifically the nature and variance of recommendations from physicians, factors influencing physician performance, and efforts to influence physician behavior in this area.

SUMMARY OF BACKGROUND DATA

While caring for patients with musculoskeletal injuries, physicians are often asked to recommend appropriate levels of activity and work. These recommendations have significant consequences for patients' general health, employment, and financial well-being.

METHODS

Medical literature search.

RESULTS

Physician recommendations limiting activity and work after injury are highly variable, often reflecting their own pain attitudes and beliefs. Patients' desires strongly predict disability recommendations (i.e., physicians often acquiesce to patients' requests). Other influences include jurisdiction, employer, insurer, and medical system factors. The most successful efforts to influence physician recommendations have used mass communication to influence public attitudes, while reinforcing the current standard of practice for physicians.

CONCLUSIONS

Physician recommendations for work and activity have important health and financial implications. Systemic, multidimensional approaches are necessary to improve performance.

Factor structure of the pain disability index in workers compensation claimants with low back injuries

OBJECTIVE

To examine the factor structure of a telephone-administered Pain Disability Index (PDI) and the effects of race and sex on the PDI.

DESIGN

Computer-assisted telephone interviews of a cohort with occupational low back injuries.

SETTING

General community.

PARTICIPANTS

Missouri workers compensation claimants (N=1329) with low back injuries.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

PDI, levels of pain severity, Social Security Disability Insurance status, and the Fear-Avoidance Behavior Questionnaire.

RESULTS

Results for the total sample and by race/sex group indicated support for a 2-factor model of the PDI corresponding to voluntary activities (eg, social, occupational, recreational) and obligatory activities (eg, activities of daily living, eating, sleeping). Additional psychometric analyses of the voluntary and obligatory subscales indicated adequate reliability and construct validity overall and in each of the race/sex groups. African Americans reported more pain-related disability on both subscales than whites. Women reported more disability on the voluntary subscale than men.

CONCLUSIONS

The results support use of the PDI as a bidimensional measure of pain-related disability, with strong psychometric properties. They also support its administration by telephone.

Ethnic differences in pain coping: factor structure of the coping strategies questionnaire and coping strategies questionnaire-revised

Coping has been examined extensively in the pain literature, although coping instruments have been typically validated in clinical populations with little ethnic diversity. This study examined the factor structure of the Coping Strategies Questionnaire (CSQ) and the CSQ-Revised (CSQ-R) in 650 healthy male and female African American (44%) and white (56%) subjects and explored associations of coping to health and pain-related measures. Factor analyses revealed 6 components for each ethnic group, accounting for comparable amounts of variance and resembling previously reported CSQ subscales. Internal consistency for both ethnic groups was acceptable (0.72-0.91). There were significant main effects for ethnicity on 4 of the CSQ-R scales (P < .05). No ethnic differences in pain or health variables emerged, although when split into high-pain versus minimal-pain groups, differences were revealed on catastrophizing. Results indicate that the factor structure of the CSQ-R in healthy adults is similar to clinical populations and is comparable across African American and white subjects. Group differences on CSQ-R scales suggest potentially important ethnic influences on pain coping. These findings support the use of the CSQ-R to assess coping in African Americans and in healthy young adults. Additional clinical research is needed to determine the practical importance of group differences in pain coping.

PERSPECTIVE

Coping has been examined extensively in the pain literature, although coping instruments typically have been validated in clinical populations with little ethnic diversity. This study examines the factor structure of the CSQ-Revised in an ethnically diverse population and supports the use of the CSQ-R to assess coping in African Americans and in healthy young adults.

Low back pain, disability and back pain myths in a community sample: prevalence and interrelationships

This study investigated the prevalence of back pain, disability, and, of most importance, the presence of misconceptions about low back pain (LBP), its diagnosis and treatment in a bicultural community sample (Belgium). Using the Graded Chronic Pain Scale [Pain 50 (1992) 133] persons were classified according to pain intensity and disability in five subgroups. The interrelationship between LBP beliefs and these five subgroups was also investigated. In our sample (n=1624) the 6-month prevalence of low back pain was 41.8%. Only in 8.2% back pain was disabling. Misconceptions about back pain were widespread, even in the group reporting no back pain. The least misconceptions were found to exist in participants with mild LBP without disability. It is suggested that recovery from an episode of acute low back pain is an active process that involves a correction of beliefs about harm, about the need to restrict physical activities and about medical diagnosis and cure. Finally, it is argued that community actions may be useful to correct LBP myths in order to prevent the development of long-term disability due to LBP.

Comorbidity of pain problems and depressive symptoms in young women: results from a cross-sectional survey among women aged 15-24 in Hungary

Frequent headaches and musculoskeletal pain problems were assessed as part of a cross-sectional health survey in a representative sample of 3615 young Hungarian women, aged 15-24 (mean age: 19.0 years). The representative sample was obtained by a multilevel stratified sampling procedure based on national statistical data, the refusal rate was 6%. Depressive symptomatology was assessed as well using the shortened form of the Beck Depression Inventory. The overall prevalence of frequent headaches was 43.8% in the sample, 25.8% of the investigated population reported chronic musculoskeletal pain problems. The co-prevalence rate of depression was significantly higher in the group of interviewees reporting pain problems, 11.2% in the group indicating frequent headaches (chi(2)=53.1, p<0.001), 10.3% in the group reporting musculoskeletal pain problems (chi(2)=12.4, p<0.001). In contrast, the prevalence of depressive symptomatology was 4.6% and 6.6% in the subgroups denying frequent headaches and musculoskeletal pain, respectively. The prevalence of chronic pain problems decreased with higher age, increased with the smaller size of residence and was lower in the non-student employment group, however, these differences across sociodemographic variables did not remain significant if tested by a multivariate logistic regression analysis. The high co-prevalence rates of depression in interviewees reporting chronic pain problem draws attention to the development of such secondary health problems and underscores the importance of early prevention. Epidemiological studies provide data for the better planning and management of prevention programs.