Is pain catastrophizing a stable trait or dynamic state in patients scheduled for knee arthroplasty? Clin J Pain. 2012;28:122-128. [PMID: 22001663 DOI: 10.1097/ajp.0b013e318226c3e2]

Emotions in search of words: Does alexithymia predict treatment outcome in chronic musculoskeletal pain?

Chronic pain, with its complex and multidimensional nature, poses significant challenges in identifying effective long-term treatments. There is growing scientific interest in how psychopathological and personality dimensions may influence the maintenance and development of chronic pain. This longitudinal study aimed to investigate whether alexithymia can predict the improvement of pain severity following a treatment-as-usual programme for chronic musculoskeletal pain over and above psychological cofactors (emotional distress, catastrophizing, and self-efficacy). A consecutive sample of 129 patients with diagnosed chronic musculoskeletal pain referred to two tertiary care centres was recruited and treated for 16 weeks. Clinical pain, psychological distress, self-efficacy, catastrophizing, and alexithymia were assessed with validated self-report measures at the first medical visit (T0) and at 16-week follow-up (T1). Compared with non-responder patients (n = 72, 55.8%), those who responded (i.e., reduction of >30% in pain severity; n = 57, 44.2%) reported an overall improvement in psychological variables except alexithymia. Alexithymia showed relative stability between baseline and follow-up within the entire sample and remained a significant predictor of treatment outcome even when other predictive cofactors (i.e., pain interference, depressive symptoms, and catastrophizing) were considered simultaneously. Our results suggest that identifying patients with a co-occurrence between alexithymia, depressive symptoms, catastrophizing, and the stressful experience of chronic pain can be clinically relevant in pain prevention and intervention programs.

Changes in illness perception, pain catastrophizing, and psychological distress following hand surgeon consultation: A prospective study

BACKGROUND

Baseline mindset factors are important factors that influence treatment decisions and outcomes. Theoretically, improving the mindset prior to treatment may improve treatment decisions and outcomes. This prospective cohort study evaluated changes in patients' mindset following hand surgeon consultation. Additionally, we assessed if the change in illness perception differed between surgical and nonsurgical patients.

METHODS

The primary outcome was illness perception, measured using the total score of the Brief Illness Perception Questionnaire (B-IPQ, range 0-80). Secondary outcomes were the B-IPQ subscales, pain catastrophizing (measured using the Pain Catastrophizing Scale (PCS)), and psychological distress (measured using the Patient Health Questionnaire-4).

RESULTS

A total of 276 patients with various hand and wrist conditions completed the mindset questionnaires before and after hand surgeon consultation (median time interval: 15 days). The B-IPQ total score improved from 39.7 (±10.6) before to 35.8 (±11.3) after consultation (p < 0.0001, Cohen's d = 0.36); scores also improved for the B-IPQ subscales Coherence, Concern, Emotional Response, Timeline, Treatment Control, and Identity and the PCS. There were no changes in the other outcomes. Surgical patients improved on the B-IPQ subscales Treatment Control and Timeline, while nonsurgical patients did not.

CONCLUSIONS

Illness perception and pain catastrophizing improved following hand surgeon consultation, suggesting that clinicians may actively influence the patients' mindset during consultations, and that they may try to enhance this effect to improve outcomes. Furthermore, surgical patients improved more in illness perceptions, indicating that nonsurgical patients may benefit from a more targeted strategy for changing mindset.

A Review of the Extent of Pain Catastrophizing in Patients Who Have Undergone Total Knee Replacement

OBJECTIVES

This study aimed to analyze the current status and influencing factors of pain catastrophizing in patients undergoing total knee replacement (TKR) and to provide a basis and reference for the clinical improvement of pain catastrophizing in these patients.

DESIGN

This study was designed in accordance with PRISMA guidelines.

DATA SOURCES

PubMed, the Web of Science, the Elton B. Stephens Company, the Cochrane Library, Embase, Chinese National Knowledge Infrastructure, the WanFang, Weipu and Chinese Biomedical Literature Databases.

REVIEW/ANALYSIS METHODS

A scoping review was performed using PubMed, the Web of Science, the Elton B. Stephens Company, the Cochrane Library, Embase, Chinese National Knowledge Infrastructure, the WanFang, Weipu, and Chinese Biomedical Literature Databases, and after literature screening and data extraction, the results were summarized.

RESULTS

A total of 23 articles were included in the study. Pain catastrophizing is mostly assessed using the Pain Catastrophizing Scale and the Coping Strategies Questionnaire. The level of pain catastrophizing is an independent predictor of pain in patients undergoing TKR and is influenced by demographic, psychological, co-morbid, and prognostic factors. Pain catastrophizing interventions mainly consist of surgery, physiotherapy, medication, and psychological therapy.

CONCLUSIONS

Pain catastrophizing involves multiple factors, and it is necessary to explore the predictors affecting pain catastrophizing, improve the systematic evaluation of pain catastrophizing and adopt the appropriate intervention methods.

Relationship of pain relief with catastrophizing following interventional pain procedures for low back pain

INTRODUCTION

Catastrophizing is associated with worse pain outcomes after various procedures suggesting its utility in predicting response. However, the stability of pain catastrophizing as a static predictor has been challenged. We assess, among patients undergoing steroid injections for chronic low back pain (cLBP), whether catastrophizing changes with the clinical response to pain interventions.

METHODS

This prospective study enrolled patients undergoing fluoroscopic-guided injections for cLBP. Patients filled out Brief Pain Inventory (BPI) and Pain Catastrophizing Scale (PCS) at baseline and 1-month follow-up. We assessed the change in PCS scores from pre-injection to post-injection and examined its predictors. We also examined the correlation of various domains of BPI, such as pain severity and effect on Relationships, Enjoyment, and Mood (REM), with PCS scores at baseline and follow-up.

RESULTS

128 patients were enrolled. Mean (SD) PCS and pain severity scores at baseline were 22.38 (±13.58) and 5.56 (±1.82), respectively. Follow-up PCS and pain severity scores were 19.76 (±15.25) and 4.42 (±2.38), respectively. The change in PCS pre-injection to post-injection was not significant (p=0.12). Multiple regression models revealed baseline PCS and REM domain of BPI as the most important predictors of change in PCS after injection. Pain severity, activity-related pain, age, sex, insurance status, depression, prior surgery, opioid use, or prior interventions did not predict change in PCS score. In correlation analysis, change in PCS was moderately correlated with change in pain (r=0.38), but weakly correlated with baseline pain in all pain domains.

CONCLUSIONS

PCS showed non-significant improvement following steroid injections; the study was not powered for this outcome. Follow-up PCS scores were predicted by the REM domain of BPI, rather than pain severity. Larger studies are needed to evaluate a statistically significant and clinically meaningful change in catastrophizing scores following pain interventions.

Changes in illness perception, pain catastrophizing, and psychological distress following hand surgeon consultation: A prospective study

BACKGROUND

Baseline mindset factors are important factors that influence treatment decisions and outcomes. Theoretically, improving the mindset prior to treatment may improve treatment decisions and outcomes. This prospective cohort study evaluated changes in patients' mindset following hand surgeon consultation. Additionally, we assessed if the change in illness perception differed between surgical and nonsurgical patients.

METHODS

The primary outcome was illness perception, measured using the total score of the Brief Illness Perception Questionnaire (B-IPQ, range 0-80). Secondary outcomes were the B-IPQ subscales, pain catastrophizing (measured using the Pain Catastrophizing Scale (PCS)), and psychological distress (measured using the Patient Health Questionnaire-4).

RESULTS

A total of 276 patients with various hand and wrist conditions completed the mindset questionnaires before and after hand surgeon consultation (median time interval: 15 days). The B-IPQ total score improved from 39.7 (±10.6) before to 35.8 (±11.3) after consultation (p < 0.0001, Cohen's d = 0.36); scores also improved for the B-IPQ subscales Coherence, Concern, Emotional Response, Timeline, Treatment Control, and Identity and the PCS. There were no changes in the other outcomes. Surgical patients improved on the B-IPQ subscales Treatment Control and Timeline, while nonsurgical patients did not.

CONCLUSIONS

Illness perception and pain catastrophizing improved following hand surgeon consultation, suggesting that clinicians may actively influence the patients' mindset during consultations, and that they may try to enhance this effect to improve outcomes. Furthermore, surgical patients improved more in illness perceptions, indicating that nonsurgical patients may benefit from a more targeted strategy for changing mindset.

Racial Differences in Head Pain and Other Pain-Related Outcomes After Mild Traumatic Brain Injury

Recent research suggests that mild traumatic brain injury (TBI) may exert deleterious effects on endogenous pain modulatory function, potentially underlying the elevated risk for persistent headaches following injury. Accumulating research also shows race differences in clinical and experimental pain, with African Americans (AA) generally reporting more severe pain, worse pain modulation, and greater pain sensitivity compared with Caucasians. However, race differences in pain-related outcomes following mild TBI have rarely been studied. The purpose of this study was to explore race differences in endogenous pain modulation, pain sensitivity, headache pain, and psychological factors among AA and Caucasian individuals with mild TBI in the first month following injury compared with healthy controls and across time. Patients with mild TBI were recruited from local emergency department trauma centers. Sixty-three participants with mild TBI (AAs: n = 23, Caucasians: n = 40) enrolled in this study and completed study sessions at 1-2 weeks and 1-month post-injury. Forty-one mild-TBI-free control participants (AAs: n = 11, Caucasians: n = 30), matched on age and sex, completed one study session. Assessments included a Headache Survey, Pain Catastrophizing Scale, Center for Epidemiological Studies-Depression Scale (CES-D), and quantitative sensory testing (QST) to measure endogenous pain modulatory function. QST included conditioned pain modulation (CPM) to measure endogenous pain inhibitory function and temporal summation (TS) of pain and pressure pain thresholds (PPTs) of the head to measure pain sensitization and sensitivity. Two-way analysis of variance (ANOVA) was used to determine whether the outcome measures differed as a function of race, mild TBI, and time. Mediation analysis was used to explore potential mediators for the race differences in headache pain intensity. The results showed that AA participants with mild TBI reported significantly greater headache pain and pain catastrophizing and exhibited higher pain sensitivity and worse pain modulation on QST compared with Caucasian participants with mild TBI. These same race differences were not observed among the healthy TBI-free control sample. The mediation analyses showed complete mediation for the relation between race and headache pain intensity by pain catastrophizing at 1-2 weeks and 1-month post-injury. Overall, the results of this study suggest that AAs compared with Caucasians are characterized by psychological and pain modulatory profiles following mild TBI that could increase the risk for the development of intense and persistent headaches following injury.

Preoperative Pain Catastrophizing and Neuropathic Pain Do Not Predict Length of Stay and Early Post-Operative Complications following Total Joint Arthroplasty

BACKGROUND

Both pain catastrophizing and neuropathic pain have been suggested as prospective risk factors for poor postoperative pain outcomes in total joint arthroplasty (TJA).

OBJECTIVE

We hypothesized that pain catastrophizers, as well as patients with pain characterized as neuropathic, would exhibit higher pain scores, higher early complication rates and longer lengths of stay following primary TJA.

METHODS

A prospective, observational study in a single academic institution included 100 patients with end-stage hip or knee osteoarthritis scheduled for TJA. In pre-surgery, measures of health status, socio-demographics, opioid use, neuropathic pain (PainDETECT), pain catastrophizing (PCS), pain at rest and pain during activity (WOMAC pain items) were collected. The primary outcome measure was the length of stay (LOS) and secondary measures were the discharge destinations, early postoperative complications, readmissions, visual analog scale (VAS) levels and distances walked during the hospital stay.

RESULTS

The prevalence of pain catastrophizing (PCS ≥ 30) and neuropathic pain (PainDETECT ≥ 19) was 45% and 20.4%, respectively. Preoperative PCS correlated positively with PainDETECT (rs = 0.501, p = 0.001). The WOMAC positively correlated more strongly with PCS (rs = 0.512 p = 0.01) than with PainDETECT (rs = 0.329 p = 0.038). Neither PCS nor PainDETECT correlated with the LOS. Using multivariate regression analysis, a history of chronic pain medication use was found to predict early postoperative complications (OR 38.1, p = 0.47, CI 1.047-1386.1). There were no differences in the remaining secondary outcomes.

CONCLUSIONS

Both PCS and PainDETECT were found to be poor predictors of postoperative pain, LOS and other immediate postoperative outcomes following TJA.

A qualitative study with orthopaedic surgeons on pain catastrophizing and surgical outcomes: shifting from a medical towards a biopsychosocial model of surgery

BACKGROUND

Pain catastrophizing (PC) moderates surgical outcomes and behavioural interventions are recommended to optimise post-operative results. Less is known about surgeons' experiences of providing care and their attitudes towards the use of interventions in practice.

OBJECTIVE

It is therefore invaluable to understand surgeons' views on how best to support patients who may be at risk of suboptimal recovery. Eleven surgeons and three registrar orthopaedic practitioners took part in semi-structured interviews within a hospital setting. The surgical decision-making process, views of PC and the use of behavioural interventions in surgical practice were explored.

RESULTS

Thematic analysis identified five themes: pain expressions and pain behaviours affect the surgeons' decision-making process, when pathologies and symptoms do not match, psychological factors pertaining to unsatisfactory outcomes, a service gap in surgical care and the acceptability of using a screening tool in surgical practice to identify patients at risk of suboptimal recovery.

CONCLUSION

Orthopaedic surgeons face challenges in identifying who is likely to reach optimal versus suboptimal outcome. Surgeons are becoming increasingly aware of patient psychological distress being detrimental to outcomes, and they support the use of behavioural interventions to optimise post-operative outcomes or stop unnecessary treatments. The surgeons accept the use of a screening tool in surgical practice with better access to support services with input from allied health professionals. A screening tool may provide great utility for identifying at risk patients, to allow for modification of surgical patients care plans.

Effect of perioperative cognitive behavioural therapy on chronic post-surgical pain among breast cancer patients with high pain catastrophising characteristics: protocol for a double-blinded randomised controlled trial

BACKGROUND

Surgery is regarded as the primary treatment for breast cancer. Chronic post-surgical pain (CPSP) is a recognised complication after breast cancer surgery, and it is estimated to affect 20-30% of women. Pain catastrophizing has emerged as one of the most influential psychological variables associated with CPSP.

METHODS

This trial will be a single-centre, prospective, double-blinded, superiority, randomised controlled trial (RCT). Patients scheduled for elective breast cancer surgery (wide local excision or mastectomy with or without axillary lymph node dissection) will be screened preoperatively for high pain catastrophising. Patients with high pain catastrophising, defined as a score of ≥ 24 on the Pain Catastrophising Scale will be deemed eligible for inclusion in the study. Participants will be randomly assigned to receive either a cognitive behavioural therapy or an educational mindfulness based programme during their perioperative period. The primary outcome is the Brief Pain Inventory short form average pain severity score at 3 months postoperatively. Secondary outcomes include patient-reported quality of recovery at days 1-2 after surgery, levels of pain catastrophising, reported depressed mood and anxiety.

DISCUSSION

To the best of our knowledge, this protocol describes the first RCT which directly examines the effect of perioperative cognitive behavioural therapy on CPSP among breast cancer patients with high pain catastrophising characteristics. The outcomes of this trial may have significant implications for these patients because perioperative cognitive behavioural therapy has the potential to become an important perioperative intervention to complement patient management.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04924010 . Registered on 11 June 2021. All item from the World Health Organisation Trial Registration Data set have been included.

Dispositional and situational personal features and acute post-collision head and neck pain: Double mediation of pain catastrophizing and pain sensitivity

Pain variability can be partially attributed to psycho-cognitive features involved in its processing. However, accumulating research suggests that simple linear correlation between situational and dispositional factors may not be sufficiently explanatory, with some positing a role for mediating influences. In addition, acute pain processing studies generally focus on a post-operative model with less attention provided to post-traumatic injury. As such, this study aimed to investigate a more comprehensive pain processing model that included direct and indirect associations between acute pain intensity in the head and neck, pain catastrophizing (using pain catastrophizing scale (PCS)), and pain sensitivity (using the pain sensitivity questionnaire (PSQ)), among 239 patients with post-motor vehicle collision pain. The effect of personality traits (using Ten Items Personality Inventory (TIPI)) and emotional status (using Hospital Anxiety and Depression Scale (HADS) and Perceived Stress Scale (PSS)) on that model was examined as well. To this end, three Structural Equation Modeling (SEM) analyses were conducted. Overall, the data had good fit to all the models, with only PSQ found to have a direct correlation with acute pain intensity. The SEM analyses conversely revealed several mediations. Specifically, that: first, PSQ fully mediated the relationship between PCS and pain intensity; second, PCS and PSQ together fully mediated the relationship between conscientiousness (personality trait) and pain intensity; and finally, emotional status had direct and indirect links with PSQ and pain intensity. In conclusion, these models suggest that during the acute post-collision phase, pain sensitivity intermediates between emotional states and personality traits, partially via elevated pain catastrophizing thoughts.

Pain Intensity Predicts Pain Catastrophizing During the Postpartum Period: A Longitudinal Random Intercept Cross-Lagged Panel Study

OBJECTIVE

Pain catastrophizing is an important psychological predictor of pain. Recent evidence suggests the relationship between catastrophizing and pain intensity could be bidirectional, but most studies have been conducted on chronic pain patients and using criticized statistical methods. The present study aimed to examine if the relationship between pain intensity and catastrophizing was bidirectional in the context of childbirth.

METHODS

A total of 504 women without chronic pain were recruited on their 32-37 gestational week. They completed measures of catastrophizing and pain intensity on the first encounter and then again at 1, 3, and 6 months postpartum. The temporal relationship between the variables was assessed using a random intercept cross-lagged panel model.

RESULTS

The hypothesis of reciprocal association did not receive support, as pain intensity predicted catastrophizing during the postpartum period, but catastrophizing did not show an effect over pain intensity at any moment.

CONCLUSIONS

Pain intensity predicting catastrophizing is consistent with previous literature, while the lack of effect of catastrophizing over pain intensity is an unexpected result, which may suggest that catastrophizing plays a different role in the postpartum period. These results highlight the importance of timely efforts for pain management during the postpartum period and contribute to the theoretical conceptualization of catastrophizing.

The association of sensory phenotype and concomitant mood, sleep and functional impairment with the outcome of carpal tunnel surgery

BACKGROUND

Up to 25% of people who have had carpal tunnel release surgery (CTR) fail to report improvement; however, evidence for prognostic indicators in this surgical cohort is limited. To identify candidate prognostic factors, this study investigated the association of quantitative sensory testing (QST) derived sensory phenotype and attendant impairment with patient-reported surgical outcome.

METHODS

With ethical approval and informed consent, this prospective observational longitudinal study recruited patients from two London hospitals. Multimodal phenotyping measures including quantitative sensory testing (QST), pain parameters, insomnia, pain-related worry, mood and function, were evaluated prior to; and at 3- and 6-months post-surgery. Pain in median nerve distribution with electrophysiologically confirmed conduction delay and DN4 score ≥ 4 was defined as neuropathic. Primary outcome was patient-rated change at 6 months, dichotomised as poor outcome; "worse" or "no change" and good outcome; "slightly better", "much better" or "completely cured".

RESULTS

Seventy-six patients participated. Prior to surgery, substantial heterogeneity in established categories of somatosensory function was observed with 21% of participants categorised as having a healthy sensory phenotype; 29% with thermal hyperalgesia; 32% mechanical hyperalgesia and 18% sensory loss. Seventy six percent of participants were classified as having neuropathic pain, 33% with high levels of pain related worry and 64% with clinical insomnia. Observed differences in pain, sleep impairment, psychological factors and function, between sensory phenotypic groups, was not significant. At 3- and 6-months post-surgery there was significant improvement in all phenotyping measures with a moderate to large effect size. Thermal and mechanical measures of somatosensation improved (p < 0.001), as did functional ability (p < 0.001). Symptom severity diminished (p < 0.001), as did pain-related worry (p < 0.001), anxiety (p = 0.02) and insomnia (p < 0.001). Patient-rated surgical outcome was good in 92% of the cohort, poor in 8%. Baseline sensory phenotype category was not associated with surgical outcome however pain-related worry, anxiety and functional interference were significantly associated with outcome (p ≤ 0.05).

CONCLUSION

In patients undergoing carpal tunnel surgery, pain-related worry, anxiety and pain functional interference are candidate prognostic outcome factors and require further elucidation.

A Mediation Appraisal of Catastrophizing, Pain-Related Outcomes, and Race in Adults With Knee Osteoarthritis

The current cross-sectional study investigates whether pain catastrophizing mediates the relationship between ethnicity/race and pain, disability and physical function in individuals with knee osteoarthritis. Furthermore, this study examined mediation at 2-year follow-up. Participants included 187 community-dwelling adults with unilateral or bilateral knee pain who screened positive for knee osteoarthritis. Participants completed several self-reported pain-related measures and pain catastrophizing subscale at baseline and 2-year follow-up. Non-Hispanic Black (NHB) adults reported greater pain, disability, and poorer functional performance compared to their non-Hispanic White (NHW) counterparts (Ps < .05). NHB adults also reported greater catastrophizing compared to NHW adults. Mediation analyses revealed that catastrophizing mediated the relationship between ethnicity/race and pain outcome measures. Specifically, NHB individuals reported significantly greater pain and disability, and exhibited lower levels of physical function, compared to NHW individuals, and these differences were mediated by higher levels of catastrophizing among NHB persons. Catastrophizing was a significant predictor of pain and disability 2-years later in both ethnic/race groups. These results suggest that pain catastrophizing is an important variable to consider in efforts to reduce ethnic/race group disparities in chronic pain. The findings are discussed in light of structural/systemic factors that may contribute to greater self-reports of pain catastrophizing among NHB individuals. PERSPECTIVE: The current study examines whether pain catastrophizing mediates the relationship between ethnicity/race and OA-related pain, disability, and functional impairment at baseline and during a 2-year follow-up period in non-Hispanic Black and non-Hispanic White adults with knee pain. These results point to the need for interventions that target pain catastrophizing.

Patients With High Chronic Postoperative Knee Pain 5 Years After Total Knee Replacement Demonstrate Low-grad Inflammation, Impairment of Function, and High Levels of Pain Catastrophizing

OBJECTIVES

Total knee replacement (TKR) normally provides improvements of physical function and reduces pain. However, ∼20% of the patients report chronic postoperative knee pain. The aims of the present study were to assess the pain, physical function, and physiological characteristics 5 years after TKR surgery.

MATERIALS AND METHODS

Eighty patients were recruited 5 years after TKR and divided into 2 groups based on their average 24-hour knee pain intensity assessed on a visual analog scale (VAS 0 to 10) ("high pain group": VAS≥3; "low pain group": VAS<3). The patients completed the PainDETECT Questionnaire (PDQ), Oxford Knee Score (OKS), Pain Catastrophizing Scale, and Forgotten Joint Score-12. Furthermore, the patients underwent a clinical examination of the knees and high-sensitivity serum C-reactive protein was measured as an inflammatory marker.

RESULTS

A total of 53% of the patients in the high pain group were not satisfied with the outcome, while only 11% of the patients in the low pain group was not satisfied, and the pain intensities in the 2 groups were 5.1 (4.6 to 5 to 6) and 1.1 (0.6 to 1.5) (P<0.001), respectively. Furthermore, the high pain group demonstrates worse scores in: Forgotten Joint Score-12 (P=0.001), OKS function (P<0.001), OKS pain (P<0.001), and Pain Catastrophizing Scale (P<0.001).The high pain group demonstrated increased level of high-sensitivity serum C-reactive protein (4.3 mg/L [3.2 to 5.5] vs. 1.7 mg/L [1.2 to 2.2], P<0.001), and decreased range of motion in the knee (110 vs. 119-degree range of motion, P=0.013).

DISCUSSION

Patients with high chronic postoperative knee pain 5 years after TKR demonstrate decreased physical function, higher levels of catastrophizing thoughts, and increased levels of inflammation.

Temporal Association of Pain Catastrophizing and Pain Severity Across the Perioperative Period: A Cross-Lagged Panel Analysis After Total Knee Arthroplasty

OBJECTIVE

Although numerous studies show that preoperative pain catastrophizing is a risk factor for pain after total knee arthroplasty (TKA), little is known about the temporal course of the association between perioperative pain catastrophizing and pain severity. The present study investigated temporal changes and their dynamic associations between pain catastrophizing and pain severity before and after TKA.

DESIGN

A secondary data analysis of a larger observational parent study featuring prospective repeated measurement over 12 months.

SETTING

Dual-site academic hospital.

SUBJECTS

A total of 245 individuals who underwent TKA.

METHODS

Participants completed pain catastrophizing and pain severity questionnaires at baseline, 6 weeks, and 3, 6, and 12 months after TKA. Cross-lagged panel analysis was conducted with structural equation modeling including age, sex, race, baseline anxiety, and depressive symptoms as covariates.

RESULTS

Reduction in pain catastrophizing from baseline to 6 weeks after TKA was associated with lower pain severity at 3 months after TKA (standardized β = 0.14; SE = 0.07, P = 0.046), while reduction in pain severity at 6 weeks after TKA was not associated with pain catastrophizing at 3 months after TKA (P = 0.905). In the chronic postsurgical period (>3 months), pain catastrophizing at 6 months after TKA predicted pain severity at 12 months after TKA (β = 0.23, P = 0.009) with controlling for auto-correlation and covariates, but not vice versa.

CONCLUSIONS

We provide evidence that changes in pain catastrophizing from baseline to 6 weeks after TKA are associated with subsequent pain severity. Future studies are warranted to determine whether targeting pain catastrophizing during the perioperative period may improve clinical outcomes for individuals undergoing TKA.

Postoperative Psychosocial Factors in Health Functioning and Health-Related Quality of Life After Knee Arthroplasty: A 6-Month Follow up Prospective Observational Study

OBJECTIVE

Knee arthroplasty (KA) is an effective and cost-effective treatment for end-stage knee osteoarthritis. Despite high surgical success rates, as many as 25% of patients report compromised postoperative functioning, persistent pain, and reduced quality of life. The purpose of this study was to assess the predictive value of psychological factors in health functioning and quality of life, during a 6-month period after KA.

DESIGN

A prospective observational study.

SETTING

Surgery at two hospitals and follow-up was carried out through the domiciliary rehabilitation service.

SUBJECTS

In total, 89 patients (age 70.27 ± 7.99 years) met the inclusion criteria.

METHOD

A test battery composed of Health functioning associated with osteoarthritis (WOMAC), Health-related quality of life (EQ-5D-5L), Anxiety and Depression (HADS), Pain attitudes (SOPA-B), Pain catastrophizing (PCS), and Fear of Movement (TSK-11) was assessed at 1 week, and 1, 3, and 6 months after surgery. A mixed effects linear model was used to estimate the effect of time and covariates. An exploratory factor analysis was used to identify the number of dimensions underlying the group of psychological measurements.

RESULTS

In WOMAC model, anxiety level (F = 120.8), PCS (F = 103.9), depression level (F = 93.6) and pain score (F = 72.8) were the most influential variables. Regarding EQ-5D-5L model, anxiety level (F = 98.5), PCS (F = 79.8), depression level (F = 78.3) and pain score (F = 45) were the most influential variables. Pain score and the psychosocial variables of PCS, TSK, HADS-A, HADS-D, SOPA-B Emotion, SOPA-B Harm and SOPA-B Disability loaded in one single dimension.

CONCLUSIONS

Postoperative acute pain and psychosocial factors of pain catastrophizing, anxiety, depression, and pain attitudes might influence health functioning and quality of life during KA rehabilitation. Such factors could be gathered into one single dimension defined as pain-related psychologic distress.

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

Background

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

Methods

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

Discussion

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

Trial registration

Clinicaltrials (NCT03969602). Registered 31 May 2019,

Assessment of postoperative health functioning after knee arthroplasty in relation to pain catastrophizing: a 6-month follow-up cohort study

BACKGROUND

Knee arthroplasty (KA) is a typically successful surgical procedure commonly performed to alleviate painin participants with end-stage knee osteoarthritis. Despite its beneficial effects, a significant proportion of individuals with KA continue experiencing persistent pain and functional limitations. The purpose of this study was to assess the postoperative outcomes after KA in relation to postoperative pain catastrophizing.

METHODS

Participants were recruited at a domiciliary physiotherapy service, using a prospective, observational, hypothesis-generating cohort design. Participants were divided into two groups based on their Pain Catastrophizing Scale (PCS) total score (50th percentile), which resulted in high and low PCS groups. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). In addition, quality of life, walking speed, physical performance, range of motion, and pain were measured. Outcome measures were collected at baseline (1 week postoperatively) and at follow-up (1, 3, and 6 months postoperatively).

RESULTS

A total of 60 participants (21 total KA and 39 unicompartmental KA) were recruited. Individuals with a higher degree of pain catastrophizing showed significantly higher WOMAC total scores at every follow-up, indicating poorer health functioning (p < 0.01). Similarly, the high PCS group showed higher WOMAC pain, stiffness and disability subscale scores (p < 0.05), poorer quality of life (p < 0.01), and poorer physical performance (p < 0.05) at every follow-up. In addition, the high PCS group achieved a slower walking speed at baseline and at 3 months follow-up (p < 0.05), and a higher degree of pain at rest, on walking and on knee flexion at every follow-up (p < 0.01, p < 0.05 and p < 0.05, respectively) except for walking pain at 3 months follow-up. No significant differences were observed between groups in range of motion, except for active knee extension at the 6-month follow-up (p < 0.05). Effect size was large at 1 month follow-up in WOMAC total score (r = 0.578) and pain intensity during knee flexion (r = 0.529). Longitudinal analyses revealed different improvement trends during the rehabilitation process between groups, with a lack of significant improvements in the high PCS group between the 3- and 6-month follow-up in WOMAC total score, WOMAC pain, WOMAC disability, quality of life, physical performance, active knee extension and resting pain (p > 0.05).

CONCLUSION

The results of the present study suggest that participants with high postoperative pain catastrophizing might have poorer outcomes during the rehabilitation process after KA. Future work should seek to clarify if this relationship is causal.

Disentangling trait versus state characteristics of the Pain Catastrophizing Scale and the PHQ-8 Depression Scale

BACKGROUND

Research on the role of trait versus state characteristics of a variety of measures among persons experiencing pain has been a focus for the past few decades. Studying the trait versus state nature of the Pain Catastrophizing Scale (PCS) and the Patient Health Questionnaire (PHQ-8) depression scale would be highly informative given both are commonly measured in pain populations and neither scale has been studied for trait/state contributions.

METHODS

The PHQ-8 and PCS were obtained on persons undergoing knee arthroplasty at baseline, 2-, 6- and 12-month post-surgery (N = 402). The multi-trait generalization of the latent trait-state model was used to partition trait and state variability in PCS and PHQ-8 item responses simultaneously. A set of variables were used to predict trait catastrophizing and trait depression.

RESULTS

For total scores, the latent traits and latent states explain 63.2% (trait = 43.2%; state = 20.0%) and 50.2% (trait = 29.4%; state = 20.8%) of the variability in PCS and PHQ-8, respectively. Patients with a high number of bodily pain sites, high levels of anxiety, young patients and African-American patients had high levels of trait catastrophizing and trait depression. The PCS and the PHQ-8 consist of both enduring trait and dynamic state characteristics, with trait characteristics dominating for both measures.

CONCLUSION

Clinicians and researchers using these scales should not assume the obtained measurements solely reflect either trait- or state-based characteristics.

SIGNIFICANCE

Clinicians and researchers using the PCS or PHQ-8 scales are measuring both state and trait characteristics and not just trait- or state-based characteristics.

Stability of Measures of Pain Catastrophizing and Widespread Pain Following Total Knee Replacement

OBJECTIVE

Pain catastrophizing and widespread pain are predictors of pain chronicity/severity. Gaps remain in our understanding of the extent to which each is a stable (trait) or dynamic (state) variable. We undertook this study to assess the stability of each variable from before to after total knee replacement (TKR) and whether changes are explained by pain improvements.

METHODS

We used data from a prospective study of TKR recipients ages ≥40 years. Questionnaires included body pain diagrams assessing widespread pain, the Pain Catastrophizing Scale (PCS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale. We divided subjects into widespread pain groups (0 versus 1-2 versus ≥3 pain regions) and into low and high PCS score groups (<16 versus ≥16). We assessed changes in group membership from pre-TKR to 12 months post-TKR, then compared these changes between subjects with most and least WOMAC pain improvement.

RESULTS

A total of 176 subjects completed scales at both time points; 64% were female, the mean age was 66 years, and baseline median WOMAC pain score was 40. In all, 71% of subjects in the high PCS score group improved to join the low PCS score group at follow-up. While 73 subjects (41%) changed widespread pain group, they were similarly likely to worsen and to improve. We found a statistically significant positive association of improvement in WOMAC pain score with improvement in PCS score (r = 0.31), but not widespread pain (r = -0.004).

CONCLUSION

The PCS score reflects state-like aspects of catastrophizing that diminish along with pain. In contrast, widespread pain scores worsened and improved equally often, regardless of knee pain relief. The findings urge caution in interpreting PCS score and widespread pain as trait measures in musculoskeletal research.

Local Anesthetic Injection Resolves Movement Pain, Motor Dysfunction, and Pain Catastrophizing in Individuals With Chronic Achilles Tendinopathy: A Nonrandomized Clinical Trial

OBJECTIVES

Peripherally directed treatments (targeted exercise, surgery) can reduce, but not fully eliminate, pain for up to 40% of patients with Achilles tendinopathy. The objectives of the present study were (1) to identify indicators of altered central processing in participants with Achilles tendinopathy compared to controls, and (2) to determine which indicators of altered central processing would persist after a local anesthetic injection in patients with Achilles tendinopathy.

DESIGN

Mechanistic clinical trial.

METHODS

Forty-six adults (23 with chronic Achilles tendinopathy, 23 matched controls) repeated (1) a movement-evoked pain rating, (2) motor performance assessment, (3) pain psychology questionnaires, and (4) quantitative sensory testing. Participants with Achilles tendinopathy received a local anesthetic injection before repeat testing and controls did not. Mixed-effects analyses of variance examined the effects of group, time, and group by time.

RESULTS

The Achilles tendinopathy group had movement-evoked pain, motor dysfunction, and higher pain psychological factors (pain catastrophizing, kinesiophobia) compared to controls (P<.05). The Achilles tendinopathy group did not have indicators of nociplastic pain with quantitative sensory testing (P>.05). In those with Achilles tendinopathy, local anesthetic injection eliminated pain and normalized the observed deficits in heel-raise performance and pain catastrophizing (group-by-time effect, P<.01), but not in kinesiophobia (P = .45). Injection did not affect measures of nociplastic pain (P>.05).

CONCLUSION

People with Achilles tendinopathy had elevated pain psychological factors and motor dysfunction but no signs of nociplastic pain with quantitative sensory testing. Removal of nociceptive input normalized movement-evoked pain and some indicators of altered central processing (motor dysfunction, pain catastrophizing), but not kinesiophobia. J Orthop Sports Phys Ther 2020;50(6):334-343. Epub 29 Apr 2020. doi:10.2519/jospt.2020.9242.

Pain Catastrophizing in College Athletes

BACKGROUND

Pain is the most common patient-reported symptom but the perception of pain is complex, differs between individuals and is not directly proportional to the extent of injury. The relationship between aberrant pain coping strategies such as pain catastrophizing and the presence of pain in competitive athletes should be further established to employ the most optimal treatment.

HYPOTHESIS

The hypotheses were that numeric pain rating and pain catastrophizing (Pain Catastrophizing Scale, PCS) scores would have a moderate to strong relationship in college athletes, and athletes with either a current injury or previous injury, or playing with pain, would have significantly higher pain catastrophizing scores compared with noninjured/nonpainful athletes.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

III.

METHODS

College athletes completed a demographic form, injury questionnaire, numeric pain rating, and the PCS. All athletes were medically cleared for sports participation at the time of survey completion. A total PCS score was calculated in addition to a rumination, magnification, and helplessness score. Spearman rank was utilized to measure the strength of relationship between the PCS score and pain rating.

RESULTS

A total of 291 athletes from 15 different sports completed the questionnaires (males: 156, females: 135; age: 19 [2] y). Negligible correlations existed between the PCS score and pain (r = .27). Athletes who were currently injured or previously injured had significantly higher PCS scores compared with uninjured athletes (P < .01).

CONCLUSIONS

Approximately one-third of college athletes reported playing injured and/or with pain, but the relationship between pain rating and PCS score was negligible. The individualistic nature of pain perception and coping strategies would suggest that clinicians may want to consider screening for pain catastrophizing either prior to athletic participation or for athletes not following an expected recovery after injury in an effort to enhance individualized patient care.

Identification of Functioning Domains in the Presurgical Period and Their Relationships with Opioid Use and Pain Catastrophizing

OBJECTIVES

The National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) is a multidimensional screening system evaluating biopsychosocial factors affecting pain and functioning. Using a military sample, the current study 1) examined the structure and domains of the PROMIS, the Defense and Veterans Pain Rating Scale 2.0 (DVPRS), and the Pain Catastrophizing Scale (PCS) within a presurgical setting and 2) examined the relationship of these variables to pre- and postsurgical opioid use.

METHODS

This cross-sectional study included 279 adult patients scheduled for surgery at the Walter Reed National Military Medical Center and a validation sample of 79 additional patients from the Naval Medical Center, San Diego. PROMIS, DVPRS, PCS, and opioid use data were collected before surgery. Exploratory factor analysis and confirmatory factor analysis identified the latent structure for the measures. A structural equation model (SEM) examined their relationship to pre- and postsurgical opioid use.

RESULTS

Two latent factors represented Psychosocial Functioning (PROMIS Depression, PROMIS Anxiety, and PROMIS Social Isolation) and Pain Impact (DVPRS, PROMIS Pain Interference, PROMIS Physical Functioning). The remaining PROMIS scales did not load onto a single factor. In the SEM, the two latent factors and PCS were significantly related to pre- and postsurgical opioid use.

CONCLUSIONS

This study highlights the utility and relative ease of using a convenient multidimensional assessment in presurgical settings. Using such an assessment can help provide targeted interventions for individuals who may be at greatest risk for negative postsurgical outcomes.

How does reduction in pain lead to reduction in disability in patients with musculoskeletal pain?

Purpose

Reduction in pain following multidisciplinary treatment is most often associated with a reduction in disability. To further elaborate the relationship between pain intensity and disability, the present study investigated three main questions: first, whether multidisciplinary treatment leads to a significant improvement in pain, disability and psychological variables (depression, pain acceptance and catastrophizing). Second, it was examined whether pain reduction may account for significant changes in the psychological variables (pre- to follow-up change scores). Finally, it was analyzed whether the psychological changes mediate the association between reduction in pain and in disability after controlling for age, sex and pain history.

Patients and methods

Patients suffering from chronic musculoskeletal pain (n=279) attended a German inpatient multidisciplinary program lasting 15 consecutive days on average, with self-report data collected at pretreatment, posttreatment and three-month follow-up.

Results

Repeated measures ANOVAs showed a significant improvement in pain intensity, disability, pain acceptance, catastrophizing and depression at posttreatment and follow-up. Univariate regression analyses revealed that changes in pain intensity accounted for significant changes in depression, pain catastrophizing and pain acceptance (pre- to follow-up change scores). The results of Multiple Mediation Procedure showed that pain reduction did affect reduction in disability through improvement of depression, catastrophizing and acceptance.

Conclusion

Our findings support a cognitive-behavioral model of pain that posits an important role for pain-related cognitive and emotional processes in long-term outcomes following multidisciplinary pain treatment, in particular for the modulation of disability due to pain. The results add evidence to the notion that pain-related cognitions are dynamic features varying over time dependent on the internal situation.

Perspective

The current findings are relevant to the management of patients with musculoskeletal pain. The results support the notion that, in contrast with the view of enduring personality traits, pain-related cognitions and emotions reflect a situational response that varies over time.

Can pain catastrophizing be changed in surgical patients? A scoping review

Background

Catastrophizing, a coping style characterized by an exaggerated negative affect when experiencing or anticipating pain, is an important factor that adversely affects surgical outcomes. Various interventions have been attempted with the goal of reducing catastrophizing and, by extension, improving treatment outcomes. We performed a systematic review to determine whether catastrophizing can be altered in surgical patients and to present evidence for interventions aimed at reducing catastrophizing in this population.

Methods

Using a scoping design, we performed a systematic search of MEDLINE and Embase. Studies reporting original research measuring catastrophizing, before and after an intervention, on the Pain Catastrophizing Scale (PCS) or Coping Strategies Questionnaire (CSQ) were selected. Studies were assessed for quality, the nature of the intervention and the magnitude of the effect observed.

Results

We identified 47 studies that measured the change in catastrophizing score following a broad range of interventions in surgical patients, including surgery, patient education, physiotherapy, cognitive behavioural therapy, psychologist-directed therapy, nursing-directed therapy and pharmacological treatments. The mean change in catastrophizing score as assessed with the PCS ranged from 0 to –19, and that with the CSQ, from +0.07 to –13. Clinically important changes in catastrophizing were observed in 7 studies (15%).

Conclusion

Catastrophizing was observed to be modifiable with an intervention in a variety of surgical patient populations. Some interventions produced greater reductions than others, which will help direct future research in the improvement of surgical outcomes.

Child and parent pain catastrophizing and pain from presurgery to 6 weeks postsurgery: examination of cross-sectional and longitudinal actor-partner effects

Child and parent pain catastrophizing are reported preoperative risk factors for children's acute and persistent postsurgical pain. This study examined dyadic relations between child and parent pain catastrophizing and child and parent ratings of child pain prior to (M = 4.01 days; "baseline") and following surgery (M = 6.5 weeks; "acute follow-up"), as well changes in pain catastrophizing during this time in 167 youth (86% female; Mage = 14.55 years) undergoing spinal fusion surgery and 1 parent (89% mothers). Actor-partner interdependence models assessed cross-sectional and longitudinal intra- and interpersonal effects. Cross-sectionally, child pain catastrophizing was positively associated with child pain at baseline and acute follow-up (actor effects: βbaseline = 0.288 and βfollow-up = 0.262; P < 0.01), and parents' ratings of child pain at baseline (partner effect: βbaseline = 0.212; P < 0.01). Parent pain catastrophizing was not cross-sectionally associated with ratings of child pain. Longitudinally, higher pain catastrophizing at baseline predicted higher pain catastrophizing at acute follow-up for children (actor effect: β = 0.337; P < 0.01) and parents (actor effect: β = 0.579; P < 0.01) with a significantly smaller effect for children (respondent × actor interaction: β = 0.121; P < 0.05). No longitudinal partner effects for catastrophizing were observed. Baseline child and parent pain catastrophizing did not predict child pain at acute follow-up. In conclusion, child, not parent, pain catastrophizing was associated with children's pre- and postsurgical pain, and showed significantly less stability over time. There is a need to better understand contributors to the stability or changeability of pain catastrophizing, the prospective relation of catastrophizing to pain, and contexts in which child vs parent pain catastrophizing is most influential for pediatric postsurgical pain.

Change in pain catastrophizing in patients with lumbar spinal surgery

BACKGROUND CONTEXT

Even though catastrophizing can negatively moderate the outcome of surgery for lumbar spinal stenosis (LSS), it is still unclear whether pain catastrophizing is an enduring stable or a dynamic structure related to pain intensity after spine surgery.

PURPOSE

The purpose of this study was to determine whether catastrophizing would change in patients who undergo spinal surgery for LSS.

STUDY DESIGN

A prospective observational cohort study was carried out.

STUDY SAMPLE

Patients who underwent spine surgery for LSS comprised the study sample.

OUTCOME MEASURES

The Visual Analog Pain Scale (VAS) scores for back/leg pain, Oswestry Disability Index (ODI), and Pain Catastrophizing Scale (PCS) were the outcome measures.

METHODS

The present observational cohort consisted of 138 patients between the ages of 40 and 80 years who were scheduled to undergo surgery for LSS. Among them, a total of 96 patients underwent a 3-year assessment after surgery. The PCS questionnaire was used for pain catastrophizing assessment before and 3 years after surgery. The VAS for back and leg pain, and ODI were assessed 3 and 6 months, and 1 and 3 years after surgery. The correlations between variables were analyzed before and 3 years after surgery. To clarify the causal relationship, time-series and linear mixed models were also used.

RESULTS

At 3 years after surgery, ODI, VAS for back and leg pain, and PCS scores were significantly decreased. The correlation of PCS with VAS and ODI was significant both before and 3 years after surgery. The correlation between change in pain or disability and change in pain catastrophizing from preoperative to 3 years after surgery was also significant. In the causal relationship between pain and catastrophizing, overall changes in pain and disability were significant predictors of overall changes in pain catastrophizing from baseline to 3 year after surgery.

CONCLUSION

The present study shows that pain catastrophizing can change in association with the improvement in pain intensity after spine surgery. Therefore, catastrophizing may not be an enduring stable construct, but a dynamic construct.

Past Pain Experience and Experimentally induced Pain Perception

Many intercurrent factors may be involved in the modulation of the pain message and its expression, such as the previous experience of pain built along the life. In this study, we aimed to determine whether susceptibility to experimentally induced pain is differentially influenced by the individual previous painful experience in subjects with schizophrenia (SC) major depression (MD), and controls (C).

METHODS

The SC (30), MD (32) and C (30) groups participated in experimental pain tests (application of pressure and induction of ischemia) after a semi-structured interview to make an inventory of the previous painful experiences, and the evaluation of anxiety either with autonomic (heart rate, blood pressure) or psychological (Hospital Anxiety Depression scale HAD) measures, and catastrophism.

RESULTS

The reported pain intensities, severities, duration, of the previous pain events, and the number of previous painful events were equivalent in the three groups, except for the number of painful events experimented before the last six months which was lower in the MD group. Experimental pain sensitivity was influenced by the diagnosis, the HAD scores or the number and intensities of previous lived painful events.

CONCLUSION

The lack of a past experience of pain was comparable for the different groups, suggesting that psychiatric disorders do not affect the experience of pain associated with daily life or past events. For each subject, the reported previous experience of pain influences the present feeling of pain.

Kinesiophobia and depression affect total knee arthroplasty outcome in a multivariate analysis of psychological and physical factors on 200 patients

PURPOSE

To evaluate the effects of kinesiophobia on the outcomes of total knee arthroplasty (TKA), and to investigate whether kinesiophobia represents an independent factor influencing the surgery success or whether the observed effects are driven by other physical or psychological aspects such as anxiety and depression.

METHODS

Two hundred patients were evaluated prospectively (mean age 65.7 ± 9.1 years, 134 women and 66 men) at 12 months after TKA. Kinesiophobia was assessed with the Tampa Scale for kinesiophobia (TSK: Activity Avoidance-TSK1 and Harm-TSK2 subscales); anxiety and depression were assessed with STAI and BDI, respectively, and preoperative pain and function, sex, age, BMI, education level, number of painful joints and years of symptoms' duration before surgery were documented as well. Results were evaluated with pain and function on 0-10 numeric rating scales, while the overall clinical outcome was documented with WOMAC and SF-12 (Physical and Mental subscales) scores.

RESULTS

TSK1 was correlated with WOMAC results at 12 months (p = 0.005, ρ = 0.197). STAI (p = 0.002, ρ = 0.222), BDI (p < 0.0005, ρ = 0.307), and sex (p = 0.004) also influenced the outcome after TKA, while other parameters, such as age, BMI, education level, and number of painful joints and years of symptoms' duration before surgery, did not correlate with the clinical outcome. The multivariate analysis confirmed the role of BDI (p = 0.006, partial η ² = 0.038), TSK1 (p = 0.011, partial η ² = 0.033), and sex (p = 0.048, partial η ² = 0.020), and a synergic interaction of BDI and TSK1, which together presented an even stronger correlation (p < 0.0005, partial η ² = 0.111) with WOMAC at 12-month follow-up.

CONCLUSIONS

Kinesiophobia is a factor influencing the outcome after TKA independently from other psychological and physical variables. This risk factor may affect TKA results, especially in women, and shows a further synergic interaction with depression in terms of lower surgical outcome. These findings are of clinical relevance because they show the impact of psychological factors such as kinesiophobia, and suggest the possibility of adopting co-interventions to overcome the fear of physical activity, and in the end improve patient recovery and final outcome after TKA.

LEVEL OF EVIDENCE

IV.

An Integrated Model of Chronic Whiplash-Associated Disorder

Synopsis The development of persistent symptoms following whiplash injury from a motor vehicle collision is common and contributes substantially to societal and personal costs. The popular Quebec Task Force classification system of whiplash-associated disorders (WADs) was meant to function as a prognostic and intervention decision aid, but its usefulness has been questioned. Emerging evidence highlights the heterogeneity of WAD by demonstrating physical and psychological impairments that are unique to those who develop persistent symptoms. These impairments are not recognized in the Quebec Task Force classification system. The purpose of this clinical commentary is to describe an integrated model that focuses on how psychological and neurobiological factors interact with, and are influenced by, existing personal and environmental factors to contribute to the development of chronic WAD. The model has been developed through more than 20 years of work in the field, consultation with experts, in-depth synthesis of existing evidence, and new evidence from the authors' own research programs. A subtheme is that a point of convergence currently exists between the psychological, physiological, and social determinants of health literature that can further explain the complex presentation of WAD. The new model is proposed to orient future research toward more interdisciplinary efforts across nontraditional fields, including data scientists and consumers, to clarify the WAD condition. J Orthop Sports Phys Ther 2017;47(7):462-471. Epub 16 Jun 2017. doi:10.2519/jospt.2017.7455.

Relationship between biological factors and catastrophizing and clinical outcomes for female patients with knee osteoarthritis

AIM

To investigate the correlations between clinical outcomes and biopsychological variables in female patients with knee osteoarthritis (OA).

METHODS

Seventy-seven patients with symptomatic knee OA were enrolled in this study. We investigated the age, body mass index (BMI), pain catastrophizing scale (PCS) and radiographic severity of bilateral knees using a Kellgren-Lawrence (K-L) grading system of the subjects. Subsequently, a multiple linear regression was conducted to determine which variables best correlated with main outcomes of knee OA, which were pain severity, moving capacity by measuring timed-up-and-go test and Japanese Knee Osteoarthritis Measure (JKOM).

RESULTS

We found that the significant contributor to pain severity was PCS (β = 0.555) and BMI (β = 0.239), to moving capacity was K-L grade (β = 0.520) and to PCS (β = 0.313), and to a JKOM score was PCS (β = 0.485) and K-L grade (β = 0.421), respectively.

CONCLUSION

The results suggest that pain catastrophizing as well as biological factors were associated with clinical outcomes in female patients with knee OA, irrespective of radiographic severity.

Depression and anxiety after total joint replacement among older adults: a meta-analysis

OBJECTIVE

Patients usually experience good physical recovery after total joint replacement (TJR); however, it is unclear whether mood also improves. The current meta-analysis examined changes in depression and anxiety following TJR in older (≥50 years) patients in order to address this gap in the literature.

METHODS

Data from 26 studies (4045 TJR, 55 controls) that assessed depression and/or anxiety pre- and post-surgery in TJR patients, with or without a control group, were analyzed. Prevalence rates and Cohen's d effect sizes were used to evaluate changes in the prevalence and severity of depression/anxiety, respectively.

RESULTS

Approximately 23% of TJR patients had clinically significant levels of depression prior to surgery, which decreased to 13% one year later. The prevalence of anxiety could not be evaluated due to the limited available data. TJR patients did not show any clinically meaningful reductions in symptoms of depression or anxiety, following surgery. Compared to controls, there was no difference in symptom progression over time; although only one study examined this.

CONCLUSIONS

TJR patients appear to have higher rates of clinically significant symptoms of depression before and after surgery, compared to the general population, however more research with adequate control groups is needed to confirm this. Only a modest improvement in the severity of depression and anxiety symptoms was noted post-surgery. However, existing research is limited; preventing definite conclusions regarding the impact of TJR on mood.

Patient kinesiophobia affects both recovery time and final outcome after total knee arthroplasty

PURPOSE

To evaluate the effects of kinesiophobia on both phases immediately after surgery and the final results after total knee arthroplasty (TKA).

METHODS

This study evaluated prospectively 101 patients (mean age 66 ± 8.0 years, 70 women and 31 men), 5 days after surgery, at 1, 6, 12 months, and at a mean final follow-up of 3.2 ± 0.7 years (2.0-4.2 years). Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia (TSK: Activity Avoidance-TSK1 and Harm-TSK2 subscales), and results were evaluated with range of motion, pain and function on 0-10 numeric rating scales, WOMAC and SF-12 (Physical and Mental subscales) scores.

RESULTS

TSK1 was correlated with the acute postoperative pain measured at 5 days (p = 0.031), pain measured at 12 months (p = 0.018), patient perceived function at 12 months (p = 0.025), SF-12P at 6 months (p < 0.001), SF-12P and SF-12M at 12 months (p = 0.001 and p = 0.005, respectively), and WOMAC at both 6 and 12 months of follow-up (p = 0.005 and p = 0.001). The effect of TSK 1 on the final WOMAC score was significant when corrected by age and sex (p = 0.049, η ² = 0.041): the youngest female patients were affected even by moderate kinesiophobia levels.

CONCLUSIONS

Fear of pain and even more avoidance of movement are strongly correlated both with the acute postoperative pain perception and recovery after surgery up to 1 year, thus presenting a relevant clinical impact on the outcome after TKA. Moreover, this study showed that even though at longer follow-up its impact decreases, patients with higher levels of kinesiophobia may present a poorer final outcome, especially women.

LEVEL OF EVIDENCE

IV.

Associations between psychological variables and pain in experimental pain models. A systematic review

BACKGROUND

The association between pain and psychological characteristics has been widely debated. Thus, it remains unclear whether an individual's psychological profile influences a particular pain experience, or if previous pain experience contributes to a certain psychological profile. Translational studies performed in healthy volunteers may provide knowledge concerning psychological factors in healthy individuals as well as basic pain physiology. The aim of this review was to investigate whether psychological vulnerability or specific psychological variables in healthy volunteers are predictive of the level of pain following experimental pain models.

METHODS

A systematic search on the databases, PubMed, Embase, Cochcrane library, and Clinicaltrials.gov was performed during September 2014. All trials investigating the association between psychological variables and experimental pain in healthy volunteers were considered for inclusion.

RESULTS

Twenty-nine trials met the inclusion criteria, with a total of 2637 healthy volunteers. The included trials investigated a total of 45 different psychological tests and 27 different types of pain models. The retrieved trials did not present a sufficiently homogenous group to perform meta-analysis. The collected results were diverse. A total of 16 trials suggested that psychological factors may predict the level of pain, seven studies found divergent results, and six studies found no significant association between psychological variables and experimental pain.

CONCLUSION

Psychological factors may have predictive value when investigating experimental pain. However, due to substantial heterogeneity and methodological shortcomings of the published literature, firm conclusions are not possible.

The reciprocal effect of pain catastrophizing and satisfaction with participation in the multidisciplinary treatment of patients with chronic back pain

Background

The aim of the study was to examine the reciprocity between pain catastrophizing, social participation and quality of life outcomes (pain intensity, pain disability, negative affectivity) in patients with low back pain in a multidisciplinary pain treatment.

Methods

Patients undergoing inpatient rehabilitation were surveyed at the beginning and two weeks after the end of rehabilitation. N = 262 low back pain patients participated (mean age: 52.2, 62.1 % female). A two-wave cross-lagged design and structural equation modeling were used to analyze data.

Results

We found evidence of reciprocal relations with regard to several outcomes. For example, pain catastrophizing at the beginning of treatment is associated with negative affectivity after rehabilitation, and the post-treatment value of pain catastrophizing is associated with pain disability and satisfaction with participation at the start of treatment. Pain disability and pain catastrophizing are predictors of lower treatment outcome while pain intensity and negative affectivity are not risk factors. Participation stands in a reciprocal relationship with some of the pain treatment outcomes. The surprising result, namely, that those patients more satisfied with social participation experience less improvement regarding catastrophizing, can be explained by ceiling effects and the Communal Coping Model.

Conclusions

This study provides evidence of the importance of taking reciprocal relations among pain catastrophizing, social participation and other pain outcomes into account. Providers of multidisciplinary pain treatment need to play attention to patients at risk with high disability and catastrophizing thoughts. Pain treatment would benefit from closer integration of psychosocial measures to foster social participation.

Pain frequency moderates the relationship between pain catastrophizing and pain

Background: Pain frequency has been shown to influence sensitization, psychological distress, and pain modulation. The present study examined if pain frequency moderates the relationship between pain catastrophizing and pain.

Method: A non-clinical (247 students) and a clinical (223 pain patients) sample completed the Danish versions of the Pain Catastrophizing Scale (PCS), Beck Depression Inventory, and the State Trait Anxiety Inventory and rated pain intensity, unpleasantness and frequency.

Results: In both samples, high pain frequency was found to moderate the association between pain catastrophizing and pain intensity, whereas low pain frequency did not. The psychometric properties and the factor structure of the Danish version of the PCS were confirmed.

Conclusions: This is the first study to validate the Danish version of the PCS and to show that pain frequency moderates the relationship between pain catastrophizing and reported pain in both non-clinical and clinical populations.

Expectations and positive emotional feelings accompany reductions in ongoing and evoked neuropathic pain following placebo interventions

Research on placebo analgesia and nocebo hyperalgesia has primarily included healthy subjects or acute pain patients, and it is unknown whether these effects can be obtained in ongoing pain in patients with chronic pain caused by an identifiable nerve injury. Eighteen patients with postthoracotomy neuropathic pain were exposed to placebo and nocebo manipulations, in which they received open and hidden administrations of pain-relieving (lidocaine) or pain-inducing (capsaicin) treatment controlled for the natural history of pain. Immediately after the open administration, patients rated their expected pain levels on a mechanical visual analogue scale (M-VAS). They also reported their emotional feelings via a quantitative/qualitative experiential method. Subsequently, patients rated their ongoing pain levels on the M-VAS and underwent quantitative sensory testing of evoked pain (brush, pinprick, area of hyperalgesia, wind-up-like pain). There was a significant placebo effect on both ongoing (P=.009 to .019) and evoked neuropathic pain (P=.0005 to .053). Expected pain levels accounted for significant amounts of the variance in ongoing (53.4%) and evoked pain (up to 34.5%) after the open lidocaine administration. Furthermore, patients reported high levels of positive and low levels of negative emotional feelings in the placebo condition compared with the nocebo condition (P⩽.001). Pain increases during nocebo were nonsignificant (P=.394 to 1.000). To our knowledge, this is the first study to demonstrate placebo effects in ongoing neuropathic pain. It provides further evidence for placebo-induced reduction in hyperalgesia and suggests that patients' expectations coexist with emotional feelings about treatments.

Changes in catastrophizing and kinesiophobia are predictive of changes in disability and pain after treatment in patients with anterior knee pain

PURPOSE

The purpose of the study was to investigate if changes in psychological variables are related to the outcome in pain and disability in patients with chronic anterior knee pain.

METHODS

A longitudinal observational study on 47 patients with chronic anterior knee pain was performed in a secondary healthcare setting. Pain was measured with the visual analogue scale and disability with the Lysholm scale. The psychological variables, such as anxiety, depression, pain coping strategies, catastrophizing and fear to movement beliefs, were studied by using self-administered questionnaires.

RESULTS

Among the pain coping strategies, only the catastrophizing subscale showed a significant reduction. Similarly, anxiety, depression and kinesiophobia were significantly reduced after treatment. Those patients who decreased the catastrophizing, kinesiophobia, anxiety and depression showed a greater improvement in pain and disability after a purely biomedical treatment. A multiple regression analysis revealed that changes in catastrophizing predicted the amount of improvement in pain severity and that changes in both catastrophizing and anxiety predicted changes in disability after treatment.

CONCLUSION

What has been found suggests that clinical improvement in pain and disability is associated with a reduction in catastrophizing and kinesiophobia. Therefore, co-interventions to reduce catastrophizing thinking and kinesiophobia may enhance the results.

LEVEL OF EVIDENCE

Prospective Cohort Study, Level I for prognosis.

O papel da catastrofização da dor no prognóstico e tratamento de idosos com osteoartrite de joelho: uma revisão crítica da literatura

A artroplastia total de joelho, procedimento realizado em pacientes com osteoartrite severa, pode levar à melhora na dor, na função física e na qualidade de vida, porém alguns indivíduos apresentam resultados negativos após esse procedimento. A catastrofização da dor tem sido apontada como o preditor psicológico mais importante para os piores resultados após a cirurgia. Assim, o objetivo deste estudo foi realizar uma revisão da literatura acerca da influência da catastrofização da dor no prognóstico e tratamento de indivíduos idosos com osteoartrite de joelho. Foi realizada uma busca da literatura nas bases de dados Medline via PubMed, Embase, Cochrane, Scopus, Science Direct, MedCarib, SciELO, LILACS e Google Acadêmico, a partir do primeiro registro até junho de 2012. A busca resultou num total de 2.227 artigos e, após exclusão por título, resumo e leitura integral, foram selecionados seis estudos. Todos os artigos mostraram como característica comum de tratamento a realização da artroplastia total de joelho. Apesar da análise de outras variáveis como depressão, ansiedade, gravidade da dor, incapacidade, somente a catastrofização revelou ser a variável que contribui significativamente para os resultados da recuperação após a artroplastia, contribuindo para maior tempo de permanência no hospital, maior intensidade de dor e piora na funcionalidade. É necessário que medidas básicas para a identificação dos indivíduos que catastrofizam mais sejam aplicadas e, assim, intervenções psicossociais podem ser necessárias para promover uma recuperação mais positiva em indivíduos que apresentam perfil de risco psicossocial, diminuindo o tempo de hospitalização.

Hair-Normalized Cortisol Waking Response as a Novel Biomarker of Hypothalamic-Pituitary-Adrenal Axis Activity following Acute Trauma: A Proof-of-Concept Study with Pilot Results

The mechanisms underlying the development of persistent posttraumatic pain and disability remain elusive. Recent evidence suggests that disordered stress-system pathway (hypothalamic-pituitary-adrenal axis) activity may be responsible for the genesis and maintenance of long-term sensory and emotional problems. However, confidence in current evidence is limited by the necessarily retrospective collection of data. Hair cortisol can serve as a calendar of HPA axis activity going back several months prior to injury. The purposes of this pilot study were to determine the feasibility of using hair cortisol and hair-normalized salivary cortisol as biomarkers of distress following traumatic injuries of whiplash or distal radius fracture. Ten subjects provided complete data within 3 weeks of injury. Hair cortisol, cortisol waking response (CWR), and mean daily cortisol (MDC) were captured at inception, as were self-report indicators of pain, disability, and pain catastrophizing. Pain and disability were also captured 3 months after injury. Results indicate that cortisol waking response may be a useful biomarker of current distress as measured using the pain catastrophizing scale, especially when normalized to 3-month hair cortisol (r = 0.77 raw, 0.93 normalized). Hair-normalized CWR may also have predictive capacity, correlating with 3-month self-reported disability at r = 0.70. While promising, the results must be viewed in light of the small sample.

Pain catastrophizing in dental patients: implications for treatment management

BACKGROUND

"Pain catastrophizing" refers to an exaggerated negative mental set brought to bear during an actual or anticipated painful experience. A patient's perception of a dental care experience as catastrophic can result not only in poor satisfaction with the therapy but also in avoidance of necessary treatments, resulting in the deterioration of oral health.

METHODS

The author reviewed literature regarding pain catastrophizing regarding dental treatment as well as behavioral models related to catastrophizing.

RESULTS

People who catastrophize show excessive attention to pain (rumination), exaggerate the threat value of pain (magnification) and feel unable to cope with their suffering (helplessness). During dental treatments, greater pain catastrophizing is associated with increased pain, dental anxiety and negative thoughts regarding pain and dental procedures.

CONCLUSIONS

It is important that clinicians identify dental patients who catastrophize so as to plan and provide the best treatment for their needs.

PRACTICAL IMPLICATIONS

To manage the care of patients who catastrophize, the clinician can actively probe patients' pain experience, help them reappraise threat, manipulate their attention to pain and improve dentist-patient communication.