Preoperative Anxiety and Catastrophizing: A Systematic Review and Meta-analysis of the Association With Chronic Postsurgical Pain

The effect of unpredictability on the perception of pain: a systematic review and meta-analysis

ABSTRACT

Despite being widely assumed, the worsening impact of unpredictability on pain perception remains unclear because of conflicting empirical evidence, and a lack of systematic integration of past research findings. To fill this gap, we conducted a systematic review and meta-analysis focusing on the effect of unpredictability on pain perception. We also conducted meta-regression analyses to examine the moderating effect of several moderators associated with pain and unpredictability: stimulus duration, calibrated stimulus pain intensity, pain intensity expectation, controllability, anticipation delay, state and trait negative affectivity, sex/gender and age of the participants, type of unpredictability (intensity, onset, duration, location), and method of pain induction (thermal, electrical, mechanical pressure, mechanical distention). We included 73 experimental studies with adult volunteers manipulating the (un)predictability of painful stimuli and measuring perceived pain intensity and pain unpleasantness in predictable and unpredictable contexts. Because there are insufficient studies with patients, we focused on healthy volunteers. Our results did not reveal any effect of unpredictability on pain perception. However, several significant moderators were found, ie, targeted stimulus pain intensity, expected pain intensity, and state negative affectivity. Trait negative affectivity and uncontrollability showed no significant effect, presumably because of the low number of included studies. Thus, further investigation is necessary to clearly determine their role in unpredictable pain perception.

Incidence and Risk Factors of Chronic Postoperative Pain in Same-day Surgery: A Prospective Cohort Study

BACKGROUND

The amount of same-day surgery has increased markedly worldwide in recent decades, but there remains limited evidence on chronic postsurgical pain in this setting.

METHODS

This study assessed pain 90 days after ambulatory surgery in an international, multicenter prospective cohort study of patients at least 45 yr old with comorbidities or at least 65 yr old. Pain was assessed using the Brief Pain Inventory. Chronic postsurgical pain was defined as a change of more than 1 point in self-rated average pain at the surgical site between baseline and 90 days, and moderate to severe chronic postsurgical pain was defined as a score greater than 4 in self-rated average pain at the surgical site at 90 days. Risk factors for chronic postsurgical pain were identified using multivariable logistic regression.

RESULTS

Between November 2021 and January 2023, a total of 2,054 participants were included, and chronic postsurgical pain occurred in 12% of participants, of whom 93.1% had new chronic pain at the surgical site (i.e., participants without pain before surgery). Moderate to severe chronic postsurgical pain occurred in 9% of overall participants. Factors associated with chronic postsurgical pain were active smoking (odds ratio, 1.82; 95% CI, 1.20 to 2.76), orthopedic surgery (odds ratio, 4.7; 95% CI, 2.24 to 9.7), plastic surgery (odds ratio, 4.3; 95% CI, 1.97 to 9.2), breast surgery (odds ratio, 2.74; 95% CI, 1.29 to 5.8), vascular surgery (odds ratio, 2.71; 95% CI, 1.09 to 6.7), and ethnicity (i.e., for Hispanic/Latino ethnicity, odds ratio, 3.41; 95% CI, 1.68 to 6.9 and for First Nations/native persons, odds ratio, 4.0; 95% CI, 1.05 to 15.4).

CONCLUSIONS

Persistent postsurgical pain after same-day surgery is common, is usually moderate to severe in nature, and occurs mostly in patients without chronic pain before surgery.

EDITOR’S PERSPECTIVE

Incidence and risk factors of new persistent opioid use after surgery and trauma: A systematic review

BACKGROUND

Persistent opioid use (POU) can occur with opioid use after surgery or trauma. Current systematic reviews include patients with previous exposure to opioids, meaning their findings may not be relevant to patients who are opioid naïve (i.e. Most recent exposure was from surgery or trauma). The aim of this review was to synthesise narratively the evidence relating to the incidence of, and risk factors for POU in opioid-naïve surgical or trauma patients.

METHOD

Structured searches of Embase, Medline, CINAHL, Web of Science, and Scopus were conducted, with final search performed on the 17th of July 2023. Searches were limited to human participants to identify studies that assessed POU following hospital admission due to surgery or trauma. Search terms relating to 'opioid', 'analgesics', 'surgery', 'injury', 'trauma' and 'opioid-related disorder' were combined. The Newcastle-Ottawa Scale for cohort studies was used to assess the risk of bias for studies.

RESULTS

In total, 22 studies (20 surgical and two trauma) were included in the analysis. Of these, 20 studies were conducted in the United States (US). The incidence of POU for surgical patients 18 and over ranged between 3.9% to 14.0%, and for those under 18, the incidence was 2.0%. In trauma studies, the incidence was 8.1% to 10.5% among patients 18 and over. Significant risk factors identified across surgical and trauma studies in opioid-naïve patients were: higher comorbidity burden, having pre-existing mental health or chronic pain disorders, increased length of hospital stay during the surgery/trauma event, or increased doses of opioid exposure after the surgical or trauma event. Significant heterogeneity of study design precluded meta-analysis.

CONCLUSION

The quality of the studies was generally of good quality; however, most studies were of US origin and used medico-administrative data. Several risk factors for POU were consistently and independently associated with increased odds of POU, primarily for surgical patients. Awareness of these risk factors may help prescribers recognise the risk of POU after surgery or trauma, when considering continuing opioids after hospitalisation. The review found gaps in the literature on trauma patients, which represents an opportunity for future research.

TRIAL REGISTRATION

PROSPERO registration: CRD42023397186.

The Impact of Diagnosed Chronic Sleep Disorders on Outcomes Following Total Knee Arthroplasty

BACKGROUND

Up to 20% of patients undergoing total knee arthroplasty (TKA) remain dissatisfied with their outcome, leading to the identification of risk factors for poor outcomes. The purpose of this study was to analyze the effect of chronic sleep disorders on patient-reported outcomes after primary TKA.

METHODS

A retrospective review of patients undergoing primary TKA was conducted using a prospectively collected database of patients from a single institution between 2018 and 2022. The cohort was split based on the presence of documented chronic sleep disorders, identified preoperatively from the electronic medical record using current procedural terminology codes. The sample was further restricted to include all patients who have sleep disorders (SDs), as well as a 3:1 propensity-matched (on age, sex, body mass index, and American Society of Anesthesiologists class) cohort of patients who had no documented SDs (NSDs) prior to surgery. The final sample included 172 patients (SD: 43; NSD: 129). Repeated-measures linear mixed model analysis was used to analyze the progression of Knee Injury and Osteoarthritis Outcome Score (KOOS) through time between groups.

RESULTS

Those who had SDs had a lower preoperative mean total KOOS score (40.2) than the NSD group (44.1); however, this was not significantly different (P = .108). At 1 year postoperatively, those who had an SD had a significantly higher mean total KOOS score (87.2) than the NSD group (80.4), P = .005. When comparing total KOOS scores by group, over each time period, the SD group showed a better progression when compared to the NSD group, P = .001.

CONCLUSIONS

Compared to patients who did not have documented chronic sleep disorders, patients who had a prior history of chronic sleep disorders reported significantly greater improvements in most KOOS domains in the 12-month period following TKA.

What is associated with painful polyneuropathy? A cross-sectional analysis of symptoms and signs in patients with painful and painless polyneuropathy

ABSTRACT

It is still unclear how and why some patients develop painful and others painless polyneuropathy. The aim of this study was to identify multiple factors associated with painful polyneuropathies (NeuP). A total of 1181 patients of the multicenter DOLORISK database with painful (probable or definite NeuP) or painless (unlikely NeuP) probable or confirmed neuropathy were investigated clinically, with questionnaires and quantitative sensory testing. Multivariate logistic regression including all variables (demographics, medical history, psychological symptoms, personality items, pain-related worrying, life-style factors, as well as results from clinical examination and quantitative sensory testing) and machine learning was used for the identification of predictors and final risk prediction of painful neuropathy. Multivariate logistic regression demonstrated that severity and idiopathic etiology of neuropathy, presence of chronic pain in family, Patient-Reported Outcomes Measurement Information System Fatigue and Depression T-Score, as well as Pain Catastrophizing Scale total score are the most important features associated with the presence of pain in neuropathy. Machine learning (random forest) identified the same variables. Multivariate logistic regression archived an accuracy above 78%, random forest of 76%; thus, almost 4 out of 5 subjects can be classified correctly. This multicenter analysis shows that pain-related worrying, emotional well-being, and clinical phenotype are factors associated with painful (vs painless) neuropathy. Results may help in the future to identify patients at risk of developing painful neuropathy and identify consequences of pain in longitudinal studies.

The Effect of Immersive Virtual Reality Application on Anxiety, Pain, and Parental Satisfaction in the Perioperative Process of Children: A Randomized Controlled Trial

PURPOSE

To determine the effects of virtual reality (VR) interventions on pre- and postoperative anxiety, pain, and parental satisfaction in children.

DESIGN

A randomized controlled trial.

METHODS

Children undergoing surgery for the first time and their families were randomly assigned to the control or VR group. The control group received conventional education regarding the perioperative process. The VR group watched a VR video illustrating the operating theater and explaining the perioperative process. The primary outcome of interest was preoperative anxiety, evaluated using the Children's State Anxiety Scale. Secondary outcomes of interest included postoperative pain ratings using the Wong-Baker Faces Pain Rating Scale and parental satisfaction scores using the PedsQL Health Care Satisfaction Scale.

RESULTS

The analysis included 70 children and their families (control = 35, VR = 35). Demographic characteristics were similar between the groups. Children in the VR group had significantly lower preoperative anxiety scores (p < .001) and postoperative anxiety scores (p = .010) compared to the control group. Parental satisfaction scores were significantly higher in the VR group (p < .001). The VR group had lower postoperative pain scores, but this difference was not statistically significant (p > .05).

CONCLUSIONS

Preoperative education using VR tours may reduce preoperative anxiety and increase parental satisfaction. However, the lack of baseline measurements limits our ability to definitively attribute these effects to the VR intervention. Despite this, VR is a promising nonpharmacological strategy for managing children's anxiety and increasing parental satisfaction.

CLINICAL IMPLICATIONS

Virtual reality interventions offer an effective nonpharmacological strategy for perioperatively managing children's anxiety and increasing parental satisfaction.

A prospective cohort study of chronic postsurgical pain after ambulatory surgeries

OBJECTIVE

The incidence and factors associated with chronic postsurgical pain (CPSP) after ambulatory surgeries have not been well studied. Our primary objective was to determine the incidence of CPSP and secondary objectives included assessment of intensity of CPSP, incidence of moderate-to-severe CPSP, and exploration of factors associated with CPSP.

METHODS

This is a prospective cohort study of ambulatory surgery patients having procedures with a potential to cause moderate-to-severe postoperative pain. All patients had participated in a randomized controlled trial (RCT) showing no difference in achieving satisfactory analgesia in a recovery unit with either morphine or hydromorphone. CPSP was defined as chronic pain that developed or increased in intensity after the surgical procedure and is localized to the surgical field or within the innervation territory of a nerve in the surgical field, and has persisted for 3 months post-surgery, with the exclusion of other causes of pain. Incidences of CPSP were reported as rate (%) with 95% CI, and intensity using a 0-10 numerical rating scale (95% CI). We used logistic regression to explore factors associated with CPSP adjusting for baseline catastrophizing and depression.

RESULTS

Among 402 RCT patients, 208 provided data for the 3-month outcome. Incidence of CPSP was 18.8% (39/208), 95% CI = 13.7%-24.7% and 78% (28/39) of them had moderate-to-severe CPSP. Average CPSP intensity was 5.5, 95% CI = 4.7-6.4. Every unit increase in pain over the first 24 h was significantly associated with increased odds of moderate-to-severe CPSP at 3 months; odds ratio = 1.28, 95% CI = 1.04-1.58.

CONCLUSIONS

Nearly one in five patients develop CPSP after ambulatory surgeries with the majority of them having moderate-to-severe pain. Considering that acute pain after discharge is associated with CPSP and that there are no formal care pathways to address this need, studies need to focus on evaluating feasible strategies to provide continuing care.

Weak Relationships Between Psychological Factors and Experimental Pain Outcomes in Pain-Free Individuals: An Aggregate Analysis of 8 Studies

Although psychological factors such as anxiety, depression, and pain catastrophizing are known to influence pain outcomes in chronic pain populations, there are mixed results regarding whether they influence experimental pain outcomes in pain-free individuals. The objectives of this study were to determine the associations between psychological factors and experimental pain outcomes in pain-free adolescents and adults. Relationships between anxiety, depression, and pain catastrophizing and experimental pain outcomes across 8 different studies (total N = 595) were examined in different populations of pain-free adult and adolescent participants. Analyses were conducted with and without controlling for sex, age, and race. Studies were analyzed separately and as part of an aggregate analysis. Individual study analyses resulted in 136 regression models. Of these, only 8 models revealed a significant association between psychological factors and pain outcomes. The significant results were small and likely due to Type 1 error. Controlling for demographic factors had minimal effect on the results. The aggregate analyses revealed weak relationships between anxiety and pressure pain threshold (Fisher's z = -.10 [-.19, -.01]), anxiety and cold pain intensity ratings (Fisher's z = .18 [.04, .32]), and pain catastrophizing and pressure pain threshold (Fisher's z = -.14 [-.26, -.02]). Sample size calculations based on the aggregate analyses indicated that several hundred participants would be required to detect true relationships between these psychological factors and pain measures. The overall negative findings suggest that in pain-free individuals, anxiety, depression, and pain catastrophizing are not meaningfully related to experimental pain outcomes. PERSPECTIVE: Psychological variables have been shown to predict pain outcomes in chronic pain populations but these relationships may not generalize to pain-free populations. An analysis of 595 pain-free individuals across 8 studies in our lab revealed that anxiety, depression, and pain catastrophizing were not meaningfully related to experimental pain outcomes.

Uniportal video-assisted thoracic surgery versus open thoracotomy for chronic pain after surgery: a prospective cohort study

PURPOSE

The potential of uniportal video-assisted thoracic surgery (U-VATS) to reduce chronic pain after thoracic surgery (CPTS) compared to open thoracotomy (OT) remains unexplored. This prospective study aims to assess the incidence of CPTS following U-VATS or OT and identify associated risk factors.

METHODS

Patients undergoing thoracic surgery were recruited from March 2021 to March 2022, categorized by surgical approach (U-VATS vs. OT). Standard clinical protocols for surgery, anesthesia, and analgesia were followed. Pain symptoms were assessed using the Short-form McGill Pain Questionnaire, with follow-ups up to 6 months. Perioperative factors influencing CPTS at 3 months were analyzed through univariate and multivariate methods.

RESULTS

A total of 694 patients were analyzed. Acute pain after thoracic surgery (APTS) was significantly less severe in the U-VATS group (p < 0.001). U-VATS patients exhibited a lower incidence of CPTS at 3 months (63.4% vs. 80.1%, p < 0.001), with reduced severity among those experiencing CPTS (p = 0.007) and a decreased occurrence of neuropathic pain (p = 0.014). Multivariate analysis identified OT incision, moderate to severe APTS (excluding moderate static pain at 24 h postoperative), nocturnal surgery, and lung surgery as risk factors for CPTS.

CONCLUSION

This study underscores the potential of U-VATS to reduce both the incidence and severity of CPTS at 3 months compared to OT. Furthermore, it highlights risk factors for CPTS, including OT incision, inadequately managed APTS, lung surgery, and nocturnal surgery. These findings emphasize the importance of considering surgical approach and perioperative pain management strategies to mitigate the burden of CPTS.

Mindfulness-Based Interventions for Perioperative Pain Management and Opioid Risk Reduction Following Surgery: A Stepped Care Approach

Surgical procedures often improve health and function but can sometimes also result in iatrogenic effects, including chronic pain and opioid misuse. Due to the known risks of opioids and the physical, emotional, and financial suffering that often accompanies chronic pain, there has been a call for greater use of complementary non-pharmacological treatments like mindfulness-based interventions. Mindfulness can be broadly described as an attentional state involving moment-by-moment meta-awareness of thoughts, emotions, and body sensations. An expanding number of randomized clinical trials have found strong evidence for the value of mindfulness techniques in alleviating clinical symptomology relevant to surgical contexts. The purpose of this review is to examine the empirical evidence for the perioperative use of mindfulness interventions. We present a mindfulness-based stepped care approach that first involves brief mindfulness to treat preoperative pain and anxiety and prevent development of postoperative chronic pain or opioid misuse. More extensive mindfulness-based interventions are then provided to patients who continue to experience high pain levels or prolonged opioid use after surgery. Finally, we review psychophysiological mechanisms of action that may be integral to the analgesic and opioid sparing effects of mindfulness.

Risk Factors for Chronic Abdominal Pain After RYGB: Are Patients Adequately Selected Beforehand?

PURPOSE

Chronic abdominal pain after RYGB is a known issue. Identifying the potential patient-related and modifiable risk factors might contribute to diminish the risk for this undesirable outcome.

METHODS

A single-center retrospective cohort study with prospective data collection was conducted with inclusion of all patients who underwent RYGB surgery between 2015 and 2021. Data from the NBSR and medical records were used. Patients with chronic abdominal pain were defined when pain lasting or recurring for more than 3 to 6 months.

RESULTS

Six hundred sixty-four patients who underwent RYGB surgery were included with a median follow-up of 60.5 months. Forty-nine patients (7.3%) presented with chronic abdominal pain. Postoperative complications (OR 13.376, p = 0.020) and diagnosis of depression (OR 1.971, p = 0.037) were associated with developing abdominal pain. On the other hand, ex-smokers (OR 0.222, p = 0.040) and older age (0.959, p = 0.004) presented as protective factors.

CONCLUSION

Postoperative complications and diagnosis of depression are risk factors for chronic pain after RYGB. The role of the bariatric MDT remains crucial to select these patients adequately beforehand.

Chronic pain after breast surgery: incidence, risk factors and impact on quality of life

INTRODUCTION AND OBJECTIVES

Breast cancer is the most frequently diagnosed malignancy, and chronic pain after breast surgery (CPBS) is an increasingly recognized therapy-related problem. We evaluated CPBS incidence, characteristics, associated factors, and impact on patient quality of life (QoL).

MATERIALS AND METHODS

Six-month observational prospective study conducted in patients undergoing breast surgery in a tertiary university hospital. Data were collected using several questionnaires: Pain Catastrophizing Scale, Brief Pain Inventory-Short Form, Douleur Neuropathique 4 Questionnaire, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and its Breast Cancer Module.

RESULTS

A total of 112 patients completed the study. Approximately, one third (34.8%) developed CPBS, and almost all with potentially neuropathic pain. CPBS interfered with patients' daily life and reduced their QoL. Diabetes (p = 0.028), catastrophizing (p = 0.042), and acute postoperative pain severity (p < 0.001) were associated with CPBS.

CONCLUSIONS

This study broadens our understanding of CPBS and shows the impact of this syndrome. Healthcare workers need to be aware of CPBS and take steps to prevent and treat it, and provide patients with adequate information.

Association Between Pain Coping and Symptoms of Anxiety and Depression, and Work Absenteeism in People With Upper Limb Musculoskeletal Disorders: A Systematic Review and Meta-analysis

OBJECTIVE

To determine the prospective association of pain coping strategies and symptoms of anxiety and depression with work absenteeism in people with upper limb musculoskeletal disorders.

DATA SOURCES

A systematic search of PubMed, Web of Science, Embase, Cochrane Library, and Scopus databases was conducted from inception to September 23, 2022.

STUDY SELECTION

Prospective observational studies of adults with upper limb musculoskeletal disorders were included. Included studies had to provide data on the association of pain coping strategies (catastrophizing, kinesiophobia, self-efficacy or fear avoidance) or symptoms of anxiety and depression with work absenteeism.

DATA EXTRACTION

Study selection, data extraction, and assessment of methodological quality (Newcastle Ottawa Scale) were performed by 2 independent authors. Random-effects models were used for quantitative synthesis.

DATA SYNTHESIS

Eighteen studies (n=12,393 participants) were included. Most studies (77.8%) reported at least 1 significant association between 1 or more exposure factors (pain coping strategies or symptoms of anxiety and depression) and work absenteeism. Meta-analyses showed a statistically significant correlation between the exposure factors of catastrophizing (r=0.28, 95% confidence interval [CI]: 0.15 to 0.40; P<.0001) and symptoms of anxiety and depression (r=0.23, 95% CI: 0.10 to 0.34; P=.0003) with work absenteeism. The correlation between self-efficacy and work absenteeism was non-significant (r=0.24, 95% CI: -0.02 to 0.47; P=.0747).

CONCLUSIONS

Rehabilitation teams should consider assessing catastrophizing and symptoms of anxiety and depression to identify patients at risk for work absenteeism. Addressing these variables may also be considered in return-to-work programs for individuals with upper limb disorders.

The moderating effect of resting heart rate variability on the relationship between pain catastrophizing and depressed mood: an empirical study

Previous research indicated that pain catastrophizing-a negative emotional and cognitive response toward actual or anticipated pain-could contribute to pain intensity and could be associated with depressive symptoms not just in chronic pain patients but in healthy population as well. Accumulated evidence suggests that resting heart rate variability (HRV) as a putative proxy of emotion regulation could moderate the association of self-reported pain catastrophizing and depressed mood. In the present cross-sectional study, we investigated these associations in a healthy young adult sample controlling for the effect of trait rumination. Seventy-two participants (58 females, mean age = 22.2 ± 1.79 years ranging from 19 to 28 years old) completed the Pain Catastrophizing Scale, the Zung Self-Rating Depression Scale and the Ruminative Response Scale. Resting HRV was measured by time domain metric of HRV, the root mean square of successive differences (RMSSD). The results showed that the relationship between pain catastrophizing and depressive symptoms is significantly moderated by resting HRV (indexed by lnRMSSD). Specifically, in participants with higher resting HRV there was no significant relationship between the two investigated variables, while in participants with relatively low or medium HRV pain catastrophizing and depressed mood showed significant positive association. The relationship remained significant after controlling for sex, age and trait rumination. These results might indicate that measuring pain catastrophizing and depressive symptoms is warranted in non-clinical samples as well and higher resting HRV could have a buffer or protective role against depressive symptoms.

Pain-Associated Psychological Distress Is of High Prevalence in Patients With Hip Pain: Characterizing Psychological Distress and Phenotypes

Purpose

To identify common pain-related psychological factors among patients seeking care for athletic hip pain, as well as characterize psychological distress phenotypes and compare hip-specific quality-of-life measures across those phenotypes.

Methods

A total of 721 patients were recruited from hip preservation clinics. The Optimal Screening for Prediction of Referral and Outcome-Yellow Flag Assessment Tool (OSPRO-YF) was used to identify the presence or absence of 11 different pain-associated psychological distress characteristics (yellow flags), while the International Hip Outcome Tool-12 (iHOT-12) was used to assess hip-related quality of life. Latent class analysis identified patient subgroups (phenotypes) based on naturally occurring combinations of distress characteristics. An analysis of variance was used to compare demographics, number of yellow flags, and iHOT-12 scores across phenotypes.

Results

The median (interquartile range) number of yellow flags was 6 (3-9), with 13.5% of the sample reporting 11 yellow flags. Latent class analysis (L2 = 543.3, classification errors = 0.082) resulted in 4 phenotypes: high distress (n = 299, 41.5%), low distress (n = 172, 23.9%), low self-efficacy and acceptance (n = 74, 10.3%), and negative pain coping (n = 276, 24.4%). Significant differences in mean yellow flags existed between all phenotypes except low self-efficacy and negative pain coping. There were no differences in demographics between phenotypes. The high distress class had the lowest mean iHOT-12 score (mean [SD], 23.5 [17.6]), with significant differences found between each phenotypic class.

Conclusions

There was a high prevalence of pain-associated psychological distress in patients presenting to tertiary hip arthroscopy clinics with hip pain. Furthermore, hip quality-of-life outcome scores were uniformly lower in patients with higher levels of psychological distress.

Level of Evidence

Level III, retrospective cohort study.

Greater Mental Health Burden is Associated With Poor Postoperative Pain Control and Increased Opioid Utilization Following Total Shoulder Arthroplasty

Background

Prolonged opioid use is associated with higher complications and worse patient-reported outcomes following total shoulder arthroplasty (TSA). Identified risk factors for prolonged postoperative use are related to several medical comorbidities, gender, diagnoses of anxiety or depressive disorders, and preoperative opioid use. In this study, we hypothesized that patient-reported mental health characteristics can help to identify patients at risk of worse postoperative pain control, worse sleep, and higher opioid utilization following TSA.

Methods

Ninety-three consecutive patients were asked to fill out 2 mental health questionnaires prior to undergoing TSA. Following surgery, patients filled out a daily pain diary to track their daily pain, pain medication use, and quality and duration of their sleep for 30 days. Preoperative opioid use and postoperative refill were determined by the New York State Prescription Monitoring Program. Mixed-model linear regressions were conducted. Significance was defined as p < 0.05.

Results

Postoperative opioid refill was associated with female gender, preoperative opioid therapy, higher inpatient opioid use, worse anxiety, depression, somatization, and pain catastrophizing scores. The number of days using opioids postoperatively was associated with worse pain catastrophizing scale (PCS) and somatization scores (patient health questionnaire-15). Preoperative opioid therapy was associated with worse somatization scores, whereas no opioids used after surgery were associated with better somatization scores. Worse sleep quality and duration were associated with worse PCS scores.

Conclusion

A greater mental health burden is associated with worse postoperative pain control and higher opioid utilization during the acute postoperative period. This is especially evident in the pain catastrophizing and somatization domains.

How to Modulate Peripheral and Central Nervous System to Treat Acute Postoperative Pain and Prevent Pain Persistence

Chronic postoperative pain (CPSP) is a major issue after surgery, which may impact on patient's quality of life. Traditionally, CPSP is believed to rely on maladaptive hyperalgesia and risk factors have been identified that predispose to CPSP, including acute postoperative pain. Despite new models of prediction are emerging, acute pain is still a modifiable factor that can be challenged with perioperative analgesic strategies. In this review we present the issue of CPSP, focusing on molecular mechanism underlying the development of acute and chronic hyperalgesia. Also, we focus on how perioperative strategies can impact directly or indirectly (by reducing postoperative pain intensity) on the development of CPSP.

Evaluation of Neuropathic Pain after Total Knee Arthroplasty: Do Yellow Flags Matter?

Up to 20% of total knee arthroplasty (TKA) patients continue to experience chronic postsurgical pain. Various factors have been identified as potential contributors, including so-called "yellow flags", encompassing symptoms of depression, anxiety, and catastrophizing, which were examined in this study to assess their predictive value concerning functional outcomes after TKA.

METHODS

Fifty TKA patients were categorized into high-risk and low-risk groups based on clinical assessment, demographic data, medication, and patient-reported outcome measures (DN4, SF-36, WOMAC, NRS, Fibromyalgia Survey Questionnaire, Pain Catastrophizing Scale, and Hospital Anxiety and Depression Scale). Postoperative outcomes within six months after TKA were then compared.

RESULTS

Both groups exhibited significant (p < 0.001) improvements in all WOMAC and NRS subscales, as well as in the physical function, role physical, pain, and energy/fatigue subdomains of the SF-36 after six months, while the high-risk group showed lower WOMAC scores regarding stiffness (19.0 ± 18.3 vs. 27.2 ± 20.7, p < 0.001) and pain (13.5 ± 13.3 vs. 15.1 ± 16.3, p = 0.029). The high-risk group showed significantly worse preoperative DN4 scores (1.8 ± 1.3 vs. 3.0 ± 1.1, p = 0.002) than the low-risk group, which persisted for one day (2.3 ± 1.2 vs. 3.5 ± 1.5, p = 0.005) and six weeks (2.2 ± 1.9 vs. 3.6 ± 2.3, p = 0.041) postoperatively.

CONCLUSIONS

Our results indicate that pre-existing yellow flags contribute to a more challenging early postoperative phase, underscoring the importance of considering individual patient characteristics and psychological factors to optimize TKA outcomes.

Effect of Catastrophic Thinking on the Analgesic Effect of Electroacupuncture

Introduction

Patients with chronic pain and high-level catastrophic thoughts often do not respond to acupuncture. This may be related to hypofunctioning of the dorsolateral prefrontal cortex and the descending pain inhibitory system. Therefore, we examined the relationship between the level of catastrophic thinking and the analgesic effect of electroacupuncture using the pain catastrophizing scale (PCS). We also evaluated the descending pain inhibitory system using conditioned pain modulation (CPM) and offset analgesia (OA). The relationship between catastrophic thinking and the descending pain inhibitory system was also examined.

Materials and Methods

After testing the hospital anxiety and depression scale and the PCS in 14 healthy adults, the current pain threshold (CPT), CPM, and OA were measured, in order, before the intervention. Thereafter, electroacupuncture was applied to 3 limbs (the dominant hand and both lower extremities) at 4 Hz, and to the scalp at 100 Hz, for 30 minutes, and the CPT was measured again immediately after the intervention. The difference in the CPT before and after the intervention was taken as the analgesic effect.

Results

The participants were divided into 2 groups, the H-PCS group (≥16 points) and the L-PCS group (≤15 points), according to the PCS score, and the analgesic effects of electroacupuncture were significantly different (P = 0.04). However, no relationship was found between the PCS score and the CPM (r = -0.02, P = 0.94) and OA effects (r = -0.19, P = 0.49).

Conclusion

It was suggested that people with high-level catastrophic thinking may find it difficult to obtain the analgesic effects of electroacupuncture.

Pain Catastrophizing and Impact on Pelvic Floor Surgery Experience

IMPORTANCE

Understanding patients' perceptions of symptoms and outcomes of urogynecologic surgery is essential for providing high-quality care.

OBJECTIVE

The aim of the study was to assess association of pain catastrophizing with pelvic floor symptom distress and impact, postoperative pain, and voiding trial in patients undergoing urogynecologic surgery.

STUDY DESIGN

Individuals whose self-identified gender was female and were undergoing surgery March 2020-December 2021 were included. Participants completed the Pain Catastrophizing Scale (range 0-52), Pelvic Floor Distress Inventory, and Pelvic Floor Impact Questionnaire preoperatively. Pain catastrophizing was score ≥30 and describes the tendency to magnify the overall threat of pain. Voiding trial failure was inability to void ≥2/3 of instilled volume (≤300 mL). The association between pain catastrophizing and symptom distress and impact was assessed with linear regression. A P < 0.05 is significant.

RESULTS

Three hundred twenty patients were included (mean age, 60 years, 87% White). Forty-six of 320 participants (14%) had a pain catastrophizing score ≥30. The pain catastrophizing group had higher body mass index (33 ± 12 vs 29 ± 5), more benzodiazepine use (26% vs 12%), greater symptom distress (154 ± 58 vs 108 ± 60), and greater urogenital (59 ± 29 vs 47 ± 28), colorectal (42 ± 24 vs 26 ± 23), and prolapse (54 ± 24 vs 36 ± 24) subscale scores, all P ≤ 0.02. The pain catastrophizing group had greater impact (153 ± 72 vs 72 ± 64, P < 0.01) and urogenital (60 ± 29 vs 34 ± 28), colorectal (36 ± 33 vs 16 ± 26), and prolapse (57 ± 32 vs 22 ± 27) subscale scores, P < 0.01. Associations remained controlling for confounders ( P < 0.01). The pain catastrophizing group had higher 10-point pain scores (8 vs 6, P < 0.01) and was more likely to report pain at 2 weeks (59% vs 20%, P < 0.01) and 3 months (25% vs 6%, P = 0.01). Voiding trial failure did not differ (26% vs 28%, P = 0.98).

CONCLUSIONS

Pain catastrophizing is associated with greater pelvic floor symptom distress and impact and postoperative pain but not voiding trial failure.

Time Effect on Acute Postoperative Pain After Total Knee Replacement Surgery: An Exploratory Study Using the Experience Sampling Method

OBJECTIVES

Acute postoperative pain (APP) is the main cause of postoperative dissatisfaction; however, traditional methods of pain assessment provide limited insights into the dynamics and development of APP. This study used the experience sampling method to understand the dynamics of APP over time in relation to various patient factors.

MATERIALS AND METHODS

Forty patients scheduled to undergo total knee replacement surgery were recruited in this study. Following an initial assessment, a short report questionnaire was sent to the patients through 10 digital alerts per day to assess the pain levels during 2 preoperative and the first 6 postoperative days. The data were analyzed using multilevel regression, including random intercept and slope.

RESULTS

Thirty-two patients submitted the prespecified minimum of 30% of their short reports, yielding 1217 records. The analysis revealed significant ( P <0.001) linear and quadratic decreases in APP and a quadratic time effect. The lowest between-day and within-day pain levels were observed on postoperative day 4.8 and during the time slot 3.8 or ~19:15, respectively. Significant random intercepts and slopes were noted, indicating variations in the mean pain level between patients and a decrease in pain. None of the 10 patient factors had any confounding effect.

DISCUSSION

Using the experience sampling method data combined with multilevel analysis, we were able to evaluate the postoperative pain course while considering inter-individual differences in the baseline pain level and nonlinear pain course over time. The findings of this study could aid clinicians in personalizing the treatment for APP.

The Interconnection Between Social Support and Emotional Distress Among Individuals with Chronic Pain: A Narrative Review

Chronic pain is a public health concern affecting over 100 million U.S. adults. Because chronic pain is multifactorial, it requires a biopsychosocial approach to understand how biological, psychological, and social factors contribute to both the development and maintenance of pain. On average, individuals with chronic pain report higher levels of emotional distress compared to pain-free individuals. Research has demonstrated that social support is associated with better pain outcomes and less emotional distress. It has been proposed that social support may improve pain outcomes by reducing the influence of stressors. However, the majority of research exploring the relationships between social support and pain-related outcomes has focused on the direct relationship between these variables, largely overlooking the process by which social support has a positive influence on pain. This narrative review synthesizes research on how chronic pain, emotional distress, and social support are highly interconnected, yet research investigating chronic pain and emotional distress within a social context is limited. We then highlight disparities in chronic pain, such that the burden of chronic pain is unequal between demographic groups. Next, we discuss existing evidence for the use of group-based interventions to address pain-related outcomes. Lastly, we summarize limitations of prior research studies and highlight gaps in the current literature. Overall, longitudinal research comprehensively investigating the distinct nuances in the measurement of social support and how these nuances relate to emotional distress and pain outcomes is needed and may provide insight into the unique needs of individuals or subgroups. Further, demographically diverse randomized controlled trials are needed to identify the process by which group-based interventions improve pain outcomes and whether these interventions are more effective for particular groups in order to personalize treatment approaches and address inequities in pain care.

Does the Association Between Psychosocial Factors and Opioid Use After Elective Spine Surgery Differ by Sex in Older Adults?

Purpose

Psychosocial disorders have been linked to chronic postoperative opioid use and the development of postoperative pain. The potential interaction between sex and psychosocial factors with respect to opioid use after elective spine surgery in the elderly has not yet been evaluated. Our aim was to assess whether any observed association of anxiety or depression indicators with opioid consumption in the first 72 hours after elective spine surgery varies by sex in adults ≥65 years.

Patients and Methods

Secondary analysis of a retrospective cohort of 647 elective spine surgeries performed at Brigham and Women's Hospital, July 1, 2015-March 15, 2017, in patients ≥65. Linear mixed-effects models were used to test whether history of anxiety, anxiolytic use, history of depression, and antidepressant use were associated with opioid consumption 0-24, 24-48, and 48-72 post surgery, and whether these potential associations differed by sex.

Results

History of anxiety, anxiolytic use, history of depression, and antidepressant use were more common among women (51.3% of the sample). During the first 24 hours after surgery, men with a preoperative history of anxiety consumed an adjusted mean of 19.5 morphine milligram equivalents (MME) (99.6% CI: 8.1, 31.0) more than men without a history of anxiety; women with a history of anxiety only consumed an adjusted mean 2.9 MME (99.6% CI: -3.1, 8.9) more than women without a history of anxiety (P value for interaction between sex and history of anxiety <0.001). No other interactions were detected between sex and psychosocial factors with respect to opioid use after surgery.

Conclusion

Secondary analysis of this retrospective cohort study found minimal evidence that the association between psychosocial factors and opioid consumption after elective spine surgery differs by sex in adults ≥65.

Development and validation of nomograms to predict preoperative anxiety and postoperative pain in patients undergoing gynecological surgery: An observational analysis

BACKGROUND

Perioperative anxiety and pain are associated with patient dissatisfaction, postoperative complications, and prolonged hospital stay. Early identification of high-risk patients with preoperative anxiety and postoperative pain will be useful for the implementation of preventive management.

METHODS

Patients, who underwent gynecological surgery in our hospital between March 2022 and September 2022, were consecutively enrolled. Perioperative anxiety and pain were evaluated with the Visual Analogue Scale of Anxiety (VAA) and Visual Analogue Scale of Pain (VAS), respectively. Step Akaike Information Criterion analysis was performed to identify risk factors and logistic regression was used to establish nomograms, followed by discrimination, calibration, and clinical utility evaluation.

RESULTS

A total of 197 patients were included for analysis, including 116 and 81 patients who were randomized to training and test groups, respectively. The prediction model of preoperative moderate to severe anxiety identified four preoperative relevant factors: age, sleep duration, preoperative pain, and regular exercise before gynecological surgery. The model had an area under the receiver operating characteristics curve of 0.808 (0.729, 0.887) and 0.754 (0.634, 0.875) in the training and test groups, respectively. The prediction model of postoperative moderate to severe pain identified four relevant factors: preoperative pain, surgery type, VAA before anesthesia, and patient-controlled analgesia. The model had an area under the receiver operating characteristics curve of 0.867 (0.798, 0.935) and 0.852 (0.761, 0.943) in the training and test groups, respectively.

CONCLUSIONS

The established nomograms accurately identified high-risk patients with preoperative anxiety and postoperative pain before gynecological surgery. Clinical registration at: www.chictr.org.cn (ChiCTR2200057757).

Anterior cingulate cortex regulates pain catastrophizing-like behaviors in rats

Negative pain expectation including pain catastrophizing is a well-known clinical phenomenon whereby patients amplify the aversive value of a painful or oftentimes even a similar, non-painful stimulus. Mechanisms of pain catastrophizing, however, remain elusive. Here, we modeled pain catastrophizing behavior in rats, and found that rats subjected to repeated noxious pin pricks on one paw demonstrated an aversive response to similar but non-noxious mechanical stimuli delivered to the contralateral paw. Optogenetic inhibition of pyramidal neuron activity in the anterior cingulate cortex (ACC) during the application of repetitive noxious pin pricks eliminated this catastrophizing behavior. Time-lapse calcium (Ca2+) imaging in the ACC further revealed an increase in spontaneous neural activity after the delivery of noxious stimuli. Together these results suggest that the experience of repeated noxious stimuli may drive hyperactivity in the ACC, causing increased avoidance of subthreshold stimuli, and that reducing this hyperactivity may play a role in treating pain catastrophizing.

Use of virtual reality in port implantation to reduce perioperative anxiety and pain: protocol for a randomised controlled pilot trial at a single German university hospital (VIP-trial; DRKS00028508)

INTRODUCTION

Intravenous access port implantation is commonly performed under local anaesthesia, which offers advantages such as increased patient satisfaction and resource savings compared with general anaesthesia. However, patients may experience increased perioperative stress and anxiety in the operating room setting without general anaesthesia. Virtual reality (VR) distraction or hypnosis during surgery under local anaesthesia may help patients to auditorily and visually separate from their real environment and engage with a virtual environment through hypnorelaxing guidance. Previous studies suggested that VR hypnosedation may reduce the use of sedatives or general anaesthesia, and may offer additional benefits such as reducing postoperative pain and nausea, and promoting faster patient discharge.

METHODS AND ANALYSIS

The VIP trial is a randomised controlled pilot trial comparing the usage of VR during port implantation with the current standard of care (local anaesthesia and analgosedation if needed). A total of 120 adult patients are included after screening for eligibility and obtaining informed consent. Patients are randomised preoperatively in a 1:1 ratio to the trial groups. The main outcomes are change of perioperative anxiety and pain. Further outcomes include patient satisfaction and tolerability, perioperative analgesia and sedation, occurrence of postoperative nausea, vomiting and VR sickness symptoms, surgeon's satisfaction, procedure duration, postoperative complications until postoperative day 30 and patient willingness to hypothetically undergo port implantation again under the same conditions.

ETHICS AND DISSEMINATION

The VIP trial has been approved by the Ethics Committee of the Medical Faculty of Ulm University (reference number 03/22). If the intervention demonstrates that VR can effectively reduce perioperative anxiety and pain, it may become a novel standard of care to minimise the need for analgosedation or general anaesthesia in port implantation procedures and improve patient outcomes. The results will be submitted to a peer-reviewed journal in the field and will be presented at applicable conferences to ensure rigorous evaluation and access for the academic community.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register: DRKS00028508; registration date 15 March 2022; Universal Trial Number: U1111-1275-4995.

Predicting chronic postsurgical pain: current evidence and a novel program to develop predictive biomarker signatures

ABSTRACT

Chronic pain affects more than 50 million Americans. Treatments remain inadequate, in large part, because the pathophysiological mechanisms underlying the development of chronic pain remain poorly understood. Pain biomarkers could potentially identify and measure biological pathways and phenotypical expressions that are altered by pain, provide insight into biological treatment targets, and help identify at-risk patients who might benefit from early intervention. Biomarkers are used to diagnose, track, and treat other diseases, but no validated clinical biomarkers exist yet for chronic pain. To address this problem, the National Institutes of Health Common Fund launched the Acute to Chronic Pain Signatures (A2CPS) program to evaluate candidate biomarkers, develop them into biosignatures, and discover novel biomarkers for chronification of pain after surgery. This article discusses candidate biomarkers identified by A2CPS for evaluation, including genomic, proteomic, metabolomic, lipidomic, neuroimaging, psychophysical, psychological, and behavioral measures. Acute to Chronic Pain Signatures will provide the most comprehensive investigation of biomarkers for the transition to chronic postsurgical pain undertaken to date. Data and analytic resources generatedby A2CPS will be shared with the scientific community in hopes that other investigators will extract valuable insights beyond A2CPS's initial findings. This article will review the identified biomarkers and rationale for including them, the current state of the science on biomarkers of the transition from acute to chronic pain, gaps in the literature, and how A2CPS will address these gaps.

Effectiveness of virtual reality in managing pain and anxiety in adults during periprocedural period: a systematic review and meta-analysis

PURPOSE

Patients undergoing medical procedures often experience pain and anxiety. These periprocedural outcomes can be overcome by providing a distraction using virtual reality (VR), decreasing their perception. VR has proved effective in reducing pediatric pain and anxiety; however, limited studies have confirmed its effectiveness in adults. We performed a systematic review and meta-analysis on the effectiveness of VR, as opposed to standard care, in reducing periprocedural pain and anxiety in adults.

METHODS

A systematic search of randomized controlled trials was conducted using the databases of MEDLINE, Cochrane CENTRAL, and Scopus. Trials involving patients (> 18 years) undergoing elective medical procedures conducted with or without local anesthesia and participating in VR therapy were included. Primary outcomes were pre-procedural anxiety, post-procedural anxiety, and intra-procedural pain. Pre-procedural pain, post-procedural pain, and intra-procedural anxiety were secondary outcomes.

RESULTS

Data from 10 studies shortlisted for inclusion revealed no significant association between the use of VR and lower pre-procedural anxiety compared to standard care (p > 0.05) (SMD = -0.02, 95% CI = -0.18 - 0.14, P = 0.81) but demonstrated that the use of VR was significantly associated with a reduction in post-procedural anxiety (SMD = -0.73, 95% CI = -1.08 - -0.39, P < 0.0001), intra-procedural pain (SMD = -0.61, 95% CI = -1.18 - -0.04, P = 0.04), and post-procedural pain (SMD = -0.25, 95% CI = -0.44 - -0.05, P = 0.01).

CONCLUSION

The use of VR caused a significant reduction in post-procedural anxiety, intra-procedural pain, and post-procedural pain in adults undergoing medical procedures, although the findings were insignificant concerning pre-procedural anxiety.

Local Periarticular Infiltration with Dexmedetomidine Results in Superior Patient Well-Being after Total Knee Arthroplasty Compared with Peripheral Nerve Blocks: A Randomized Controlled Clinical Trial with a Follow-Up of Two Years

BACKGROUND

This study aimed to compare local periarticular infiltration (LIA) with ultra-sound guided regional anesthesia (USRA) with ropivacaine and dexmedetomidine as an additive agent in primary total knee arthroplasty (TKA).

METHODS

Fifty patients were randomized into two groups in a 1:1 ratio. Patients in the LIA group received local periarticular infiltration into the knee joint. The USRA group received two single-shot USRA blocks. Functional outcomes and satisfaction (range of movement, Knee Society Knee Score, Western Ontario and McMaster Universities Osteoarthritis Index, Oxford Knee Score, and Forgotten Joint Score), including well-being, were analyzed preoperatively and at five days, six weeks, and one and two years postoperatively.

RESULTS

Functional outcomes did not significantly differ between the two groups at six weeks and one and two years after the implementation of TKA. A moderate correlation was observed in the LIA group regarding well-being and pain on day five. Six weeks postoperatively, the LIA group showed significantly superior well-being but worse pain scores. No differences between the groups in well-being and functional outcomes could be observed one and two years postoperatively.

CONCLUSION

Patients treated with LIA had superior postoperative well-being in the early postoperative phase of up to six weeks. Furthermore, LIA patients had similar functionality compared to patients treated with USRA but experienced significantly more pain six weeks postoperatively. LIA leads to improved short-term well-being, which is potentially beneficial for faster knee recovery. We believe that LIA benefits fast-track knee recovery with respect to improved short-term well-being, higher practicability, and faster application.

Establishing the Reliability, Validity, and Prognostic Utility of the Momentary Pain Catastrophizing Scale for Use in Ecological Momentary Assessment Research

Despite the marked increase in ecological momentary assessment research, few reliable and valid measures of momentary experiences have been established. The goal of this preregistered study was to establish the reliability, validity, and prognostic utility of the momentary Pain Catastrophizing Scale (mPCS), a 3-item measure developed to assess situational pain catastrophizing. Participants in 2 studies of postsurgical pain outcomes completed the mPCS 3 to 5 times per day prior to surgery (N = 494, T = 20,271 total assessments). The mPCS showed good psychometric properties, including multilevel reliability and factor invariance across time. Participant-level average mPCS was strongly positively correlated with dispositional pain catastrophizing as assessed by the Pain Catastrophizing Scale (r = .55 and .69 in study 1 and study 2, respectively). To establish prognostic utility, we then examined whether the mPCS improved prediction of postsurgical pain outcomes above and beyond one-time assessment of dispositional pain catastrophizing. Indeed, greater variability in momentary pain catastrophizing prior to surgery was uniquely associated with increased pain immediately after surgery (b = .58, P = .005), after controlling for preoperative pain levels and dispositional pain catastrophizing. Greater average mPCS score prior to surgery was also uniquely associated with lesser day-to-day improvement in postsurgical pain (b = .01, P = .003), whereas dispositional pain catastrophizing was not (b = -.007, P = .099). These results show that the mPCS is a reliable and valid tool for ecological momentary assessment research and highlight its potential utility over and above retrospective measures of pain catastrophizing. PERSPECTIVE: This article presents the psychometric properties and prognostic utility of a new measure to assess momentary pain catastrophizing. This brief, 3-item measure will allow researchers and clinicians to assess fluctuations in pain catastrophizing during individuals' daily lives, as well as dynamic relationships between catastrophizing, pain, and related factors.

Central sensitization in CRPS patients with widespread pain: a cross-sectional study

OBJECTIVE

Widespread pain hypersensitivity and enhanced temporal summation of pain (TSP) are commonly reported in patients with complex regional pain syndrome (CRPS) and discussed as proxies for central sensitization. This study aimed to directly relate such signs of neuronal hyperexcitability to the pain phenotype of CRPS patients.

METHODS

Twenty-one CRPS patients and 20 healthy controls (HC) were recruited. The pain phenotype including spatial pain extent (assessed in % body surface) and intensity were assessed and related to widespread pain hypersensitivity, TSP, and psychological factors. Quantitative sensory testing (QST) was performed in the affected, the contralateral and a remote (control) area.

RESULTS

CRPS patients showed decreased pressure pain thresholds in all tested areas (affected: t(34)  = 4.98, P < .001, contralateral: t(35) = 3.19, P = .005, control: t(31) = 2.65, P = .012). Additionally, patients showed increased TSP in the affected area (F(3,111) = 4.57, P = .009) compared to HC. TSP was even more enhanced in patients with a high compared to a low spatial pain extent (F(3,51) = 5.67, P = .008), suggesting pronounced spinal sensitization in patients with extended pain patterns. Furthermore, the spatial pain extent positively correlated with the Bath Body Perception Disturbance Scale (ρ = 0.491; P = .048).

CONCLUSIONS

Overall, we provide evidence that the pain phenotype in CRPS, that is, spatial pain extent, might be related to sensitization mechanism within the central nociceptive system. This study points towards central neuronal excitability as a potential therapeutic target in patients with more widespread CRPS.

Chronic post-thoracotomy pain after lung cancer surgery: a prospective study of preoperative risk factors

OBJECTIVES

The objective of this longitudinal cohort study was to investigate if preoperative pain mechanisms, anxiety, and depression increase risk of developing chronic post-thoracotomy pain (CPTP) after lung cancer surgery.

METHODS

Patients with suspected or confirmed lung cancer undergoing surgery by either video-assisted thoracoscopic surgery or anterior thoracotomy were recruited consecutively. Preoperative assessments were conducted by: quantitative sensory testing (QST) (brush, pinprick, cuff pressure pain detection threshold, cuff pressure tolerance pain threshold, temporal summation and conditioned pain modulation), neuropathic pain symptom inventory (NPSI), and the Hospital Anxiety and Depression Scale (HADS). Clinical parameters in relation to surgery were also collected. Presence of CPTP was determined after six months and defined as pain of any intensity in relation to the operation area on a numeric rating scale form 0 (no pain) to 10 (worst pain imaginable).

RESULTS

A total of 121 patients (60.2 %) completed follow-up and 56 patients (46.3 %) reported CPTP. Development of CPTP was associated with higher preoperative HADS score (p=0.025), higher preoperative NPSI score (p=0.009) and acute postoperative pain (p=0.042). No differences were observed in relation to preoperative QST assessment by cuff algometry and HADS anxiety and depression sub-scores.

CONCLUSIONS

High preoperative HADS score preoperative pain, acute postoperative pain intensity, and preoperative neuropathic symptoms were was associated with CPTP after lung cancer surgery. No differences in values of preoperative QST assessments were found. Preoperative assessment and identification of patients at higher risk of postoperative pain will offer opportunity for further exploration and development of preventive measures and individualised pain management depending on patient risk profile.

Pain Management in Dermatology

BACKGROUND

The dermatologist has to deal with many situations where the patient feels pain and must therefore know how to manage it.

SUMMARY

The aim of this review was to explore the treatments available to manage pain in dermatology in different circumstances, with an emphasis on pharmacological and non-pharmacological interventions specifically studied in dermatology.

The mechanisms and management of persistent postsurgical pain

An estimated 10%-50% of patients undergoing a surgical intervention will develop persistent postsurgical pain (PPP) lasting more than 3 months despite adequate acute pain management and the availability of minimally invasive procedures. The link between early and late pain outcomes for surgical procedures remains unclear-some patients improve while others develop persistent pain. The elective nature of a surgical procedure offers a unique opportunity for prophylactic or early intervention to prevent the development of PPP and improve our understanding of its associated risk factors, such as pre-operative anxiety and the duration of severe acute postoperative pain. Current perioperative pain management strategies often include opioids, but long-term consumption can lead to tolerance, addiction, opioid-induced hyperalgesia, and death. Pre-clinical models provide the opportunity to dissect mechanisms underpinning the transition from acute to chronic, or persistent, postsurgical pain. This review highlights putative mechanisms of PPP, including sensitisation of peripheral sensory neurons, neuroplasticity in the central nervous system and nociceptive signalling along the neuro-immune axis.

A cross-sectional study of fear of surgery in female breast cancer patients: Prevalence, severity, and sources, as well as relevant differences among patients experiencing high, moderate, and low fear of surgery

BACKGROUND

Fear of surgery has been associated with more postoperative pain, disability, and a lower quality of life among patients undergoing various surgical procedures. While qualitative studies indicate breast cancer patients to be afraid of surgery, detailed quantitative analyses are lacking. The present research aimed at investigating the prevalence, severity, and sources of fear of surgery in this patient group and to compare patients reporting different degrees of such fear.

METHODS

This cross-sectional study included 204 breast cancer patients, 18-70 years old, and scheduled for surgery at Oslo University Hospital, Norway. Following their preoperative visit participants completed validated psychological questionnaires online. Among these, the primary outcome measure, the Surgical Fear Questionnaire (SFQ; scores: 0-10 per item, 0-80 overall). Patients were grouped based on SFQ-percentiles (<25th = little, 25th-75th = moderate and >75th percentile = high fear) and compared on psychological (anxiety, depression, experienced injustice, optimism and expected postsurgical pain), sociodemographic, and medical outcomes.

RESULTS

195 patients completed the SFQ. On average fear of surgery was low (M = 26.41, SD = 16.0, median = 26, min-max = 0-80), but omnipresent. Only 1.5% (n = 3) indicated no fear at all. Overall, patients feared surgery itself the most (M = 3.64, SD = 2.8). Groups differed significantly (p < .001) in their experience of anxiety, depression, and injustice, as well as their disposition to be optimistic, and expectance of postsurgical pain. Differences between groups concerning demographic and medical information were largely insignificant.

DISCUSSION

This study was the first to demonstrate fear of surgery to be prevalent and relevant among female breast cancer patients. The higher a patients' fear group, the poorer their preoperative psychological constitution. This, largely irrespective of their current diagnoses or treatments, medical history, and demographics. Fear of surgery might thus cater as a prognostic marker and treatment target in this patient group. However, given the cross-sectional character of the present data, prognostic studies are needed to evaluate such claims.

Risk factors and protective factors of acute postoperative pain: an observational study at a German university hospital with cross-sectional and longitudinal inpatient data

OBJECTIVES

Surgical fear is one of the most important psychological risk factors for postoperative pain, but less is known about the contribution of protective factors. This study investigated somatic and psychological risk and resilience factors of postoperative pain and validated the German version of the Surgical Fear Questionnaire (SFQ).

SETTING

University Hospital of Marburg, Germany.

DESIGN

Single-centre observational study and cross-sectional validation study.

PARTICIPANTS

Data for validating the SFQ were obtained from a cross-sectional observational study (N=198, mean age 43.6 years, 58.8% female) with persons undergoing different kinds of elective surgery. A sample of N=196 (mean age 43.0 years, 45.4% female) undergoing elective (orthopaedic) surgery was analysed to investigate somatic and psychological predictors of relevant acute postsurgical pain (APSP).

OUTCOME MEASURES

Participants completed preoperative and postoperative assessments at postoperative days 1, 2 and 7. Presurgical pain, age, gender, pain expectation, surgical setting, physical status, anaesthesia, surgical fear, pain catastrophising, depression, optimism and self-efficacy were examined as predictors.

RESULTS

Confirmatory factor analysis confirmed the original two-factor structure of the SFQ. Correlation analyses indicated good convergent and divergent validity. Internal consistency (Cronbach's α) was between 0.85 and 0.89. Blockwise logistic regression analyses for the risk of APSP revealed outpatient setting, higher preoperative pain, younger age, more surgical fear and low dispositional optimism as significant predictors.

CONCLUSIONS

The German SFQ is a valid, reliable and economical instrument with which the important psychological predictor surgical fear can be assessed. Modifiable factors that increase the risk of postoperative pain were higher pain intensity before surgery and being fearful about negative consequences of the surgery whereas positive expectations seem to buffer against postsurgical pain.

TRIAL REGISTRATION NUMBERS

DRKS00021764 and DRKS00021766.

Can perioperative psychological interventions reduce chronic pain after surgery?

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

Individual Differences in Pain Catastrophizing and Regional Gray Matter Volume Among Community-dwelling Adults With Chronic Pain: A Voxel-based Morphology Study

OBJECTIVES

Elevations in pain catastrophizing (PC) are associated with more severe pain, emotional distress, and impairment within samples with chronic pain. However, brain structure correlates underlying individual differences in PC are not well understood and predict more severe pain and impairment within samples with chronic pain. This study assessed links between regional gray matter volume (GMV) and individual differences in PC within a large mixed chronic pain sample.

MATERIALS AND METHODS

Chinese adult community dwellers with chronic pain of at least 3 months duration (101 women and 59 men) completed self-report measures of background characteristics, pain severity, depression, and a widely validated PC questionnaire as well as a structural magnetic resonance imagining scan featuring voxel-based morphology to assess regional GMV correlates of PC.

RESULTS

After controlling for demographic correlates of PC, pain severity, and depression, higher PC scores had a significant, unique association with lower GMV levels in the inferior temporal area of the right fusiform gyrus, a region previously implicated in emotion regulation.

DISCUSSION

GMV deficits, particularly in right temporal-occipital emotion regulation regions, correspond to high levels of PC among individuals with chronic pain.

What is the Association Between Clinically Diagnosed Psychiatric Illness and Total Joint Arthroplasty? A Systematic Review Evaluating Outcomes, Healthcare Use, and Patient-reported Outcome Measures

BACKGROUND

Studies evaluating the effects of a psychiatric illness on orthopaedic surgical outcomes have yielded mixed results. Because awareness of patient comorbid mental health disorders has become increasingly important to tailor treatment plans, the aim of our systematic review was to present the findings of all studies reporting on the association between clinically diagnosed psychiatric illnesses and total joint arthroplasty (TJA) outcomes and evaluate the quality of evidence to provide a comprehensive summary.

QUESTION/PURPOSE

Is there a consistently reported association between comorbid psychiatric illness and (1) complication risk, (2) readmission rates, (3) healthcare use and discharge disposition, and (4) patient-reported outcome measures (PROMs) after TJA?

METHODS

The PubMed, EBSCO host, Medline, and Google Scholar electronic databases were searched on April 9, 2022, to identify all studies that evaluated outcomes after TJA in patients with a comorbid clinically diagnosed mental health disorder between January 1, 2000, and April 1, 2022. Studies were included if the full-text article was available in English, reported on primary TJA outcomes in patients with clinically diagnosed mental health disorders, included patients undergoing TJA without a psychiatric illness for comparison, and had a minimum follow-up time of 30 days for evaluating readmission rates, 90 days for other perioperative outcomes such as length of stay and complications, and 1-year minimum follow-up if assessing PROMs. Studies that used a mental health screening examination instead of clinical diagnoses were excluded to isolate for verified psychiatric illnesses. Additionally, systematic reviews, case reports, duplicate studies between the databases, and gray literature were excluded. Twenty-one studies were included in our final analysis comprising 31,023,713 patients with a mean age range of 57 to 69 years. Mental health diagnoses included depression, anxiety, bipolar disorder, schizophrenia, major personality disorder, and psychosis as well as concomitant mental disorders. Two reviewers independently evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies (MINORS) tool. The mean MINORS score was 19.5 ± 0.91 of 24, with higher scores representing better study quality. All the articles included were retrospective, comparative studies. Given the heterogeneity of the included studies, a meta-analysis was not performed, and results are instead presented descriptively.

RESULTS

Patients with schizophrenia were consistently reported to have higher odds of medical and surgical complications than patients without psychiatric illness, particularly anemia and respiratory complications. Among studies with the largest sample sizes, patients with depression alone or depression and anxiety had slightly higher odds of complications. Most studies identified higher odds of readmission among patients with depression, schizophrenia, and severe mental illness after TJA. However, for anxiety, there was no difference in readmission rates compared with patients without psychiatric illness. Slightly higher odds of emergency department visits were reported for patients with depression, anxiety, concomitant depression and anxiety, and severe mental illness across studies. When evaluating healthcare use, articles with the largest sample sizes reporting on depression and length of stay or discharge disposition found modestly longer length of stay and greater odds of nonhome discharge among patients with depression. Although several studies reported anxiety was associated with slightly increased total costs of hospitalization, the most robust studies reported no difference or slightly shorter average length of stay. However, the included studies only reported partial economic analyses of cost, leading to relatively superficial evidence. Patients with schizophrenia had a slightly longer length of stay and modestly lower odds of home discharge and cost. Likewise, patients with concomitant depression and anxiety had a slightly longer average length of stay, according to the two articles reporting on more than 1000 patients. Lastly, PROM scores were worse in patients with depression at a minimum follow-up of 1 year after TJA. For anxiety, there was no difference in improvement compared with patients without mental illness.

CONCLUSION

Our systematic review found that individuals with psychiatric illness had an increased risk of postoperative complications, increased length of stay, higher costs, less frequent home discharge, and worse PROM scores after TJA. These findings encourage inclusion of comorbid psychiatric illness when risk-stratifying patients. Attention should focus on perioperative interventions to minimize the risk of thromboembolic events, anemia, bleeding, and respiratory complications as well as adequate pain management with drugs that do not exacerbate the likelihood of these adverse events to minimize emergency department visits and readmissions. Future studies are needed to compare patients with concomitant psychiatric illnesses such as depression and anxiety with patients with either diagnosis in isolation, instead of only comparing patients with concomitant diagnoses with patients without any psychiatric illnesses. Similarly, the results of targeted interventions such as cognitive behavioral therapy are needed to understand how orthopaedic surgeons might improve the quality of care for patients with a comorbid psychiatric illness.

Perception of Heaviness Induced by Sensorimotor Incongruence Is Associated with Pain Prognosis: A Pilot Study

Background. Patients with chronic musculoskeletal pain experience not only pain but also abnormal body perception. Such abnormal body perception has been reported to be caused by incongruence between motor intentions and sensory feedback (i.e., sensorimotor incongruence). However, the influence of abnormal body perception with sensorimotor incongruence on pain prognosis in musculoskeletal pain patients has not been investigated. Objective. We aimed at clarifying the influence of abnormal body perception on pain prognosis using an experimental procedure for inducing sensorimotor incongruence in patients with musculoskeletal pain. Methods. We recruited 18 patients within 2 months after limb fracture or ligament injury. In the experiment, patients sat with the intact upper or lower limb reflected in a large mirror aligned with the sagittal plane. A motor task was performed for 20 seconds in each of the congruent and incongruent conditions. In the congruent condition, patients were asked to perform flexion-extension movements with the intact and affected limbs in-phase, while observing the intact limb in the mirror. In the incongruent condition, patients were asked to perform flexion-extension movements antiphase, while observing the intact limb in the mirror. After performing the congruent and incongruent conditions, patients were asked to complete a questionnaire about abnormal body perception. These procedures were conducted within 2 months after the fracture (first), 2 weeks after the first measurement (second), and 4 weeks (third) after the first measurement. Results. Pain, heaviness, and peculiarity were more likely to be experienced in incongruent conditions. Additionally, structural equation modeling indicated that heaviness at the first time point predicted the pain intensity at the second and third time points. Conclusions. Heaviness caused by sensorimotor incongruence may predict pain prognosis in patients with musculoskeletal pain after one month.

Effect of music listening on perioperative anxiety, acute pain and pain catastrophizing in women undergoing elective cesarean delivery: a randomized controlled trial

BACKGROUND

Anxiety may adversely impact mother and her newborn. Music listening is a safe and efficacious treatment that may to reduce perioperative anxiety. The effect on acute pain and pain catastrophizing scores remains unclear. We aimed to determine whether perioperative music listening reduces anxiety, acute pain, and pain catastrophizing scale (PCS) scores following elective cesarean delivery under spinal anesthesia.

METHODS

After randomization into music listening and control groups, baseline patient characteristics, visual analog scale-anxiety (VAS-A) scores, pain scores, PCS total and sub-scores, and music preferences were collected preoperatively. Before surgery, parturients in the experimental group listened to music of their own choice for 30 min. Music listening was continued during administration of spinal anesthesia and cesarean delivery, and for 30 min following surgery. Postoperative VAS-A score, acute pain score, PCS scores, music preferences, satisfaction score, and feedback were recorded.

RESULTS

We analyzed 108 parturients (music: n = 53; control: n = 55). Music listening was associated with reduced postoperative VAS-A (mean difference (MD) -1.43, 95%CI -0.63 to -2.22), PCS total score (MD -6.39, 95%CI -2.11 to -10.66), PCS sub-scores on rumination (MD -1.68, 95%CI -0.12 to -3.25), magnification (MD -1.53, 95%CI -0.45 to -2.62), and helplessness (MD -3.17, 95%CI -1.29 to -5.06) sub-scores. There was no significant difference in postoperative acute pain scores. The majority (> 95%) of parturients reported "excellent" and "good" satisfaction with music listening, and most provided positive feedback.

CONCLUSION

Perioperative music listening was associated with reduced postoperative anxiety and lower pain catastrophizing. Based on the good patient satisfaction and positive feedback received, the use of music listening in the obstetric setting is recommended.

TRIAL REGISTRATION

This study was registered on Clinicaltrials.gov NCT03415620 on 30/01/2018.

Risk factors for persistent pain after breast cancer surgery: a multicentre prospective cohort study

Identifying factors associated with persistent pain after breast cancer surgery may facilitate risk stratification and individualised management. Single-population studies have limited generalisability as socio-economic and genetic factors contribute to persistent pain development. Therefore, this prospective multicentre cohort study aimed to develop a predictive model from a sample of Asian and American women. We enrolled women undergoing elective breast cancer surgery at KK Women's and Children's Hospital and Duke University Medical Center. Pre-operative patient and clinical characteristics and EQ-5D-3L health status were recorded. Pain catastrophising scale; central sensitisation inventory; coping strategies questionnaire-revised; brief symptom inventory-18; perceived stress scale; mechanical temporal summation; and pressure-pain threshold assessments were performed. Persistent pain was defined as pain score ≥ 3 or pain affecting activities of daily living 4 months after surgery. Univariate associations were generated using generalised estimating equations. Enrolment site was forced into the multivariable model, and risk factors with p < 0.2 in univariate analyses were considered for backwards selection. Of 210 patients, 135 (64.3%) developed persistent pain. The multivariable model attained AUC = 0.807, with five independent associations: age (OR 0.85 95%CI 0.74-0.98 per 5 years); diabetes (OR 4.68, 95%CI 1.03-21.22); pre-operative pain score at sites other than the breast (OR 1.48, 95%CI 1.11-1.96); previous mastitis (OR 4.90, 95%CI 1.31-18.34); and perceived stress scale (OR 1.35, 95%CI 1.01-1.80 per 5 points), after adjusting for: enrolment site; pre-operative pain score at the breast; pre-operative overall pain score at rest; postoperative non-steroidal anti-inflammatory drug use; and pain catastrophising scale. Future research should validate this model and evaluate pre-emptive interventions to reduce persistent pain risk.

Optimising psychological treatment for pain after breast cancer: a factorial design study protocol in Denmark

INTRODUCTION

One in five breast cancer (BC) survivors are affected by persistent pain years after completing primary treatment. While the efficacy of psychological interventions for BC-related pain has been documented in several meta-analyses, reported effect sizes are generally modest, pointing to a need for optimisation. Guided by the Multiphase Optimization Strategy, the present study aims to optimise psychological treatment for BC-related pain by identifying active treatment components in a full factorial design.

METHODS AND ANALYSIS

The study uses a 2×3 factorial design, randomising 192 women with BC-related pain (18-75 years) to eight experimental conditions. The eight conditions consist of three contemporary cognitive-behavioural therapy components, namely: (1) mindful attention, (2) decentring, and (3) values and committed action. Each component is delivered in two sessions, and each participant will receive either zero, two, four or six sessions. Participants receiving two or three treatment components will be randomised to receive them in varying order. Assessments will be conducted at baseline (T1), session by session, every day for 6 days following the first session in each treatment component, at post-intervention (T2) and at 12-week follow-up (T3). Primary outcomes are pain intensity (Numerical Rating Scale) and pain interference (Brief Pain Inventory interference subscale) from T1 to T2. Secondary outcomes are pain burden, pain quality, pain frequency, pain catastrophising, psychological distress, well-being and fear of cancer recurrence. Possible mediators include mindful attention, decentring, and pain acceptance and activity engagement. Possible moderators are treatment expectancy, treatment adherence, satisfaction with treatment and therapeutic alliance.

ETHICS AND DISSEMINATION

Ethical approval for the present study was received from the Central Denmark Region Committee on Health Research Ethics (no: 1-10-72-309-40). Findings will be made available to the study funders, care providers, patient organisations and other researchers at international conferences, and published in international, peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05444101).

Pre-existing anxiety and depression disorders and return to work after musculoskeletal strain or sprain: a phased-based approach

PURPOSE

To examine the impact of pre-existing anxiety and depression disorders on return to work (RTW) using a phase-based approach.

METHODS

Accepted lost-time workers' compensation claims for upper limb or spine strain or sprain from 2009 to 2013 were extracted for workers in the Canadian province of British Columbia (n = 78,186). Pre-existing anxiety and depression disorders were identified using health claims data. Probability of RTW following a first or second work lost-time episode was analyzed using Prentice, Williams and Peterson models for recurrent events (common hazards ratios (cHR)). Probability of a first lost-time recurrence was analyzed using Cox models (HR). All models included two years of follow up and were stratified by gender.

RESULTS

For men, anxiety alone (cHR = 0.90, 95% CI: 0.85 to 0.94) or comorbid with depression (cHR = 0.95, 95% CI: 0.92 to 0.99) was significantly associated with a lower probability of RTW, and comorbid anxiety and depression with a higher probability of recurrence (HR = 1.29, 95% CI: 1.13 to 1.48). In women, comorbid anxiety and depression was significantly associated with a lower probability of RTW (cHR = 0.96, 95% CI: 0.93 to 0.99) and a higher probability of recurrence (HR = 1.15, 95% CI: 1.04 to 1.28); and anxiety alone with a higher probability of recurrence (HR = 1.25, 95% CI: 1.09 to 1.43). There was little evidence that depression alone was associated with RTW or recurrence.

CONCLUSIONS

Workers with a pre-existing anxiety disorder may require additional supports both during lost-time and after initial RTW.

Virtual Reality as a Hypnotic Tool in the Management of Anxiety During the Performance of the Axillary Block

Regional anaesthesia is a gold standard in upper limb orthopaedic surgery. Carried out on an awake patient, it can be a source of anxiety. In recent years, hypnotic techniques have been proposed in the management of perioperative anxiety. Among them, virtual reality is increasingly used as a distraction tool during anxious or painful actions despite the scarcity of proof of its benefit in the literature. Before implementing the systematic use of virtual reality when performing regional anaesthesia in our institution, we designed a study hypothesizing that the use of a virtual reality headset when performing an axillary block would reduce patient's anxiety. The study is an investigator-initiated, prospective monocentric and observational trial comparing anxiety scores of patients who underwent upper limb surgery under an axillary block with or without virtual reality headset. The perioperative anxiety was assessed by a numerical range scale before and after the peripheral nerve block performance. Between June 2021 and June 2022, 99 patients were included: 53 wearing the virtual reality headset and 46 not. The difference in numerical range scale for anxiety before and after the axillary block performance did not differ in the virtual reality group compared to the group without headset (mean = -1.9 ± 2.5 vs -1.5 ± 2.0, (p = 0.2520)). Technical difficulties reported by the operators were similar in both groups. Despite the large number of patients included, the virtual reality headset did not reduce patient's anxiety during a peripheral nerve block. Perioperative anxiety was low in all patients.

Pilot Investigation of Somatosensory Functioning and Pain Catastrophizing in Pediatric Spinal Fusion Surgery

PURPOSE

Chronic post-surgical pain (CPSP) is a significant concern and contributes to the opioid epidemic; however, little is known about CPSP in young people.

DESIGN

This prospective study aimed to identify sensory, psychological, and demographic factors that may increase the risk of CPSP after spinal fusion surgery for children and adolescents with idiopathic scoliosis.

METHODS

32 children and adolescents from two children's hospitals completed quantitative sensory testing (QST) and the Pain Catastrophizing Scale Child (PCS-C) pre-and 4-6 months post spinal fusion surgery. Between-group differences were assessed using an independent samples t-test. Pearson's correlations and stepwise linear regression were used to assess the relationship between variables at both time points.

RESULTS

56% of patients endorsed pain post-surgery. They were more sensitive tomechanical detection on both a control non-pain site (r = -2.87, p = .004) and the back (r = -1.83, p = .04), as well as pressure pain (r=-2.37, p = .01) on the back. This group also reported worse pain scores pre-surgery. Pre-surgery helplessness positively correlated with preoperative pain (r = .67 p < .001), and age was negatively correlated with the post-surgical catastrophizing total score (r =-.39, p = .05), suggesting that younger patients endorsed more pain-related worry after surgery.

CONCLUSIONS

Patients who present with pain during their preoperative appointment may need to be monitored with increased vigilance throughout the perioperative period, possibly with bedside QST and psychological questionnaires, which nurses could administer. Biobehavioral interventions targeting pain intensity and feelings of helplessness and anxiety during the preoperative period may alleviate the transition to CPSP.

Integrating mechanistic-based and classification-based concepts into perioperative pain management: an educational guide for acute pain physicians

Chronic pain begins with acute pain. Physicians tend to classify pain by duration (acute vs chronic) and mechanism (nociceptive, neuropathic and nociplastic). Although this taxonomy may facilitate diagnosis and documentation, such categories are to some degree arbitrary constructs, with significant overlap in terms of mechanisms and treatments. In clinical practice, there are myriad different definitions for chronic pain and a substantial portion of chronic pain involves mixed phenotypes. Classification of pain based on acuity and mechanisms informs management at all levels and constitutes a critical part of guidelines and treatment for chronic pain care. Yet specialty care is often siloed, with advances in understanding lagging years behind in some areas in which these developments should be at the forefront of clinical practice. For example, in perioperative pain management, enhanced recovery protocols are not standardized and tend to drive treatment without consideration of mechanisms, which in many cases may be incongruent with personalized medicine and mechanism-based treatment. In this educational document, we discuss mechanisms and classification of pain as it pertains to commonly performed surgical procedures. Our goal is to provide a clinical reference for the acute pain physician to facilitate pain management decision-making (both diagnosis and therapy) in the perioperative period.

Dysmenorrhea catastrophizing and functional impairment in female pelvic pain

Background

Dysmenorrhea is suggested to increase the risk of chronic pain by enhancing central sensitization. However, little is known about whether emotional and cognitive responses induced by dysmenorrhea contribute to chronic pain interference. This study examined the association between catastrophizing specific to dysmenorrhea and both dysmenorrhea and chronic pelvic pain (CPP)-associated pain interference.

Methods

Women (N = 104) receiving care for CPP through a tertiary gynecological pain clinic between 2017 and 2020 were recruited. They completed the Pain Catastrophizing Scale, the Brief Pain Inventory-pain interference, and a separate questionnaire regarding dysmenorrhea symptoms and treatment preceding the development of CPP. Dysmenorrhea catastrophizing and interference measures were developed and tested for internal consistency and construct validity. Multiple linear regression models examined dysmenorrhea catastrophizing in association with dysmenorrhea interference and CPP-associated pain interference.

Results

Dysmenorrhea catastrophizing and interference measures demonstrated excellent internal consistency (Cronbach's Alpha = 0.93 and 0.92 respectively) and evidence of construct validity (correlated with dysmenorrhea severity and treatment, Ps < 0.01). Dysmenorrhea catastrophizing was moderately correlated with pain catastrophizing (ρ = 0.30, P = 0.003), and was associated with greater dysmenorrhea interference (P < 0.001) and CPP-associated pain interference (P = 0.032) accounting for general pain catastrophizing and other outcome-specific confounders. Dysmenorrhea intensity was most predictive of dysmenorrhea catastrophizing.

Conclusion

Among our clinical sample of women with CPP, dysmenorrhea catastrophizing was associated with greater dysmenorrhea interference and subsequent CPP-associated pain interference. More research is needed to determine whether reduction in dysmenorrhea catastrophizing leads to reduced pain interference associated with female pelvic pain.

Predictors of continued opioid use 6 months after total joint arthroplasty: a multi-site study

PURPOSE

Continued opioid use after total knee and hip arthroplasty (TKA/THA) is well-documented and associated with both surgical and patient-reported factors. Research examining the combined effects of a multitude of factors on continued, and even chronic, opioid use in a systematic algorithmic manner is lacking. This study prospectively evaluated the combined effect of patient-related and surgical factors associated with continued opioid use after TKA/THA.

METHODS

From 2016 to 2018, 198 participants undergoing TKA or THA were recruited from two tertiary care facilities. Participants completed surveys before surgery and at 2 weeks, 1, 3, and 6 months following surgery. A LASSO approach, followed by an exhaustive covariate selection procedure, was used to build a multivariable mixed-effects logistic regression model estimating the odds ratio of continued postoperative opioid use based on surgical factors and patient-reported factors.

RESULTS

Approximately half of the participants underwent either TKA (49%) or THA (51%). Preoperatively, 15% of participants reported taking opioid medication. Opioid use decreased from 68% at 2-week follow-up to 7% by 6 months. In addition, preoperative opioid use (95% CI 1.07-4.37), increased pain (95% CI 1.21-1.62), elevated preoperative Pain Catastrophizing Scale scores (95% CI 1.01-1.04), lower Physical Function scores (95% CI 0.87-0.95), and participants undergoing TKA, compared to THA, (95% CI 0.25-0.67) were found to be significantly associated with continued postoperative opioid use up to 6 months.

CONCLUSION

Preoperative opioid use, average pain, reduced physical function, and TKA were significantly associated with continued postoperative opioid use. Findings illustrate the need for preoperative and longitudinal assessment of patient-reported outcomes to mitigate poor postoperative pain outcomes.

LEVEL OF EVIDENCE

II.

Association of pain, analgesic, psychological, and socioeconomic factors with sub-acute pain after childbirth: A prospective cohort study

STUDY OBJECTIVE

To determine if acute postpartum pain, psychological distress, socioeconomic factors, and labor analgesia were associated with sub-acute pain after childbirth (SAPC; pain starting after childbirth and lasting between four weeks to three months).

DESIGN

Prospective cohort study, from pre-conception to post-partum three months.

SETTING

Singapore's major public maternity institution.

PATIENTS

We included women planning to conceive within a year. We excluded women who were pregnant, taking chemotherapy or psychotropic medications, had diabetes mellitus, received assisted fertility interventions or contraception, did not conceive after 12 months, with multiple pregnancies, or who developed obstetric complications.

INTERVENTIONS

None.

MEASUREMENTS

We investigated the relationship between average pain score during the three days after childbirth (primary exposure) and incidence of SAPC at postpartum three months (primary outcome). Secondarily, psychological distress at pre-conception (Beck Depression Inventory (BDI), Edinburgh Postnatal Depression Scale (EPDS), State-Trait Anxiety Inventory (STAI), Perceived Stress Scale (PSS), General Health Questionnaire-12 (GHQ-12), Life Experiences Survey (LES)) and second trimester of pregnancy (BDI, EPDS, STAI, PSS, Pregnancy Experience Scale (PES)) were assessed. Baseline maternal and socioeconomic characteristics, labor analgesia, maternal and neonatal outcomes were also collected accordingly.

MAIN RESULTS

Of 317 women who met the study criteria, 30 (9.5%) developed SAPC. Higher average pain score during the three days after childbirth (adjusted odds ratio (aOR) 1.46, 95% CI 1.17 to 1.82, p = 0.001), use of meperidine for labor analgesia (aOR 4.23, 95% CI 1.03 to 17.43, p = 0.046), higher pre-conception GHQ-12 score (aOR 1.14, 95% CI 1.03 to 1.27, p = 0.013), and lack of employment with income during pregnancy (aOR 9.62, 95% CI 3.07 to 30.30, p < 0.001) were independently associated with SAPC, with area under the curve (AUC) of 0.837.

CONCLUSIONS

Higher acute postpartum pain scores, use of meperidine for labor analgesia, poorer pre-conception general psychological health, and lack of employment with income during pregnancy are associated with SAPC.