Clinically meaningful scores on pain catastrophizing before and after multidisciplinary rehabilitation: a prospective study of individuals with subacute pain after whiplash injury

Role of Pain Catastrophizing in the Effects of Cognitive Behavioral Therapy for Chronic Pain in Different Subgroups: An Exploratory Secondary Data Analysis Using Finite Mixture Models

INTRODUCTION

Providing effective treatment for debilitating chronic pain is a challenge among many populations including military service members. Cognitive behavioral therapy for chronic pain (CBT-CP) is a leading psychological pain treatment. Pain catastrophizing is a pivotal mediator of pain-related outcomes. The purpose of this study was (1) to identify patient subgroups who differ in response to CBT-CP and (2) to explore the characteristics that define these patient subgroups. The overall goal was to obtain a better understanding of factors that may influence response to CBT-CP.

MATERIALS AND METHODS

This study was a secondary analysis of data from a clinical trial of 149 U.S. active duty service members with chronic pain. Participants underwent group-based CBT-CP for 6 weeks and completed pre- and posttreatment assessments. Finite mixture models were employed to identify subgroups in treatment response, with pain impact score as the primary outcome measure.

RESULTS

We identified two classes of nearly equal size with distinct pain impact responses. One class reported improved pain impact scores following CBT-CP. This improvement was significantly associated with lower (better) baseline depression scores and greater improvement in posttreatment pain catastrophizing. In contrast, the other class reported slightly worse mean pain impact scores following CBT-CP treatment; this response was not related to baseline depression or change in pain catastrophizing.

CONCLUSIONS

Our findings demonstrate that a sizable proportion of individuals with chronic pain may not respond to group-based CBT-CP and may require a more individualized treatment approach.

Patients with worse disability respond best to cognitive functional therapy for chronic low back pain: a pre-planned secondary analysis of a randomised trial

QUESTION

Do five baseline moderators identify patients with chronic low back pain who respond best to cognitive functional therapy (CFT) when compared with usual care?

DESIGN

Secondary analysis of the RESTORE randomised controlled trial.

PARTICIPANTS

A total of 492 adults with low back pain for > 3 months with at least moderate pain-related activity limitation.

INTERVENTION

Participants were allocated to CFT alone or CFT plus biofeedback; these two groups were combined for this secondary analysis. The control group was usual care.

OUTCOME MEASURES

The outcome was activity limitation measured using the Roland Morris Disability Questionnaire (RMDQ) at 3, 6, 13, 26, 40 and 52 weeks. Investigated effect modifiers were baseline measures of activity limitation, cognitive flexibility, pain intensity, self-efficacy and catastrophising.

RESULTS

Baseline levels of activity limitation and, potentially, cognitive flexibility were associated with different effects of CFT treatment, while pain intensity, self-efficacy and catastrophising were not. Patients who had higher baseline activity limitation had greater treatment effects at 13 and 52 weeks. A person with a baseline RMDQ score of 18 (90th percentile) would on average be 6.1 (95% CI 4.8 to 7.4) points better at 13 weeks if they received CFT compared with usual care. However, a person with a baseline score of 7 (10th percentile) would on average be 3.6 (95% CI 2.6 to 4.6) points better at 13 weeks.

CONCLUSION

The finding that CFT is most effective among patients who are most disabled and incur the greatest burden strongly suggests that CFT should be considered as a treatment for this group of patients.

REGISTRATION

ACTRN12618001396213.

Interdisciplinary pain program participants with high catastrophizing scores improve function utilizing enriched therapeutic encounters and integrative health techniques: a retrospective study

Introduction

Pain catastrophizing describes helplessness, rumination, and magnification of a pain experience. High pain catastrophizing is an independent risk factor for disability, pain severity, inadequate treatment response, chronicity, and opioid misuse. Interdisciplinary pain programs (IPPs) are beneficial and cost-effective for individuals with chronic pain, but their functional impact on individuals with high pain catastrophizing is not well established. The emerging field of placebo studies suggests that patient-provider relationships, positive treatment expectations, and sociobiologically informed care trigger physiological responses that may enhance therapeutic interventions.

Methods

In this retrospective observational cohort study, we compared admission and discharge data for 428 adults with high-impact chronic pain (mean 8.5 years) who completed the Spaulding-Medford Functional Restoration Program (FRP). The interdisciplinary FRP team of physiatrists, behavioral health clinicians, physical therapists, and occupational therapists specializes in evidenced-based conventional rehabilitation, integrative health, and pain psychoeducation via enriched therapeutic encounters, fostering collaboration, validation, trust, self-efficacy, and positive expectations. Clinical outcome measures included the Canadian Occupational Performance Measure (COPM) assessing functional performance (COPM-PS) and satisfaction with function (COPM-SS), the Pain Numeric Rating Scale (NRS), the Pain Catastrophizing Scale (PCS), and the Patient Health Questionnaire-9 (PHQ-9).

Results

FRP participants with clinically elevated catastrophizing at baseline (PCS ≥30, mean PCS 39) achieved statistically significant improvements in function (mean delta -2.09, CHI2 = 15.56, p < 0.001), satisfaction with function (COPM-SS mean delta -2.50, CHI2 = 7.42, p = 0.007), pain (NRS mean delta 2.7), mood (PHQ-9 mean delta 1.87, p = 0.002), and catastrophizing (PCS mean delta 4.16, p < 0.001). Subgroup analysis revealed racial disparities in pain scores, and exploratory analysis showed a trend toward reducing opiate consumption.

Discussion

Despite the known association of adverse outcomes with high catastrophizing, FRP participation was associated with increased productive engagement, reduced pain, reduced maladaptive thought processes, and improved mood. Although causation and efficacy cannot be established from a retrospective design, this is the first study to identify functional improvement in patients with high-impact chronic pain and clinically relevant high pain catastrophizing who participate in an IPP combining conventional and complementary rehabilitation with psychoeducation. These enriched therapeutic encounters may enhance the treatment process by promoting trust, empathy, collaboration, and beneficial reframing of patients' experiences, expectations, and goals.

Differences in dynamic balance control based on pain catastrophizing level in individuals with nonspecific chronic low back pain

BACKGROUND

Pain catastrophization (PC) is related to motor control changes in individuals with nonspecific chronic low back pain (NSCLBP). However, differences in dynamic balance control based on the level of PC still remain unclear in these individuals.

OBJECTIVE

The aim of this study was to compare the dynamic balance control between healthy controls and individuals with NSCLBP with high and low PC.

METHODS

Forty individuals with NSCLBP and 20 healthy participants were enrolled in this cross-sectional study. Individuals with NSCLBP were classified into two groups of high and low PC. Dynamic balance control was assessed using the Modified Star Excursion Balance Test (MSEBT), Five-Time Sit-to-Stand Test (FTSST), and Timed Up and Go Test (TUGT).

RESULTS

Statistical analyses showed that mean values of reach distances in the anterior, posteromedial, and posterolateral directions of the MSEBT were significantly lower in individuals with NSCLBP with high PC compared to low PC (p = .04, p = .01, and p = .04, respectively) and healthy controls (p < .001, p = .001, and p = .006, respectively). In addition, for both the FTSS and TUG tests, the mean time was significantly greater in individuals with NSCLBP with high PC compared to low PC (p < .001 and p = .004, respectively) and healthy controls (p < .001).

CONCLUSIONS

Our results showed poor dynamic balance control in individuals with NSCLBP with high PC. This suggests that PC could contribute to the impaired dynamic balance control in individuals with NSCLBP. Combining balance exercises and cognitive-behavioral treatments targeting PC may be useful for the improvement of dynamic balance control in individuals with NSCLBP with high PC.

Randomized Placebo-Controlled Trial of 60-Day Percutaneous Peripheral Nerve Stimulation Treatment Indicates Relief of Persistent Postoperative Pain, and Improved Function After Knee Replacement

OBJECTIVES

Total knee arthroplasty (TKA) is an effective surgery for end-stage knee osteoarthritis, but chronic postoperative pain and reduced function affect up to 20% of patients who undergo such surgery. There are limited treatment options, but percutaneous peripheral nerve stimulation (PNS) is a promising nonopioid treatment option for chronic, persistent postoperative pain. The objective of the present study was to evaluate the effect of a 60-day percutaneous PNS treatment in a multicenter, randomized, double-blind, placebo-controlled trial for treating persistent postoperative pain after TKA.

MATERIALS AND METHODS

Patients with postoperative pain after knee replacement were screened for this postmarket, institutional review board-approved, prospectively registered (NCT04341948) trial. Subjects were randomized to receive either active PNS or placebo (sham) stimulation. Subjects and a designated evaluator were blinded to group assignments. Subjects in both groups underwent ultrasound-guided placement of percutaneous fine-wire coiled leads targeting the femoral and sciatic nerves on the leg with postoperative pain. Leads were indwelling for eight weeks, and the primary efficacy outcome compared the proportion of subjects in each group reporting ≥50% reduction in average pain relative to baseline during weeks five to eight. Functional outcomes (6-minute walk test; 6MWT and Western Ontario and McMaster Universities Osteoarthritis Index) and quality of life (Patient Global Impression of Change) also were evaluated at end of treatment (EOT).

RESULTS

A greater proportion of subjects in the PNS groups (60%; 12/20) than in the placebo (sham) group (24%; 5/21) responded with ≥50% pain relief relative to baseline (p = 0.028) during the primary endpoint (weeks 5-8). Subjects in the PNS group also walked a significantly greater distance at EOT than did those in the placebo (sham) group (6MWT; +47% vs -9% change from baseline; p = 0.048, n = 18 vs n = 20 completed the test, respectively). Prospective follow-up to 12 months is ongoing.

CONCLUSIONS

This study provides evidence that percutaneous PNS decreases persistent pain, which leads to improved functional outcomes after TKA at EOT.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pain Catastrophizing: Controversies, Misconceptions and Future Directions

Recent reports have pointed to problems with the term "pain catastrophizing." Critiques of the term pain catastrophizing have come from several sources including individuals with chronic pain, advocates for individuals with chronic pain, and pain scholars. Reports indicate that the term has been used to dismiss the medical basis of pain complaints, to question the authenticity of pain complaints, and to blame individuals with pain for their pain condition. In this paper, we advance the position that the problems prompting calls to rename the construct of pain catastrophizing have little to do with the term, and as such, changing the term will do little to solve these problems. We argue that continued calls for changing or deleting the term pain catastrophizing will only divert attention away from some fundamental flaws in how individuals with pain conditions are assessed and treated. Some of these fundamental flaws have their roots in the inadequate training of health and allied health professionals in evidence-based models of pain, in the use of psychological assessment and intervention tools for the clinical management of pain, and in gender equity and antiracism. Critiques that pain scholars have leveled against the defining, operational, and conceptual bases of pain catastrophizing are also addressed. Arguments for reconceptualizing pain catastrophizing as a worry-related construct are discussed. Recommendations are made for remediation of the problems that have contributed to calls to rename the term pain catastrophizing. PERSPECTIVE: The issues prompting calls to rename the construct of pain catastrophizing have their roots in fundamental flaws in how individuals with pain are assessed and treated. Efforts to address these problems will require more than a simple change in terminology.

Prognostic Factors of Perceived Disability and Perceived Recovery After Whiplash: A Longitudinal, Prospective Study With One-year Follow-up

OBJECTIVES

The understanding of the role that cognitive and emotional factors play in how an individual recovers from a whiplash injury is important. Hence, we sought to evaluate whether pain-related cognitions (self-efficacy beliefs, expectation of recovery, pain catastrophizing, optimism, and pessimism) and emotions (kinesiophobia) are longitudinally associated with the transition to chronic whiplash-associated disorders in terms of perceived disability and perceived recovery at 6 and 12 months.

METHODS

One hundred sixty-one participants with acute or subacute whiplash-associated disorder were included. The predictors were: self-efficacy beliefs, expectation of recovery, pain catastrophizing, optimism, pessimism, pain intensity, and kinesiophobia. The 2 outcomes were the dichotomized scores of perceived disability and recovery expectations at 6 and 12 months. Stepwise regression with bootstrap resampling was performed to identify the predictors most strongly associated with the outcomes and the stability of such selection.

RESULTS

Baseline perceived disability, pain catastrophizing, and expectation of recovery were the most likely to be statistically significant, with an overage frequency of 87.2%, 84.0%, and 84.0%, respectively.

CONCLUSION

Individuals with higher expectations of recovery and lower levels of pain catastrophizing and perceived disability at baseline have higher perceived recovery and perceived disability at 6 and 12 months. These results have important clinical implications as both factors are modifiable through health education approaches.

A Randomized Controlled Trial of Clinical Hypnosis as an Opioid-Sparing Adjunct Treatment for Pain Relief in Adults Undergoing Major Oncologic Surgery

Clinical hypnosis is an effective strategy for managing acute pain in the surgical setting. However, the opioid sparing effects of clinical hypnosis are not as well understood. This pre-registered (NCT03730350) randomized, controlled trial (RCT) examined the impact of clinical hypnosis, pre- and post-surgery, on opioid consumption during hospitalization as well as on measures of pain intensity, pain interference, depressed mood, anxiety, sleep, and pain catastrophizing. Participants (M = 57.6 years; SD = 10.9) awaiting oncologic surgery were randomized to treatment-as-usual (n = 47) or hypnosis (n = 45). Intent-to-treat analyses were conducted using linear mixed effects modeling. A significant Group × Time interaction, F(6, 323.34) = 3.32, p = 0.003, indicated an opioid sparing effect of clinical hypnosis during the acute postoperative period. Hypnosis also protected against increases in pain catastrophizing at one-week after surgery, F (1, 75.26) = 4.04, p = 0.048. A perioperative clinical hypnosis intervention had a sparing effect on opioid consumption in-hospital after major oncologic surgery. These findings extend the efficacy of clinical hypnosis as an adjunct tool for perioperative pain management.

Fear of Movement in People With CRPS: A Psychometric Evaluation of the Tampa Scale-11 for Kinesiophobia

BACKGROUND

People with complex regional pain syndrome (CRPS) commonly report a fear of movement that can worsen symptoms and increase disability. The Tampa Scale of Kinesiophobia (TSK) is used to evaluate fear of movement and (re)injury, but findings have been inconsistent in different populations.

OBJECTIVE

To evaluate the psychometric properties of the Persian version of TSK-11 in individuals with upper limb CRPS. Specifically, to determine whether the factor structure aligns with the original 2-factor model, consisting of "activity avoidance" and "somatic focus."

MATERIALS AND METHODS

People with CRPS (n=142, mean age=42, 54% female) completed the TSK. The psychometric testing included internal consistency, test-retest reliability (intraclass correlation coefficient), and convergent construct validity. Confirmatory and exploratory factor analyses were performed to evaluate the structural validity.

RESULTS

The TSK-11 showed acceptable internal consistency (Cronbach alpha 0.93) and excellent test-retest reliability (intraclass correlation coefficient=0.93, 95% CI: 0.92-0.94). The Standard Error of Measurement and Minimal Detectable Change were 4.3 and 11.7, respectively. The results also demonstrated excellent criterion validity ( r =0.81). Confirmatory factor analysis demonstrated that the original 2-factor model did not fit. Exploratory factor analysis derived a 2-factor solution with different items. The factor structure accounted for 64.91% of the variance, and the internal consistency of the factors was acceptable (>0.90). Expert consensus suggested naming these 2 factors as fear avoidance and magnification and helplessness.

DISCUSSION

The TSK-11 demonstrates excellent retest reliability in people with CRPS. The original 2-factor structure was not confirmed, and a new 2-factor structure of the TSK-11 was proposed consisting of subscales for Fear Avoidance Beliefs and Magnification/Helplessness. Given the overlap between these constructs and the construct of pain catastrophizing, further study is needed to clarify both measures' content validity and relative uniqueness.

Establishing the interpretability and utility of the 4-item BriefPCS

To reduce the patient burden associated with completing the 13-item Pain Catastrophizing Scale (PCS), the 4-item "BriefPCS" was developed. To date, no crosswalk has been developed that associates scores on the BriefPCS with PCS scores. Further, no study has compared the use of BriefPCS and PCS scores in a randomized clinical trial (RCT). We aimed to: (1) establish the interpretability of BriefPCS scores in reference to PCS scores, (2) compare the concurrent validity between the BriefPCS and PCS, and (3) asssess the use of BriefPCS in an RCT. First, we conducted equipercentile linking, created a crosswalk that associated scores of BriefPCS with PCS, and calculated differences between PCS and crosswalked PCS scores. Secondly, we compared Bootstrap correlation coefficients between PCS and self-reported measures of other domains. Lastly, we compared results from an RCT using BriefPCS scores versus PCS scores. Findings indicated that the correlation coefficient estimates with the BriefPCS and PCS scores were not significantly different. BriefPCS and PCS scores had similar ability to detect treatment-related changes. The BriefPCS scores validly, reliably, and accurately distinguish levels of pain catastrophizing. Additionally, the BriefPCS scores are sensitive to changes after behavioral interventions, with less respondent burden compared to the PCS scores.

Fear of movement was associated with sedentary behaviour 12 months after lumbar fusion surgery in patients with low back pain and degenerative disc disorder

BACKGROUND

Movement behaviours, such as sedentary behaviour (SB) and moderate to vigorous physical activity (MVPA), are linked with multiple aspects of health and can be influenced by various pain-related psychological factors, such as fear of movement, pain catastrophising and self-efficacy for exercise. However, the relationships between these factors and postoperative SB and MVPA remain unclear in patients undergoing surgery for lumbar degenerative conditions. This study aimed to investigate the association between preoperative pain-related psychological factors and postoperative SB and MVPA in patients with low back pain (LBP) and degenerative disc disorder at 6 and 12 months after lumbar fusion surgery.

METHODS

Secondary data were collected from 118 patients (63 women and 55 men; mean age 46 years) who underwent lumbar fusion surgery in a randomised controlled trial. SB and MVPA were measured using the triaxial accelerometer ActiGraph GT3X+. Fear of movement, pain catastrophising and self-efficacy for exercise served as predictors. The association between these factors and the relative time spent in SB and MVPA 6 and 12 months after surgery was analysed via linear regression models, adjusting for potential confounders.

RESULTS

Preoperative fear of movement was significantly associated with relative time spent in SB at 6 and 12 months after surgery (β = 0.013, 95% confidence interval = 0.004 to 0.022, p = 0.007). Neither pain catastrophising nor self-efficacy for exercise showed significant associations with relative time spent in SB and MVPA at these time points.

CONCLUSIONS

Our study demonstrated that preoperative fear of movement was significantly associated with postoperative SB in patients with LBP and degenerative disc disorder. This finding underscores the potential benefits of preoperative screening for pain-related psychological factors, including fear of movement, preoperatively. Such screenings could aid in identifying patients who might benefit from targeted interventions to promote healthier postoperative movement behaviour and improved health outcomes.

Pain Catastrophizing and Its Association with Military Medical Disability Among US Active Duty Service Members with Chronic Predominately Musculoskeletal Pain: A Retrospective Cohort Analysis

Context

Pain catastrophizing is characterized by negative emotional and cognitive responses to pain and is a predictor of work-related disability. Its association with military medical disability has not been studied.

Objective

To (1) identify the pain catastrophizing scale (PCS) score cut point most strongly associated with military medical disability, (2) measure the difference in rate of disability between service members with baseline PCS scores above versus below the cut point, and (3) determine if improvement in PCS score during pain specialty care is associated with decreased likelihood of disability.

Methods

This was a retrospective cohort analysis comparing PCS scores collected from US Army active duty service members at time of initial visit to an interdisciplinary pain management center and periodically during pain treatment. Outcome was determination during the following year of a military service-disqualifying disability.

Results

Receiver operating characteristic (ROC) curves determined that a PCS score of 20 was the single cut point most closely associated with subsequent disability. Kaplan-Meier curves showed significantly higher disability rate during the following year among those with baseline PCS scores ≥20 (52%) compared to those with lower scores (26%). Scheffe-adjusted contrasts showed that service members with PCS scores ≥20 whose scores improved to <20 at follow-up were significantly less likely to have a medical disability (42.6%; 95% CI, 0.07-0.58) than those whose PCS score remained ≥20 (76.3%; 95% CI, 68.0%-84.7%).

Conclusion

A PCS score cut point of 20 distinguishes between high versus low likelihood of disability among service members. Those with high baseline PCS score had twice the likelihood of disability than those with low scores. Service members who decreased their PCS score from high to low during pain specialty care had lower likelihood of disability. Prospective research is needed to determine if treatments that lower pain catastrophizing yield reduced likelihood of subsequent disability.

Predictors of Sustained Response to Functional Restoration in a Military Population

INTRODUCTION

The purpose of this study was to determine if improvement in pain impact and functional performance following a functional restoration (FR) program was sustained up to 6 months posttreatment and to identify predictors of sustained improvement.

MATERIALS AND METHODS

Secondary analysis of data collected during randomized clinical trial. Study population included 108 US active duty service members who completed an FR program, as well as 3- and/or 6-month follow-up assessments. Primary outcome measure was the NIH Research Task Force (pain) impact score (PIS). Secondary outcome was a composite functional performance measure of treadmill, lifting, and carrying tolerances. Variables analyzed to determine their predictive value included demographics; treatment hours; measures of pain intensity, function, mood, sleep, social satisfaction, pain catastrophizing, kinesiophobia, self-efficacy, pain acceptance, patient activation, functional performance, and neuropathic pain.

RESULTS

Mean PIS and functional performance improved significantly immediately following FR, but after 6 months, only improvement in functional performance sustained. Responder analysis showed that 6 months after FR, 42% of participants reported improvement that exceeded the minimal clinically important difference in PIS or functional performance. Predictors of sustained PIS improvement included younger age, absence of neuropathic pain features, less self-rated disability, better baseline functional performance, and worse baseline PIS. Predictors of sustained functional performance improvement included more treatment hours, lower baseline pain catastrophizing, and lower baseline functional performance.

CONCLUSIONS

This study supports the investment of treatment time in FR to yield sustained clinically meaningful improvement, as observed in over 40% of this study's military participants. Pretreatment predictors of sustained response included lower pain catastrophizing and absence of neuropathic pain. Further research is needed to determine if treatments that improve pain catastrophizing and neuropathic pain will result in sustained improvement in pain impact and functional performance following FR program participation.

Effect of Peritalar Subluxation Correction for Progressive Collapsing Foot Deformity on Patient-Reported Outcomes

BACKGROUND

Peritalar subluxation (PTS) is part of progressive collapsing foot deformity (PCFD). This study aimed to evaluate initial deformity correction and PTS optimization in PCFD patients with flexible hindfoot deformity undergoing hindfoot joint-sparing surgical procedures and its relationship with improvements in patient-reported outcome measures (PROMs) at latest follow-up. We hypothesized that significant deformity/PTS correction would be observed postoperatively, positively correlating with improved PROMs.

METHODS

A prospective comparative study was performed with 26 flexible PCFD patients undergoing hindfoot joint-sparing reconstructive procedures, mean age 47.1 years (range, 18-77). We assessed weightbearing computed tomography (WBCT) overall deformity (foot and ankle offset [FAO]) and PTS markers (distance and coverage maps) at 3 months, as well as PROMs at final follow-up. A multivariate regression model assessed the influence of initial deformity correction and PTS optimization in patient-reported outcomes.

RESULTS

Mean follow-up was 19.9 months (6-39), and the average number of procedures performed was 4.8 (2-8). FAO improved from 9.4% (8.4-10.9) to 1.9% (1.1-3.6) postoperatively (P < .0001). Mean coverage improved by 69.6% (P = .012), 12.1% (P = .0343) and 5.2% (P = .0074) in, respectively, the anterior, middle, and posterior facets, whereas the sinus tarsi coverage decreased by an average 57.1% (P < .0001) postoperatively. Improvements in patient-reported outcomes were noted for all scores assessed (P < .03). The multivariate regression analysis demonstrated that improvement in both FAO and PTS measurements significantly influenced the assessed PROMs.

CONCLUSION

This study demonstrated significant improvements in the overall 3D deformity, PTS markers, and PROMs following hindfoot joint-sparing surgical treatment in patients with flexible PCFD. More importantly, initial 3D deformity correction and improvement in subtalar joint coverage and extraarticular impingement have been shown to influence PROMs significantly and positively. Addressing these variables should be considered as goals when treating PCFD.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Reliability and validity of the Japanese short-form arthritis self-efficacy scale in patients with knee osteoarthritis: A cross-sectional study

Self-efficacy is the belief that one can perform a specific behavior or task in the future, and it has been associated with physical and psychological aspects in people with chronic musculoskeletal disorders. The self-efficacy of individuals with arthritis can be assessed using the Arthritis Self-Efficacy Scale. The 8-item Short-Form ASES (ASES-8) has been employed in recent times. However, the reliability and validity of the Japanese ASES-8 (ASES-8J) have not been investigated. Therefore, this study aimed to investigate the reliability and validity of the ASES-8J. Overall, 179 Japanese participants with knee osteoarthritis (OA) were enrolled. Cronbach's alpha was calculated to confirm internal validity. Intraclass correlation coefficients (ICCs) were used to estimate test-retest reliability. Construct validity was analyzed using the Pain Self-Efficacy Questionnaire (PSEQ) and the problem-solving and positive thinking subscales of Brief Coping Orientation to Problems Experienced (Brief COPE). Discriminant validity was analyzed by comparing "worse" and "better" groups based on pain severity; short-form version of Depression, Anxiety, and Stress Scale-21 (DASS-21); Brief Fear of Movement Scale for Osteoarthritis (BFOMSO); Pain Catastrophizing Scale (PCS); and physical function subscale of Western Ontario and McMaster Arthritis Index. Cronbach's alpha and ICC were 0.94 and 0.81, respectively. Correlation coefficients among ASES-8J, PSEQ, and Brief COPE problem-solving and positive thinking subscales were 0.42, 0.43, and 0.32, respectively. Regarding the depression and stress subscales of DASS-21, BFOMSO, and PCS, the worse group showed significantly lower ASES-8J scores than the better group. Coefficients of correlation among ASES-8J, PSEQ, and the problem-solving and positive thinking subscales of Brief COPE were low to moderate. These findings suggest that the ASES-8J is a valid and reliable tool for assessing self-efficacy in Japanese patients with knee OA and can facilitate comparisons of arthritis self-efficacy between Japanese patients and non-Japanese patients.

Treatment of Refractory Low Back Pain Using Passive Recharge Burst in Patients Without Options for Corrective Surgery: Findings and Results From the DISTINCT Study, a Prospective Randomized Multicenter Controlled Trial

OBJECTIVE

Spinal cord stimulation (SCS) is effective for relieving chronic intractable pain conditions. The Dorsal spInal cord STImulatioN vs mediCal management for the Treatment of low back pain study evaluates the effectiveness of SCS compared with conventional medical management (CMM) in the treatment of chronic low back pain in patients who had not undergone and were not candidates for lumbar spine surgery.

METHODS AND MATERIALS

Patients were randomized to passive recharge burst therapy (n = 162) or CMM (n = 107). They reported severe pain and disability for more than a decade and had failed a multitude of therapies. Common diagnoses included degenerative disc disease, spondylosis, stenosis, and scoliosis-yet not to a degree amenable to surgery. The six-month primary end point compared responder rates, defined by a 50% reduction in pain. Hierarchical analyses of seven secondary end points were performed in the following order: composite responder rate (numerical rating scale [NRS] or Oswestry Disability Index [ODI]), NRS, ODI, Pain Catastrophizing Scale responder rate, Patient Global Impression of Change (PGIC) responder rate, and Patient-Reported Outcome Measure Information System-29 in pain interference and physical function.

RESULTS

Intention-to-treat analysis showed a significant difference in pain responders on NRS between SCS (72.6%) and CMM (7.1%) arms (p < 0.0001). Of note, 85.2% of those who received six months of therapy responded on NRS compared with 6.2% of those with CMM (p < 0.0001). All secondary end points indicated the superiority of burst therapy over CMM. A composite measure on function or pain relief showed 91% of subjects with SCS improved, compared with 16% of subjects with CMM. A substantial improvement of 30 points was observed on ODI compared with a

CONCLUSIONS

This study found substantial improvement at six months in back pain, back pain-related disability, pain-related emotional suffering, PGIC, pain interference, and physical function in a population with severe, debilitating back pain for more than a decade. These improvements were reported in conjunction with reduced opioid use, injection, and ablation therapy.

CLINICAL TRIAL REGISTRATION

The Clinicaltrials.gov registration number for the study is NCT04479787.

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Key Words

• composite outcomes
• persistent spinal pain syndrome
• refractory chronic low back pain
• spinal cord stimulation

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MESH Headings

• Humans
• Low Back Pain/therapy
• Low Back Pain/psychology
• Treatment Outcome
• Prospective Studies
• Back Pain
• Spinal Cord Stimulation/methods
• Chronic Pain/diagnosis
• Chronic Pain/therapy

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Grants

• K08 CA228039 NCI NIH HHS

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Affiliation(s)

Timothy Deer The Spine and Nerve Center of the Virginias, Charleston, WV, USA
Christopher Gilligan Brigham & Women's Hospital, Boston, MA, USA
Steven Falowski Center for Interventional Pain & Spine, Lancaster, PA, USA
Mehul Desai International Spine, Pain & Performance Center, Washington, DC, USA
Julie Pilitsis Florida Atlantic University, FL, USA
Jessica Jameson Axis Spine Center, ID, USA
Susan Moeschler Mayo Clinic, Rochester, NY, USA
Robert Heros Spinal Diagnostics, OR, USA
Edward Tavel Clinical Trials of South Carolina, Charleston, SC, USA
Anne Christopher Saint Louis Pain Consultants, Chesterfield, MO, USA
Denis Patterson Nevada Advanced Pain Specialists, Reno, NV, USA
Sayed Wahezi Montefiore Medical Center-Waters Place, New York, NY, USA
Jacqueline Weisbein Napa Valley Orthopedic Medical Group, Napa, CA, USA
Ajay Antony The Orthopaedic Institute, FL, USA
Robert Funk Indiana Spine Group, IN, USA
Mohab Ibrahim Banner University Medical Center Tucson Campus, Tucson, AZ, USA
Chi Lim Carolina Orthopaedic & Neurosurgical Associates, SC, USA
Derron Wilson Goodman Campbell Brain & Spine, IN, USA
Michael Fishell Advanced Pain Care, NV, USA
Keith Scarfo Rhode Island Hospital, Providence, RI, USA
David Dickerson Northshore University HealthSystem, Chicago, IL, USA
Edward Braun Kansas University Medical Center, KS, USA
Patrick Buchanan Spanish Hills Interventional Pain Specialists, Camarillo, CA, USA
Robert M Levy Anesthesia Pain Care Consultants-Tamarac
Nathan Miller Coastal Pain & Spinal Diagnostics Medical Group, Carlsbad, CA, USA
Jonathan Duncan Burkhart Research Institute for Orthopaedics, San Antonio, TX, USA
Jijun Xu The Cleveland Clinic Foundation, OH, USA
Kenneth Candido Chicago Anesthesia Associates, SC, Chicago, IL, USA
Scott Kreiner Barrow Brain & Spine-Ahwatukee, Phoenix, AZ, USA
Marie E Fahey Abbott Labs, Austin, TX, USA
James Yue Connecticut Orthopaedics, CT, USA

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Pain-related cognitions and emotional distress are not associated with conditioned pain modulation: an explorative analysis of 1142 participants with acute, subacute, and chronic pain

ABSTRACT

Reduced conditioned pain modulation (CPM) and psychological distress co-occur frequently in many pain conditions. This study explored whether common negative pain cognitions and emotional factors were related to lower CPM in individuals across the spectrum from acute to chronic pain. Previously collected data on the CPM effect, pain-related cognitions (fear of movement, pain catastrophizing), and emotional distress (depression, anxiety) through questionnaires from 1142 individuals with acute, subacute, or chronic pain were used. The presence of negative psychological factors was dichotomized according to cutoff values for questionnaires. Associations between the presence of each negative psychological factor and the amplitude of pain reduction in the CPM paradigm was explored with Generalized Linear Models adjusted for sex, age, body mass index, and pain duration. A secondary analysis explored the cumulative effect of psychological factors on CPM. When dichotomized according to cutoff scores, 20% of participants were classified with anxiety, 19% with depression, 36% with pain catastrophizing, and 48% with fear of movement. The presence of any negative psychological factor or the cumulative sum of negative psychological factors was associated with lower CPM (individual factor: β between -0.15 and 0.11, P ≥ 0.08; total: β between -0.27 and -0.12, P ≥ 0.06). Despite the common observation of psychological factors and reduced CPM in musculoskeletal pain, these data challenge the assumption of a linear relationship between these variables across individuals with acute, subacute, and chronic pain. Arguably, there was a nonsignificant tendency for associations in nonexpected directions, which should be studied in a more homogenous population.

An Assessment of the Longitudinal Construct Validity of the Pain Behavioral Scale (PaBS) in a Saudi Population with Chronic Low Back Pain: A Preliminary Study

Background: The Pain Behavioral Scale (PaBS) measures the presence and severity of pain behavior. We examine the longitudinal construct validity of the PaBS using convergent and known-groups approaches on a population of 23 participants with chronic lower back pain (LBP) undergoing routine physiotherapy care and pain neuroscience education. Methods: Participants who satisfied study inclusion and exclusion criteria were recruited from patients who attended two testing sessions at physiotherapy clinics in Saudi Arabia. Participant pain behavior was initially measured using the PaBS scale; participants performed standardized physical tests (e.g., repeated trunk flexion) and provided baseline demographic, clinical data, and self-reported measurements using the Modified Roland and Morris disability questionnaire (MODI), fear-avoidance questionnaire (FABQ), and pain catastrophizing scale (PCS). In subsequent visits, a physiotherapist provided usual care to participants, and weekly sessions were established for online pain-neuroscience education. During week six, participants repeated the same questionnaires and physical performance tests with the PaBS. Paired t-tests are used to compare changes in health characteristics from baseline responses to those in week six. Correlations between changes in PaBS from baseline to week six, with changes in outcome measures (i.e., disability, pain intensity, fear-avoidance beliefs, catastrophizing), were determined. To assess known-group validity, we also used a general linear model. Results: A total of 23 participants completed the PNE and follow-up data collection. The mean change from baseline in the PaBS score was statistically significant, as were changes in MODI, FABQ, and PCS. Almost 70% of participants improved their PaBS scores over the six-week period, with PaBS scores of almost 40% of them improving by three units or more. The change in PaBS score correlated significantly with changes in the PCS-rumination subscale, supporting a proposed approach to estimate convergent validity (r = 0.44, 95% CI = 0.04-0.72, p = 0.035). Conclusions: The mean change from baseline in the PaBS score is statistically significant, as are changes in MODI, FABQ, and PCS, supporting its convergent validity. According to our STarT Back groups, the medium to low-risk group had a lower PaBS score, and high-risk group had a higher PaBS score, indicating that PaBS use in clinical assessment may identify people according to pain-behavior severity, or those at increased risk of developing disability.

Interdisciplinary Multimodal Pain Rehabilitation in Patients with Chronic Musculoskeletal Pain in Primary Care-A Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP)

Chronic pain is a major public health issue. Mounting evidence suggests that interdisciplinary multimodal pain rehabilitation programs (IMMRPs) performed in specialist pain care are an effective treatment for patients with chronic pain, but the effects of such treatment if performed in primary care settings have been less studied. The aims of this pragmatic study were to (1) describe characteristics of patients participating in IMMRPs in primary care; (2) examine whether IMMRPs in primary care improve pain, disability, quality of life, and sick leave 1-year post discharge in patients with chronic pain; and (3) investigate if outcomes differ between women and men. Data from 744 (645 women and 99 men, age range 18-65 years) patients with non-malignant chronic pain included in the Swedish Quality Registry for Pain Rehabilitation Primary Care were used to describe patient characteristics and changes in health and sick leave. At 1-year follow-up, the patients had improved significantly (p < 0.01) in all health outcome measures and had reduced sick leave except in men, where no significant change was shown in physical activity level. This study indicates that MMRPs in primary care improved pain and physical and emotional health and reduced sick leave, which was maintained at the 1-year follow-up.

Diagnosis and treatment of intractable idiopathic orofacial pain with attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) has been reported to be associated with primary chronic pain syndromes, such as fibromyalgia, migraine, and chronic low back pain. Although idiopathic orofacial pain (IOP) is classified as burning mouth syndrome or persistent idiopathic facial or dentoalveolar pain and as a primary chronic pain, the association between IOP and ADHD has not been investigated. This retrospective cohort study investigated the severity of ADHD symptoms measured using the ADHD scale and the effects of treatment using ADHD drugs and the dopamine system stabilizer aripiprazole. The participants were 25 consecutive patients with refractory IOP referred to a psychiatrist and diagnosed with coexisting ADHD according to the Diagnostic and Statistical Manual of Mental Disorders-5. The ADHD scale scores were higher in patients with intractable IOP than those in the general population. Pharmacotherapy used in this study led to clinically significant improvements in pain, anxiety/depression, and pain catastrophizing. Intractable IOP and ADHD were shown to be associated. In the future, screening and pharmacotherapy for ADHD should be considered in the treatment of intractable IOP.

Effects of Depression, Anxiety, and Pain Catastrophizing on Total Hip Arthroplasty Patient Activity Level

BACKGROUND

Improvements in psychological factors are strongly associated with increased physical activity in the general population. The effects of depression, anxiety, and pain catastrophizing on activity level have not been thoroughly explored in patients undergoing total hip arthroplasty (THA). Mental health markedly influences patient perspectives on treatment success and quality of life. We hypothesized that improvements in screenings for depression, anxiety, and catastrophizing correlate with improvements in activity levels after THA.

METHODS

Two hundred ninety two patients (313 hips) who underwent THA with a minimum 1-year (mean 615 ± 270 days) follow-up completed preoperative and postoperative surveys containing the University of California Los Angeles (UCLA) Activity Score, Hospital Anxiety Depression Scale (HADS), Pain Catastrophizing Scale (PCS), and Depression Anxiety Stress Scale-21 (DASS). Wilcoxon signed-rank tests were performed between preoperative and postoperative times for outcome measures. Partial Spearman's rank-order correlations were performed between the change in UCLA Score and the change in HADS, PCS, and DASS.

RESULTS

There were significant improvements in UCLA Score (P value < .0001) and every subscale of PCS, HADS, and DASS (P values < .0001). Significant negative correlations existed between change in UCLA Score and change in HADS-anxiety (r_s = -0.21, P value < .001), change in HADS-depression (r_s = -0.23, P value < .001), and change in DASS-anxiety (r_s = -0.22, P value = .004) following THA. Weaker significant negative correlations existed between change in UCLA Score and change in the remaining PCS (P values = .006) and DASS-depression(P value = .037) subscales.

CONCLUSION

Improvements in patient-reported depression, anxiety, and pain catastrophizing screenings following THA were associated with increased activity levels. Patients who were screened for catastrophizing, depression, and anxiety achieved statistically and clinically meaningful improvements in symptoms following THA. Addressing patient mental health provides another avenue for holistic care of THA patients.

Factors associated with disability and pain intensity in patients with complex regional pain syndrome

PURPOSE

To examine the associations between psychological factors (pain catastrophizing, pain-related anxiety, and fear of pain) and level of pain and disability in patients with complex regional pain syndrome (CRPS).

METHODS

One hundred and two patients with CRPS were recruited from tertiary care centers with the different upper limb injuries were evaluated for pain, disability, and psychological factors. Patients completed the Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire, Patient Rated Wrist Evaluation (PRWE), Pain Catastrophizing Scale (PCS), Tampa Scale of Kinesiophobia (TSK-11), and Depression, Anxiety, and Stress Scale (DASS). The associations of pain and disability with presence of these behavioral and mental health factors were examined using bivariate and multivariable analyses. These models were adjusted for age, sex, injured dominant hand, and previous surgery.

RESULTS

A higher pain catastrophizing score (β = 0.55, p = 0.00) was associated with greater disability. A higher pain catastrophizing score (β = 0.35, p = 0.001) and female gender (β = 0.24, p = 0.01) were associated with greater pain at rest (PAR). A higher pain catastrophizing score and having a surgical history were associated with greater pain with movement (β = 0.25, p = 0.02). Scores of ≥18.5 in PCS, ≥57.5 on TSK, and ≥15.5 on DASS were associated with higher risk of experiencing pain and disability.

CONCLUSIONS

Pain catastrophizing, female sex, and surgical intervention are associated with poor outcomes. Physiologic, psychological factors, and treatment factors interact to influence outcomes. The results of this study further validate the associations of chronic pain and disability with pain catastrophizing in patients with CRPS. The novel finding of this study is introducing cut-off scores for TSK, PCS, and DASS as a screening tool to predict pain, functional limitations.Implication for rehabilitationPain catastrophizing has a vital role in the magnitude of disability and pain in patients with CRPS.The novel finding of this paper was the cut-off scores on the psychological evaluations that can enable using them as screening tool for bad outcomes in patients with CRPS.Cut off scores from different psychological evaluations can be used as a yellow flag for clinician's for detecting patients with increased risk of pain and disability.The identification of a cut-off can also have implications for implementing change in clinical practice by identifying the need for early and intensive interventions.

Reducing the question burden of patient reported outcome measures using Bayesian networks

Patient Reported Outcome Measures (PROMs) are questionnaires completed by patients about aspects of their health status. They are a vital part of learning health systems as they are the primary source of information about important outcomes that are best assessed by patients such as pain, disability, anxiety and depression. The volume of questions can easily become burdensome. Previous techniques reduced this burden by dynamically selecting questions from question item banks which are specifically built for different latent constructs being measured. These techniques analyzed the information function between each question in the item bank and the measured construct based on item response theory then used this information function to dynamically select questions by computerized adaptive testing. Here we extend those ideas by using Bayesian Networks (BNs) to enable Computerized Adaptive Testing (CAT) for efficient and accurate question selection on widely-used existing PROMs. BNs offer more comprehensive probabilistic models of the connections between different PROM questions, allowing the use of information theoretic techniques to select the most informative questions. We tested our methods using five clinical PROM datasets, demonstrating that answering a small subset of questions selected with CAT has similar predictions and error to answering all questions in the PROM BN. Our results show that answering 30% - 75% questions selected with CAT had an average area under the receiver operating characteristic curve (AUC) of 0.92 (min: 0.8 - max: 0.98) for predicting the measured constructs. BNs outperformed alternative CAT approaches with a 5% (min: 0.01% - max: 9%) average increase in the accuracy of predicting the responses to unanswered question items.

A systematic review shows minimal evidence for measurement properties of psychological functioning outcomes in whiplash

OBJECTIVES

The aim of this study was to systematically identify, synthesize, and appraise studies on the measurement properties of patient-reported outcome measures (PROMs) for anxiety, depression, fear of movement, pain catastrophizing, post-traumatic stress, self-efficacy, and stress in people with whiplash-associated disorders (WAD).

STUDY DESIGN AND SETTING

PsycINFO, MEDLINE, EMBASE, CINAHL, PILOTS, Web of Science, and Scopus were searched (November 9, 2021). Studies evaluating any measurement property of relevant PROMs in WAD were included. Two reviewers independently screened the studies and assessed the measurement properties in accordance with the COSMIN guidelines.

RESULTS

Measurement properties of 10 PROMs were evaluated in WAD: Pictorial Fear of Activity Scale-Cervical (PFActS-C), Tampa Scale of Kinesiophobia-11, Pain Catastrophizing Scale (PCS), Pain Self-Efficacy Questionnaire (PSEQ), PSEQ-4 item, PSEQ-2a, PSEQ-2b, Self-Efficacy Scale, Harvard Trauma Questionnaire, and Post-Traumatic Stress Diagnostic Scale. Content validity was not examined in any of these PROMs in whiplash. Moderate- or high-quality evidence showed adequate internal structure for the PSEQ, PCS, and PFActS-C, whereas the original structures of the remaining seven PROMs were not confirmed in whiplash.

CONCLUSION

Until further research on the measurement properties of these PROMs is available, researchers may opt to use the PSEQ, PCS, or PFActS-C if the construct is aligned with research aims.

Changes in task-specific fear of movement and impaired trunk motor control by pain neuroscience education and exercise: A preliminary single-case study of a worker with low back pain

We report a case (a worker with low back pain) who was provided patient education and therapeutic exercise, and we performed a detailed kinematic analysis of his work-related activity over time. The subjects were one 28-year-old male worker with low back pain. In addition, to clearly identify impaired trunk movement during work-related activity in the low back pain subject, 20 age-matched healthy males (control group) were also included as a comparison subject. He received pain neurophysiology education and exercise instruction. We analyzed the subject's trunk movement pattern during a lifting task examined by a three-dimensional-motion capture system. In addition, task-specific fear that occurred during the task was assessed by the numerical rating scale. The assessment was performed at the baseline phase (4 data points), the intervention phase (8 data points), and the follow-up phase (8 data points), and finally at 3 and 8 months after the follow-up phase. No intervention was performed in the control group; they underwent only one kinematic evaluation at baseline. As a result, compared to the control group, the low back pain subject had slower trunk movement velocity (peak trunk flexion velocity = 50.21 deg/s, extension velocity = -47.61 deg/s), and his upper-lower trunk segments indicated an in-phase motion pattern (mean absolute relative phase = 15.59 deg) at baseline. The interventions reduced his pain intensity, fear of movement, and low back pain-related disability; in addition, his trunk velocity was increased (peak trunk flexion velocity = 82.89 deg/s, extension velocity = -77.17 deg/s). However, the in-phase motion pattern of his trunk motor control remained unchanged (mean absolute relative phase = 16.00 deg). At 8 months after the end of the follow-up, the subject's in-phase motion pattern remained (mean absolute relative phase = 13.34 deg) and his pain intensity had increased. This report suggests that if impaired trunk motor control remains unchanged after intervention, as in the course of the low back pain subject, it may eventually be related to a recurrence of low back pain symptoms.

Study protocol: Effects of active versus passive recharge burst spinal cord stimulation on pain experience in persistent spinal pain syndrome type 2: a multicentre randomized trial (BURST-RAP study)

Background

Spinal cord stimulation (SCS) has shown to be an effective treatment for patients with persistent spinal pain syndrome type 2 (PSPS Type 2). The method used to deliver electrical charge in SCS is important. One such method is burst stimulation. Within burst stimulation, a recharge pattern is used to prevent buildup of charge in stimulated tissues. Two variations of burst waveforms are currently in use: one that employs active recharge and one that uses passive recharge. It has been suggested that differences exist between active and passive recharge paradigms related to both efficacy of pain relief and their underlying mechanism of action. Active recharge has been shown to activate both the medial spinal pathway, engaging cortical sensorimotor areas involved in location and intensity of pain, and lateral pathway, reaching brain areas involved with cognitive-emotional aspects of pain. Passive recharge has been suggested to act via modulation of thalamic neurons, which fire in a similar electrical pattern, and thereby modulate activity in various cortical areas including those related to motivational and emotional aspects of pain. The objective of this randomized clinical trial is to assess and compare the effect of active versus passive recharge Burst SCS on a wide spectrum of pain in PSPS Type 2 patients.

Methods

This multicentre randomized clinical trial will take place in 6 Dutch hospitals. PSPS Type 2 patients (n=94) will be randomized into a group receiving either active or passive recharge burst. Following a successful trial period, patients are permanently implanted. Patients complete the Pain Catastrophizing Scale (PCS) (primary outcome at 6 months), Numeric Pain Rating Scale (NRS), Patient Vigilance and Awareness Questionnaire (PVAQ), Hospital Anxiety and Depression Scale (HADS), Quality of Life (EQ-5D), Oswestery Disability Index (ODI), Patient Global Impression of Change (PGIC) and painDETECT questionnaires (secondary outcomes) at baseline, after trial, 1, 3, 6 and 12 months following implantation.

Discussion

The BURST-RAP trial protocol will shed light on possible clinical differences and effectivity of pain relief, including emotional-motivational aspects between active and passive burst SCS in PSPS Type 2 patients.

Trial registration

ClinicalTrials.gov registration: NCT05421273. Registered on 16 June 2022. Netherlands Trial Register NL9194. Registered on 23 January 2021.

The Association Between Sleep Disturbance and Health Outcomes in Chronic Whiplash-Associated Disorders: A Series of Mediation Analyses

OBJECTIVES

To investigate the association between sleep disturbance and clinical features of chronic whiplash-associated disorders. We also aimed to use a bootstrapped mediation analysis approach to systematically examine both direct and indirect pathways by which sleep disturbance may affect chronic pain and functional status.

METHODS

One hundred and sixty-five people (63% female) with chronic whiplash-associated disorders and not taking medications for sleep disturbance completed questionnaires evaluating sleep disturbance, pain intensity, pain interference, disability, physical and mental health quality of life, stress, anxiety, depression, pain catastrophizing, and posttraumatic stress severity.

RESULTS

Greater sleep disturbance was associated with increased duration of symptoms, higher levels of pain and disability, higher levels of emotional distress and pain catastrophizing, and functional impairment (reduced health-related quality of life). Mediation analyses demonstrated that sleep disturbance influenced chronic pain intensity and interference through both direct and indirect associations inclusive of stress, anxiety and pain catastrophizing. Similarly, sleep disturbance was associated with higher levels of disability and poor health-related quality of life, both directly and also through its negative association with pain intensity and interference.

DISCUSSION

Sleep disturbance in chronic WAD was associated with worse health outcomes and demonstrated both direct and indirect effects on both chronic pain and function.

Case report: Treatment of persistent atypical odontalgia with attention deficit hyperactivity disorder and autism spectrum disorder with risperidone and atomoxetine

Chronic pain has recently been associated with developmental disorders [autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD)]. Regarding chronic pain in adulthood, fibromyalgia, migraine, and chronic low back pain have been associated with ADHD. The ICD-11 disease classification categorizes these pain diseases as chronic primary pain, suggesting high comorbidity with developmental disorders in chronic primary pain. Atypical odontalgia (AO) is a persistent tooth pain that occurs in the absence of any of the usual dental causes, most of which are triggered by dental treatment. Conditions characterized by tooth pain with no apparent cause are also classified as chronic primary pain. Approximately half the patients with AO are diagnosed with psychiatric disorders; the most common are depression (15.4%) and anxiety disorders (10.1%). However, there are no reports on neurodevelopmental disorders comorbid with AO. In the present study, we report a case of a 46-year-old man with numerous complaints (e.g., occlusal instability, difficulty eating, difficulty speaking), who took work leave due to worsening of his symptoms after periodontal scaling (“gingival recession” and “aggressive periodontal treatment”) and frequently expressed dissatisfaction and anger at the hospital, making the dental treatment difficult. After a referral to a psychiatrist specializing in chronic pain, AO and previously undiagnosed comorbidity of ASD and ADHD were confirmed. Atypical antipsychotic risperidone for ASD irritability and an ADHD medication, atomoxetine dramatically reduced anger, pain, anxiety, depression, and pain catastrophizing thoughts, leading to reduced obsession with his symptoms and less frequent complaints. After risperidone (1 mg/day) + atomoxetine (120 mg/day) were ultimately prescribed after adjustment, he was able to return to work 226 days after initiation of psychiatric treatment. Recent studies show that comorbidity of developmental disorders in patients with chronic pain is likely to be undetected. Clinicians should include screening for ASD and ADHD not only in cases of fibromyalgia, migraine, and chronic low back pain, but also in orofacial pain such as AO and other treatments for chronic primary pain. For patients diagnosed with ASD or ADHD, an effective drug therapy for ASD and ADHD should be considered.

Measurement precision of the Pain Catastrophizing Scale and its short forms in chronic low back pain

The Pain Catastrophizing Scale (PCS) is a widely studied tool to assess pain catastrophizing for chronic low back pain (LBP). Short forms of the PCS exist, but their measurement precision at individual level is unclear. This study aimed to analyze the Rasch psychometric characteristics of the PCS and three of its short forms (two 4-item and one 6-item) in a sample of 180 Italian-speaking patients with chronic LBP, and compare their measurement precision at the individual level. We performed a Rasch analysis on each version of the PCS and calculated test information functions (TIFs) to examine conditional measurement precision. Rasch analysis showed appropriate rating category functioning, unidimensionality, and acceptable fit to the Rasch model for all PCS versions. This represented a prerequisite for performing further advanced psychometric analyses. According to TIFs, the PCS full scale showed—at any score level—higher measurement precision in estimating individual pain catastrophizing than its short forms (which had unacceptably high standard errors of measurement). Our results show acceptable conditional precision of the PCS full scale in estimating pain catastrophizing. However, further studies are needed to confirm its diagnostic accuracy at individual level. On the other hand, the study warns against use of the three PCS short forms for clinical decision-making at the individual level.

A comparison of psychological characteristics in people with knee osteoarthritis from Japan and Australia: A cross-sectional study

The aim of this study was to investigate differences in psychological characteristics between people with knee osteoarthritis (OA) from Japan and Australia. Sixty-two adults from Japan and 168 adults from Australia aged over 50 years with knee pain were included. Japanese data were collected from patients with knee OA diagnosed by medical doctors. Australian data were baseline data from a randomized controlled trial. Participants were not exercising regularly or receiving physiotherapy at the time. Psychological characteristics evaluated were depressive symptoms, fear of movement, and pain catastrophizing. These psychological characteristics were compared between the Japanese and Australian cohorts by calculating 95% confidence intervals (CIs) for difference of the mean. To test for equivalence, an equivalence margin was set at 0.5 standard deviations (SD) of the mean, where these SDs were based on the Australian data. When the 95%CI for the difference of the mean value lay entirely within the range of equivalence margin (i.e. between -0.5 and 0.5 times the Australian SD), the outcome was considered equivalent. There were no differences between the groups from Japan and Australia for depressive symptoms and the two groups were considered equivalent. There was no difference between groups for fear of movement, however the criteria for equivalence was not met. People from Japan with knee OA had higher scores for pain catastrophizing than people from Australia. The findings should be confirmed in other samples of people with knee OA from Japan and Australia due to the limitations of the participant recruitment strategy in this study. However, our findings suggest there may be a greater need to consider pain catastrophizing and build pain self-efficacy when managing Japanese people with knee OA. Implementation of international clinical practice guidelines for OA management may require different strategies in different countries due to different psychological profiles.

Burst spinal cord stimulation can attenuate pain and its affective components in chronic pain patients with high psychological distress: results from the prospective, international TRIUMPH study

BACKGROUND CONTEXT

Psychological characteristics such as catastrophizing and depression have been shown to negatively impact outcome prognosis after spinal interventions.

PURPOSE

To evaluate whether high psychological distress, defined as clinically elevated levels of catastrophizing and depression, is associated with poorer outcomes after spinal cord stimulation utilizing a passive recharge burst stimulation design. This proprietary waveform may uniquely attenuate the emotional aspects of chronic pain given its affects on the medial pain pathway projecting to the dorsal anterior cingulate cortex and anterior insula.

STUDY DESIGN/SETTINGS

Data were extracted from the prospective, multi-center, single-arm, international TRIUMPH study. The purpose of TRIUMPH was to assess long-term (2 years) safety and effectiveness of spinal cord stimulation for chronic pain in the trunk and/or limbs using a passive recharge enabled burst spinal cord stimulation (B-SCS) system.

PATIENT SAMPLE

Two subsets of study patients were identified; those with (n=31) and those without (n=54) high psychological distress.

OUTCOME MEASURES

Psychological and functional outcomes as well as pain intensity and impact of pain on life were administered at baseline and all follow intervals. Additionally, patient satisfaction and patient global impression of change were assessed at all follow-up intervals.

METHODS

Psychological distress (PD) was defined as a baseline score of ≥ 30 on the Pain Catastrophizing Scale (PCS) and ≥ 10 on the Patient Health Questionnaire Depression scale (PHQ-9). Nondistressed (ND) patients had scores below these thresholds on both scales. All patients were implanted with a B-SCS system and completed data collection for the 24-month follow-up visit. This study was funded by Abbott. JMH is a consultant for Abbott and has received <$20,000 in lifetime consulting fees from Abbott. SMF is a consultant for Abbott and has received >$50,000 in lifetime consulting fees from Abbott. BB is an Abbott employee. RAC is a former Abbott employee. JJY is a consultant for Abbott and has received <$2,500 in lifetime consulting fees from Abbott.

RESULTS

Of the 128 participants with 24-month data, 31 (24%) and 54 (35%) met the criteria for PD and ND, respectively. Baseline measures indicated a more severe chronic pain profile and worse quality of life in the PD group. Two years after implant, 71% were no longer clinically catastrophizing and 58% were no longer clinically depressed. Notably, more than half of the PD patients on antidepressants discontinued or decreased their medication. Health-related quality of life was 82% higher in the PD group at 24 months, reaching levels similar to the ND group. Psychological distress did not impact outcomes after SCS therapy; composite multi-responder rates were similar in the 2 groups throughout the follow-up period. Patient reported pain relief (58% PD vs. 61% ND) was equivalent in each group. In both groups, 81% were satisfied or very satisfied with the pain relief provided.

CONCLUSIONS

Our results showed that B-SCS appears to be as effective in a chronic pain population with high psychological distress as in those without distress. This may be due to the unique mechanism of action with the stimulation design involving the emotional-affective medial pain pathway in the brain.

Responsiveness and minimal important change of the Pain Catastrophizing Scale in people with chronic low back pain undergoing multidisciplinary rehabilitation

BACKGROUND

The Pain Catastrophizing Scale (PCS), a widely used tool to assess catastrophizing related to spinal disorders, shows valid psychometric properties in general but the minimal important change (MIC) is still not determined.

AIM

The aim of this study was to assess responsiveness and MIC of the PCS in individuals with chronic low back pain (LBP) undergoing multidisciplinary rehabilitation.

DESIGN

Prospective observational study.

SETTING

The setting was outpatient rehabilitation hospital.

POPULATION

Two hundred and five patients with chronic LBP.

METHODS

Before and after an 8-week multidisciplinary rehabilitation program, 205 patients completed the Italian version of the PCS (PCS-I). We calculated the PCS-I responsiveness by distribution-based methods (effect size [ES], standardized response mean [SRM], and minimum detectable change [MDC]) and anchor-based methods [receiver operating characteristic (ROC) curves]. After the program, participants completed a 7-point global perceived effect scale (GPE), based on which they were classified as "improved" vs. "stable." ROC curves computed the best cut-off level (taken as the MIC) between the two groups. ROC analysis was also performed on subgroups according to patients' baseline PCS scores.

RESULTS

ES, SRM and MDC were 0.71, 0.67 and 7.73, respectively. ROC analysis yielded an MIC of 8 points (95% confidence interval [CI]: 6-10; area under the curve [AUC]: 0.88). ROC analysis of the PCS subgroups confirmed an MIC of 8 points (95%CI: 6-10) for no/low catastrophizers (score <30, N.=159; AUC: 0.90) and indicated an MIC of 11 points (95%CI: 8-14) for catastrophizers (score >30, N.=33; AUC: 0.84).

CONCLUSIONS

The PCS-I showed good ability to detect patient-perceived clinical changes in chronic LBP postrehabilitation. The MIC values we determined provide a benchmark for assessing individual improvement in this clinical context.

CLINICAL REHABILITATION IMPACT

The present study calculated - in a sample of people with chronic LBP - the responsiveness and MIC of the PCS. These values increase confidence in interpreting score changes, enhancing their meaningfulness for both research and clinical contexts.

Severity of persistent pain and disability can accurately screen for presence of pain catastrophizing and fear of performing wrist movements in individuals with distal radius fracture

BACKGROUND

The evidence indicating presence of psychological factors concerns in individuals who report persistent residual pain and disability over a longer term after distal radius fractures (DRF) is emerging but requires further inquiry.

OBJECTIVES

To examine the associations of persistent wrist pain and disability at 6-months after DRF with the presence of psychological factors.

METHODS

Eighty-five patients with DRF were evaluated for wrist pain and disability with subscales of Patient-rated wrist evaluation (PRWE), 6-months after the fracture. The associations of wrist pain and disability with these psychological factors at 6-months after DRF were examined using multivariable logistic regression models. The ability of PRWE scores at 6-months after DRF to accurately classify individuals with and without these psychological factors was examined using the area under the receiver operating characteristic curve (AUC).

RESULTS

Higher PRWE-P scores were significantly associated with worse pain catastrophizing, having emotional distress, and fear of performing wrist movements. In addition, higher PRWE-F scores were also highly associated with worse pain catastrophizing, having emotional distress, and fear of performing wrist movements. The PRWE-P or PRWE-F Scores of ≥18/50 showed the best combination of sensitivity and specificity in identifying individuals with pain catastrophizing, emotional distress, and fear of performing wrist movements at 6-months after DRF (AUC values of ≥0.88).

CONCLUSION

The novel finding of this study is that scores of ≥18/50 PRWE-P or PRWEF can be used to screen for the presence of these psychological factors.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Restriction of range effects in post-metabolic and bariatric surgery outcomes research: considerations for clinical decision making

BACKGROUND

Preoperative psychopathology does not consistently predict postoperative outcomes in patients who undergo metabolic and bariatric surgery (MBS). Individuals with elevated pre-MBS psychopathology may be less likely to undergo surgery, which may create a floor effect given the limited range of scores on measures of psychopathology included in postoperative analyses, thereby decreasing the power to detect clinically significant differences between groups.

OBJECTIVES

Our objective was to compare rates of clinically significant pre-MBS psychopathology across domains of functioning in patients who did and did not undergo MBS: surgical completers (SCs, n = 286) and nonsurgical completers (NSCs, n = 125).

SETTING

Academic medical center, United States.

METHODS

Participants (n = 411) were a racially diverse sample of MBS candidates who completed a preoperative psychosocial evaluation including measures of disordered eating, alcohol and tobacco use, pain catastrophizing, anxiety, and depressive symptomatology.

RESULTS

Compared with SCs, NSCs had larger scale score variance on measures of psychopathology and were more likely to be Black; to report clinically significant scores on measures of binge eating, depression, anxiety, and pain catastrophizing; and to use tobacco.

CONCLUSION

Results support the presence of a restriction-of-range effect but do not demonstrate a floor effect. These data suggest that current outcome data for MBS patients may not generalize to those who report clinically significant psychopathology at the pre-MBS psychosocial evaluation and may warrant caution when using the current literature to inform clinical decision making for this group. Findings also suggest a need for interventions that will better engage Black patients.

Use of Complementary and Integrative Health Therapies Prior to Intensive Functional Restoration in Active Duty Service Members with Chronic Pain

OBJECTIVE

Psychosocial factors are known to predict chronic pain, and the use of complementary and integrative health (CIH) therapies to address pain is emerging among military population. However, conflicting results on pain outcomes warrant additional research. This study aimed to (1) evaluate the benefit of adding a CIH pain management program to standard rehabilitative care (SRC), as compared to SRC alone, as precursor to an intensive functional restoration (FR) program; (2) identify factors that predict improvement in pain outcomes following treatment; and (3) determine the proportion of participants who experience clinically meaningful response.

DESIGN

Pragmatic randomized controlled clinical trial. Participants were randomized to a 3-week course of either SRC alone or SRC+CIH (stage 1), followed by a 3- to 6-week course of FR (stage 2).

SETTING AND SUBJECTS

Active duty service members with chronic pain.

METHODS

Participants completed either SRC alone or SRC+CIH (stage 1), followed by a course of FR (stage 2). Patient-reported and provider-determined outcomes were collected at baseline, after stage 1, and after stage 2. A covariance pattern model with unstructured residual covariance matrix was used to compare treatment arms while accounting for dependency due to repeated measurements.

RESULTS

A total of 210 service members participated. Most were Army (82%) and male (84%). Participants randomized to the SRC+CIH intervention had greater improvement in the pain impact score than those in the SRC alone group. Predictors of outcomes were baseline impact score, anger, depression, and educational status.

CONCLUSIONS

This study found that military service members with the highest pain impact benefit the most from interdisciplinary pain care.

A bifactor structural model of the Hungarian Pain Catastrophizing Scale and latent classes of a clinical sample

Pain catastrophizing is an exaggerated cognitive-affective response to actual or anticipated pain, usually measured by the Pain Catastrophizing Scale (PCS). Our study aimed to test the bifactor measurement model of the Hungarian PCS and to identify a catastrophizing risk group with a clinically meaningful cut-off score.

The data of 404 chronic spine-related (neck, back and low-back) pain patients (mean age: 58.61 (SD = 14.34)) were used in our cross-sectional study. Besides pain-related and demographic data, pain catastrophizing and depressive symptoms were measured with questionnaires. Confirmatory factor analyses confirmed that the bifactor model outperformed the other tested measurement models, and the general catastrophizing factor was responsible for 81.5% of the explained variance. Using latent class analysis, we found that even moderately elevated pain catastrophizing score was related to more depressive symptoms and higher perceived pain intensity, and 22 score could be used as a cut-off score. Our results support the concept of global pain catastrophizing and the validity of the Hungarian PCS. Further studies are needed to evaluate the bifactor structure of this scale and the predictive value of the proposed cut-off score.

Multidimensional Perioperative Recovery Trajectories in a Mixed Surgical Cohort: A Longitudinal Cluster Analysis Utilizing National Institutes of Health Patient-Reported Outcome Measurement Information System Measures

BACKGROUND

Pain trajectories have been described in numerous surgical settings where preoperative characteristics have been used to predict trajectory membership. Suboptimal pain intensity trajectories have been linked to poor longitudinal outcomes. However, numerous biopsychosocial modulators of postoperative pain may also have distinct longitudinal trajectories that may inform additional targets to improve postoperative recovery.

METHODS

Patients undergoing total joint arthroplasty, thoracic surgery, spine surgery, major abdominal surgery, or mastectomy completed Patient Reported Outcome Measurement Information System (PROMIS) measures and additional scales preoperatively and at 1 week, 2 weeks, 1 month, 3 months, and 6 months postoperatively. A k-means clustering for longitudinal data was utilized to explore and describe distinct pain impact (PROMIS Pain Interference and Physical Function) trajectories and associated changes in additional biopsychosocial measures. Follow-up analyses examined participant demographics and clinical characteristics associated with trajectory memberships.

RESULTS

Three postoperative biopsychosocial symptom clusters were identified across all patients (n = 402): low (35%), average (47%), and high (18%) performance cluster trajectories. Participants undergoing total knee arthroplasty (TKA), spinal surgery, reporting presurgical opioid use, and higher pain catastrophizing scale scores were found to be associated with the low performance trajectory. Patients within the low performance trajectory, while demonstrating small improvements by 6 months, remained mild to moderately impaired in both pain impact and physical health outcomes. Alternatively, participants in the average performance trajectory demonstrated improvement in pain impact to population norms compared to baseline and demonstrated continued improvement across physical and psychological outcomes. Patients within the high performance cluster started within population norms across all measures at baseline and returned to baseline or exceeded baseline values by 6 months postoperatively. Self-reported opioid utilization was significantly higher in the low performance cluster across all time points. While a larger proportion of average performance patients reported opioid utilization during the first postoperative month compared to the high performance cluster, no differences were detected at 6 months postoperatively between these 2 clusters.

CONCLUSIONS

These pain impact trajectories build upon previous unidimensional pain intensity trajectories and suggest that additional distinct biopsychosocial measures may have unique trajectories related to cluster assignment. Additionally, these findings highlight the importance of continued pain impact surveillance through the perioperative recovery period to detect patients at risk of experiencing a poor trajectory and subsequently poor longitudinal health outcomes.

Efficacy of a Single-Session "Empowered Relief" Zoom-Delivered Group Intervention for Chronic Pain: Randomized Controlled Trial Conducted During the COVID-19 Pandemic

BACKGROUND

Cognitive behavioral therapy-pain is an evidence-based treatment for chronic pain that can have significant patient burden, including health care cost, travel, multiple sessions, and lack of access in remote areas.

OBJECTIVE

The study aims to pilot test the efficacy of a single-session videoconference-delivered empowered relief (ER) intervention compared to waitlist control (WLC) conditions among individuals with chronic pain. We hypothesized that ER would be superior to WLC in reducing pain catastrophizing, pain intensity, and other pain-related outcomes at 1-3 months posttreatment.

METHODS

We conducted a randomized controlled trial involving a web-based sample of adults (N=104) aged 18-80 years with self-reported chronic pain. Participants were randomized (1:1) to 1 of 2 unblinded study groups: ER (50/104, 48.1%) and WLC (54/104, 51.9%). Participants allocated to ER completed a Zoom-delivered class, and all participants completed follow-up surveys at 2 weeks and 1, 2, and 3 months posttreatment. All the study procedures were performed remotely and electronically. The primary outcome was pain catastrophizing 1-month posttreatment, with pain intensity, pain bothersomeness, and sleep disruption as secondary outcomes. We also report a more rigorous test of the durability of treatment effects at 3 months posttreatment. Data were collected from September 2020 to February 2021 and analyzed using intention-to-treat analysis. The analytic data set included participants (18/101, 17.8% clinic patients; 83/101, 82.1% community) who completed at least one study survey: ER (50/101, 49.5%) and WLC (51/104, 49%).

RESULTS

Participants (N=101) were 69.3% (70/101) female, with a mean age of 49.76 years (SD 13.90; range 24-78); 32.7% (33/101) had an undergraduate degree and self-reported chronic pain for 3 months. Participants reported high engagement (47/50, 94%), high satisfaction with ER (mean 8.26, SD 1.57; range 0-10), and high satisfaction with the Zoom platform (46/50, 92%). For the between-groups factor, ER was superior to WLC for all primary and secondary outcomes at 3 months posttreatment (highest P<.001), and between-groups Cohen d effect sizes ranged from 0.45 to 0.79, indicating that the superiority was of moderate to substantial clinical importance. At 3 months, clinically meaningful pain catastrophizing scale (PCS) reductions were found for ER but not for WLC (ER: PCS -8.72, 42.25% reduction; WLC: PCS -2.25, 11.13% reduction). ER resulted in significant improvements in pain intensity, sleep disturbance, and clinical improvements in pain bothersomeness.

CONCLUSIONS

Zoom-delivered ER had high participant satisfaction and very high engagement. Among adults with chronic pain, this single-session, Zoom-delivered, skills-based pain class resulted in clinically significant improvement across a range of pain-related outcomes that was sustained at 3 months. Web-based delivery of ER could allow greater accessibility of home-based pain treatment and could address the inconveniences and barriers faced by patients when attempting to receive in-person care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04546685; https://clinicaltrials.gov/ct2/show/NCT04546685.

Development and Underlying Structure of a Second-Generation Appropriateness Classification System for Total Knee Arthroplasty

OBJECTIVE

Evidence supports the validity of total knee arthroplasty (TKA) appropriateness classification based on the RAND Corporation and University of California Los Angeles system.The system, however, is ~2 decades old, and the science and clinical application of TKA has changed dramatically. We undertook this study to describe the methods used to develop a second-generation system and to examine the structure of the system to determine the extent to which each of the indication criteria informed appropriateness.

METHODS

Multivariable multinomial regression analyses determined the extent to which each of the 8 individually analyzed indication criteria informed appropriateness judgments. Classification tree analysis illustrates how the indication criteria, in combination, led to judgments of appropriate, inappropriate, or uncertain.

RESULTS

An expert panel selected 8 indication criteria (i.e., age, knee pain, function, radiographic osteoarthritis severity, osteoarthritis location, psychological factors, pain catastrophizing, and comorbidities). A total of 1,008 clinical scenarios were written, based on the criteria. Regression analyses indicated that age, knee pain, function, and radiographic severity dominated prediction of appropriateness, while the other criteria played a smaller role. Classification tree analysis confirmed the regression findings.

CONCLUSION

Our second-generation classification system, which incorporates contemporary indicators of TKA prognosis and risk, demonstrated preliminary evidence for utility in clinical practice.

Comparison of a Single-Session Pain Management Skills Intervention With a Single-Session Health Education Intervention and 8 Sessions of Cognitive Behavioral Therapy in Adults With Chronic Low Back Pain: A Randomized Clinical Trial

IMPORTANCE

Chronic low back pain (CLBP), the most prevalent chronic pain condition, imparts substantial disability and discomfort. Cognitive behavioral therapy (CBT) reduces the effect of CLBP, but access is limited.

OBJECTIVE

To determine whether a single class in evidence-based pain management skills (empowered relief) is noninferior to 8-session CBT and superior to health education at 3 months after treatment for improving pain catastrophizing, pain intensity, pain interference, and other secondary outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This 3-arm randomized clinical trial collected data from May 24, 2017, to March 3, 2020. Participants included individuals in the community with self-reported CLBP for 6 months or more and an average pain intensity of at least 4 (range, 0-10, with 10 indicating worst pain imaginable). Data were analyzed using intention-to-treat and per-protocol approaches.

INTERVENTIONS

Participants were randomized to (1) empowered relief, (2) health education (matched to empowered relief for duration and format), or (3) 8-session CBT. Self-reported data were collected at baseline, before treatment, and at posttreatment months 1, 2, and 3.

MAIN OUTCOMES AND MEASURES

Group differences in Pain Catastrophizing Scale scores and secondary outcomes at month 3 after treatment. Pain intensity and pain interference were priority secondary outcomes.

RESULTS

A total of 263 participants were included in the analysis (131 women [49.8%], 130 men [49.4%], and 2 other [0.8%]; mean [SD] age, 47.9 [13.8] years) and were randomized into 3 groups: empowered relief (n = 87), CBT (n = 88), and health education (n = 88). Empowered relief was noninferior to CBT for pain catastrophizing scores at 3 months (difference from CBT, 1.39 [97.5% CI, -∞ to 4.24]). Empowered relief and CBT were superior to health education for pain catastrophizing scores (empowered relief difference from health education, -5.90 [95% CI, -8.78 to -3.01; P < .001]; CBT difference from health education, -7.29 [95% CI, -10.20 to -4.38; P < .001]). Pain catastrophizing score reductions for empowered relief and CBT at 3 months after treatment were clinically meaningful (empowered relief, -9.12 [95% CI, -11.6 to -6.67; P < .001]; CBT, -10.94 [95% CI, -13.6 to -8.32; P < .001]; health education, -4.60 [95% CI, -7.18 to -2.01; P = .001]). Between-group comparisons for pain catastrophizing at months 1 to 3 were adjusted for baseline pain catastrophizing scores and used intention-to-treat analysis. Empowered relief was noninferior to CBT for pain intensity and pain interference (priority secondary outcomes), sleep disturbance, pain bothersomeness, pain behavior, depression, and anxiety. Empowered relief was inferior to CBT for physical function.

CONCLUSIONS AND RELEVANCE

Among adults with CLBP, a single-session pain management class resulted in clinically significant improvements in pain catastrophizing, pain intensity, pain interference, and other secondary outcomes that were noninferior to 8-session CBT at 3 months.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03167086.

Ultra-Low Energy Cycled Burst Spinal Cord Stimulation Yields Robust Outcomes in Pain, Function, and Affective Domains: A Subanalysis From Two Prospective, Multicenter, International Clinical Trials

INTRODUCTION

DeRidder's burst stimulation design has become a key spinal cord stimulation (SCS) waveform because it reduces the intensity of pain as well as its associated emotional distress. The brain pathways underlying these outcomes may also allow for the effects of stimulation to carry over after stimulation is turned off, making it amenable to intermittent application. Here, the utility of intermittently cycled burst was evaluated using data from two large real-world prospective studies (TRIUMPH, REALITY).

MATERIALS AND METHODS

Subjects used intermittent dosing in a 1:3 ratio (30 sec on, 90 sec off; N = 100) in TRIUMPH and 1:12 ratio in REALITY (30-sec on, 360-sec off; N = 95) for six months. Pain intensity (0-10 numeric rating scale), pain-related emotions on the pain catastrophizing scale (PCS), and physical function on PROMIS questionnaires were compared with preimplant baseline ratings and by group.

RESULTS

In both groups, mean pain intensity decreased by nearly 50% relative to baseline, PCS scores significantly decreased, and physical function improved. Importantly, no differences between the 1:3 and 1:12 groups were identified. A high proportion, 80% and 77% of the 1:3 and 1:12 groups, respectively, were considered responders on a multiple measures. No adverse events were associated with intermittent stimulation.

DISCUSSION

Intermittent cycling of burst SCS lowers the overall electric charge delivered to the spinal cord and preserves battery consumption, without compromising pain relief and associated symptoms.

Chronic musculoskeletal pain, catastrophizing, and physical function in adult women were improved after 3-month aerobic-resistance circuit training

Although exercise is beneficial for chronic musculoskeletal pain (CMP), the optimal type and amount of exercise are unclear. This study aimed to determine the impact of circuit training that combines aerobic and resistance exercises on adult women with CMP. A total of 139 women with CMP underwent circuit training for 3 months and were asked to complete the following questionnaires at baseline and 3 months later: Numeric Rating Scale (NRS), Pain Catastrophizing Scale (PCS), Roland-Morris Disability Questionnaire (RDQ), Shoulder36, and Knee injury and Osteoarthritis Outcome Score (KOOS). Significant improvements were observed in NRS, PCS, RDQ, and KOOS activities of daily living (ADL) scores after the intervention relative to baseline (p < 0.0001, p = 0.0013, 0.0004, and 0.0295, respectively), whereas shoulder function did not improve. When considering the impact of exercise frequency, NRS scores improved regardless of exercise frequency. Furthermore, PCS, RDQ, and KOOS scores improved in participants who exercised at least twice a week (24 sessions over the course of 3 months). In conclusion, CMP, pain catastrophizing, and physical function in adult female fitness club participants with CMP of NRS 4 or higher improved after 3 months of aerobic-resistance circuit training.

A Prospective Single-Arm Study Evaluating the Effects of a Multimodal Physical Therapy Intervention on Psychosexual Outcomes in Women With Dyspareunia After Gynecologic Cancer

BACKGROUND

Dyspareunia affects most women after treatment for gynecologic malignancies. However, to date, evidence-based interventions remain limited and no study has examined the effects of multimodal physical therapy on psychosexual outcomes in these patients.

AIM

To assess the effects of multimodal physical therapy on psychosexual outcomes including sexual distress, body image concerns, pain anxiety, pain catastrophizing, pain self-efficacy and depressive symptoms in women with dyspareunia after treatment for gynecologic malignancies.

METHODS

Thirty-one gynecologic cancer survivors with dyspareunia enrolled in this prospective single-arm interventional study. The participants undertook 12 weekly sessions of physical therapy incorporating education, pelvic floor muscle exercises with biofeedback, manual therapy and home exercises. Outcome measures were evaluated pre- and post-treatment. Paired t-tests were conducted to investigate the changes from pre-treatment (P-value ˂ 0.05) while effect sizes (Cohen's d) were calculated to measure the magnitude of the change.

MAIN OUTCOME MEASURES

Sexual distress (Female Sexual Distress Scale-Revised), body image concerns (Body Image Scale), pain anxiety (Pain Anxiety Symptoms Scale), pain catastrophizing (Pain Catastrophizing Scale), pain self-efficacy (Painful Intercourse Self-Efficacy Scale) and depressive symptoms (Beck Depression Inventory-II).

RESULTS

Significant changes were found from pre- to post-treatment for all psychosexual outcomes. Women reported reductions in sexual distress (P ˂ 0.001, d = 1.108), body image concerns (P ˂ 0.001, d = 0.829), pain anxiety (P ˂ 0.001, d = 0.980), pain catastrophizing (P ˂ 0.001, d = 0.968) and depression symptoms (P = 0.002, d = 0.636) with an increase in pain self-efficacy (P ˂ 0.001, d ≥ 0.938) following the intervention.

CLINICAL IMPLICATIONS

The results suggest that multimodal physical therapy significantly improves sexual distress, body image concerns, pain anxiety, pain catastrophizing, pain self-efficacy and depressive symptoms in our sample of women with dyspareunia after treatment for gynecologic malignancies. The medium to large effect sizes obtained with the high proportion of women presenting meaningful changes according to the known minimal clinically important difference or clinical cut-off underlines the significance of these effects.

STRENGTHS & LIMITATIONS

The current study used validated questionnaires to assess the psychosexual outcomes of a well-designed physical therapy intervention using multiple modalities to address the multifaceted aspect of dyspareunia in cancer survivors. This study did not include a control group, which may limit drawing definitive conclusions.

CONCLUSION

Findings showed that multimodal physical therapy yielded significant improvements in psychosexual outcomes in gynecologic cancer survivors with dyspareunia. A randomized controlled trial is indicated to confirm these results. Cyr M-P, Dumoulin C, Bessette P, et al. A Prospective Single-Arm Study Evaluating the Effects of a Multimodal Physical Therapy Intervention on Psychosexual Outcomes in Women With Dyspareunia After Gynecologic Cancer. J Sex Med 2021;18:946-954.

Online questionnaire, clinical and biomechanical measurements for outcome prediction of plantar heel pain: feasibility for a cohort study

BACKGROUND

Plantar heel pain (PHP) accounts for 11-15% of foot symptoms requiring professional care in adults. Recovery is variable, with no robust prognostic guides for sufferers, clinicians or researchers. Therefore, we aimed to determine the validity, reliability and feasibility of questionnaire, clinical and biomechanical measures selected to generate a prognostic model in a subsequent cohort study.

METHODS

Thirty-six people (19 females & 17 males; 20-63 years) were recruited with equal numbers in each of three groups: people with PHP (PwPHP), other foot pain (PwOP) and healthy (H) controls. Eighteen people performed a questionnaire battery twice in a randomised order to determine online and face-to-face agreement. The remaining 18 completed the online questionnaire once, plus clinical measurements including strength and range of motion, mid-foot mobility, palpation and ultrasound assessment of plantar fascia. Nine of the same people underwent biomechanical assessment in the form of a graded loaded challenge augmenting walking with added external weight and amended step length on two occasions. Outcome measures were (1) feasibility of the data collection procedure, measurement time and other feedback; (2) establishing equivalence to usual procedures for the questionnaire battery; known-group validity for clinical and imaging measures; and initial validation and reliability of biomechanical measures.

RESULTS

There were no systematic differences between online and face-to-face administration of questionnaires (p-values all > .05) nor an administration order effect (d = - 0.31-0.25). Questionnaire reliability was good or excellent (ICC2,1_absolute)(ICC 0.86-0.99), except for two subscales. Full completion of the survey took 29 ± 14 min. Clinically, PwPHP had significantly less ankle-dorsiflexion and hip internal-rotation compared to healthy controls [mean (±SD) for PwPHP-PwOP-H = 14°(±6)-18°(±8)-28°(±10); 43°(±4)- 45°(±9)-57°(±12) respectively; p < .02 for both]. Plantar fascia thickness was significantly higher in PwPHP (3.6(0.4) mm vs 2.9(0.4) mm, p = .01) than the other groups. The graded loading challenge demonstrated progressively increasing ground reaction forces.

CONCLUSION

Online questionnaire administration was valid therefore facilitating large cohort recruitment and being relevant to remote service evaluation and research. The physical and ultrasound examination revealed the expected differences between groups, while the graded loaded challenge progressively increases load and warrants future research. Clinician and researchers can be confident about these methodological approaches and the cohort study, from which useful clinical tools should result, is feasible.

LEVEL OF EVIDENCE

IV.

Effects of SNAG mobilization combined with a self-SNAG home-exercise for the treatment of cervicogenic headache: a pilot study

INTRODUCTION

Cervicogenic headache (CGH) may originate from the C1-C2 zygapophyseal joints. CGH is often associated with loss of range of motion (ROM), specific to this segment, and measurable by the cervical flexion-rotation test (CFRT). The main purposes of the study were: 1) to investigate the immediate effect of C1-C2 rotation SNAG mobilizations plus C1-C2 self-SNAG rotation exercise for patients with CGH and 2) to explore the link between the CFRT results and treatment response.

METHODS

A prospective quasi-experimental single-arm design was used where patients with CGH received eight physical therapy treatments using a C1-C2 rotational SNAG technique combined with a C1-C2 self-SNAG rotation exercise over a four-week period. Outcome measures were pain intensity/frequency and duration, active cervical ROM, CFRT, neck-related and headache-related self-perceived physical function, fear-avoidance beliefs, pain catastrophizing and kinesiophobia.

RESULTS

The intervention produced strong effects on pain intensity, CFRT, physical function and pain catastrophizing. Moderate improvement was noted on active cervical ROM and on fear-avoidance beliefs and kinesiophobia. No link was found between pre-intervention CFRT ROM and treatment response.

CONCLUSION

SNAG mobilization combined with a self-SNAG exercise resulted in favorable outcomes for the treatment of CGH on patient-important and biomechanical outcomes, as well as pain-related cognitive-affective factors.

Development of the Hausa version of the Pain Catastrophizing Scale: translation, cross-cultural adaptation and psychometric evaluation in mixed urban and rural patients with chronic low back pain

Background

Catastrophizing has been recognized as an important contributor to chronicity in individuals with chronic pain syndromes including low back pain (LBP). The Pain Catastrophizing Scale (PCS) is perhaps the most widely used tool to evaluate the degree of pain catastrophizing. However, its use is limited in Hausa-speaking countries due to the lack of a validated translated version.

Objective

To translate and cross-culturally adapt the PCS into Hausa (Hausa-PCS), and evaluate its psychometric properties in mixed urban and rural patients with chronic LBP.

Methods

The PCS was translated and cross-culturally adapted into Hausa in accordance with established guidelines. To evaluate its psychometric properties, a consecutive sample of 200 patients with chronic LBP was recruited from urban and rural Nigerian hospitals. Validity was evaluated by exploring content validity, factorial structure (confirmatory factor analysis [CFA]), construct validity (Spearman’s rho for a priori hypotheses) and known-groups validity. Reliability was evaluated by calculating internal consistency (Cronbach’s α), intraclass correlation coefficient (ICC), standard error of measurement (SEM), minimal detectable change (MDC) and limits of agreement with 95% confidence interval (LOA_95%).

Results

The Hausa-PCS was comprehensible with good content validity. The CFA confirmed a 3-factor structure similar to the original English version. The concurrent validity was supported as 83% (5/6) of the a priori hypotheses were confirmed. Known-groups comparison showed that the questionnaire was unable to differentiate between male and female or urban and rural patients (p > 0.05). Internal consistency and ICC were adequate for the Hausa-PCS total score (α = 0.84; ICC = 0.90) and the subscale helplessness (α = 0.78; ICC = 0.89) but for the subscales rumination (α = 0.69; ICC = 0.68) and magnification (α = 0.41; ICC = 0.43). The LOA_95% for the Hausa-PCS total score was between − 8.10 and + 9.75, with SEM and MDC of 3.47 and 9.62 respectively.

Conclusion

The Hausa-PCS was successfully developed and psychometrically adequate in terms of factorial structure, construct validity, internal consistency and test–retest reliability when applied in mixed urban and rural patients with chronic LBP. However, the internal consistency and reliability coefficients (ICC) for the individual subscales are inadequate. Thus, we support the use of the total score when evaluating pain catastrophizing for clinical or research purposes.