Biological stress systems, adverse life events and the onset of chronic multisite musculoskeletal pain: a 6-year cohort study

Childhood maltreatment and chronic "all over" body pain in adulthood: a counterfactual analysis using UK Biobank

ABSTRACT

Evidence linking adverse childhood experiences and chronic pain in adulthood is largely cross-sectional, potentially subject to recall bias and does not allow exploration of mediating pathways. We analysed a large population-based cohort (UK Biobank) using a causal framework, to determine if childhood maltreatment is related to chronic "all over" body pain in adulthood. We used doubly robust estimation with inverse probability weights to estimate the difference in risk of chronic pain "all over" between those exposed/not exposed to childhood maltreatment (abuse or neglect). In addition, we looked at interaction with adult stressful life events and examined mediation using inverse odds weighting in a generalized linear model. Using cases with complete data (n = 118,347), the risk of chronic "all over" body pain was higher in the exposed (6.3%, 95% confidence interval [CI] 6.0%-6.5%) than in the unexposed (4.0%; 95% CI 3.8%-4.2%). This difference remained in analyses stratified by sex. Conversely, when analyses were repeated with a negative control exposure, childhood sunburn, risk differences were 0.8% in women (95% CI 0.3%-1.3%) and 0.5% in men (95% CI 0.1%-0.9%). Childhood maltreatment and adult life events had similar effects, and there was a supra-additive risk (1.2%; 95% CI 0.6-1.7) when experiencing both. In mediation analyses, the total effect was a relative risk of 1.57 (95% CI 1.49-1.66), while the estimated indirect effect via all mediators was relative risk 1.16 (95% CI 1.14-1.18). Reducing childhood maltreatment would likely prevent cases of chronic widespread pain in adulthood. Stressful adult events and mediators may offer opportunities for intervention.

Early-life adversity predicting the incidence of multisite chronic pain in the general population

INTRODUCTION

Adverse childhood events (ACEs) have been linked to widespread chronic pain (CP) in various cross-sectional studies, mainly in clinical populations. However, the independent role of different ACEs on the development of different types of CP remains elusive. Accordingly, we aimed to prospectively assess the associations between specific types of ACEs with the development of multisite CP in a large population-based cohort.

METHODS

Data stemmed from the three first follow-up evaluations of CoLaus|PsyCoLaus, a prospective population-based cohort study of initially 6734 participants (age range: 35-75 years). The present sample included 1537 participants with 2161 analyzable intervals (49.7% men, mean age 57.3 years). Diagnostic criteria for ACEs were elicited using semi-structured interviews and CP was assessed by self-rating questionnaires. Multinomial logistic regressions with generalized estimating equations method analyzed the relationship between the different ACEs measured in the beginning of the interval and the risk of developing multisite CP during the follow-up. Sensitivity analyses were performed to assess the predictive value of ACEs on multisite CP with neuropathic features.

RESULTS

Participants with a history of parental divorce or separation had an increased risk of developing multisite CP at during follow-up in comparison to those without (RR1.98; 95% CI 1.13-3.47). A strong association was highlighted between parental divorce or separation and the risk of subsequent CP with neuropathic characteristics (RR 4.21, 95% CI 1.45-12.18).

CONCLUSION

These results highlight the importance of psychotherapeutic management of people experiencing parental separation to prevent CP in the future.

Insecure Attachment, Oxytocinergic System and C-Tactile Fibers: An Integrative and Translational Pathophysiological Model of Fibromyalgia and Central Sensitivity Syndromes

Although the pathophysiology of fibromyalgia syndrome has been better understood in recent decades, a unified model of its pathogenesis and an effective therapeutic approach are still far from being realized. The main aim of this article will be to delve into the fundamental mechanisms of the pathophysiology of fibromyalgia conceptualized as stress intolerance syndrome. Using the biopsychosocial model of chronic pain syndromes, we will describe the potential role of the attachment system, C-tactile fibers, and oxytocinergic system dysfunction in the pathophysiology of fibromyalgia syndrome and other central sensitivity syndromes. At the end of the article, the therapeutic implications of this new global and translational pathophysiological model will be briefly discussed.

Biobehavioral Predictors of Pain Intensity, Pain Interference, and Chronic Pain Episodes: A Prospective Cohort Study of African-American Adults

Racial disparities in pain experiences are well-established, with African-American (AA) adults reporting higher rates of daily pain, increased pain severity, and greater pain-related interference compared to non-Hispanic Whites. However, the biobehavioral factors that predict the transition to chronic pain among AA adults are not well understood. This prospective cohort study provided a unique opportunity to evaluate predictors of chronic pain onset among 130 AA adults (81 women), ages 18 to 44, who did not report chronic pain at their baseline assessment and subsequently completed follow-up assessments at 6- and 12-months. Outcome measures included pain intensity, pain-related interference, and chronic pain status. Comprehensive assessments of sociodemographic and biobehavioral factors were used to evaluate demographics, socioeconomic status, stress exposure, psychosocial factors, prolonged hypothalamic-pituitary-adrenal secretion, and quantitative sensory testing responses. At baseline, 30 adults (23.1%) reported a history of prior chronic pain. Over the 12-month follow-up period, 13 adults (10.0%) developed a new chronic pain episode, and 18 adults (13.8%) developed a recurrent chronic pain episode. Whereas socioeconomic status measures (ie, annual income, education) predicted changes in pain intensity over the follow-up period, quantitative sensory testing measures (ie, pain threshold, temporal summation of pain) predicted changes in pain interference. A history of chronic pain and higher depressive symptoms at baseline independently predicted the onset of a new chronic pain episode. The present findings highlight distinct subsets of biobehavioral factors that are differentially associated with trajectories of pain intensity, pain-related interference, and onset of chronic pain episodes in AA adults. PERSPECTIVE: This prospective study sought to advance understanding of biobehavioral factors that predicted pain outcomes over a 12-month follow-up period among AA adults without chronic pain at their initial assessment. Findings revealed distinct subsets of factors that were differentially associated with pain intensity, pain-related interference, and onset of chronic pain episodes.

Perceived Stress and Life Stressors in Adults with and without Fibromyalgia

Chronic medical conditions (i.e., chronic widespread pain) may contribute to accelerated/accentuated aging, such that middle-aged individuals with comorbidities may actually show increased declines in physical, cognitive, and mental health compared to normal aging adults. We examined perceived stress, life stressors, and depression in adults with and without fibromyalgia, a chronic pain condition. Ninety-four participants (52% with fibromyalgia, 78% female) aged 50 to 93 were administered the Perceived Stress Scale, Social Readjustment Rating Scale, and Beck Depression Inventory. Hierarchical regression analyses were conducted: the predictor variables were age, gender, fibromyalgia status, depression, and fibromyalgia-depression interaction. The interaction term significantly predicted perceived stress, but not life stressors. Depression significantly predicted stress for Social Readjustment Rating Scale measures after controlling for covariates. Significant associations were found between perceived stress and life stressors in all participants. In addition, those with fibromyalgia were significantly more likely to report higher levels of stress above standardized scores on both the Perceived Stress Scale and the Social Readjustment Rating Scale. Finally, depressive symptoms played a more significant role than fibromyalgia status in predicting life stressors. Conclusions: These findings emphasize the importance of assessing different types of stress and stressors in individuals with chronic widespread pain and/or depression in mid-life and beyond to better treat individuals with these conditions.

Deciphering nociplastic pain: clinical features, risk factors and potential mechanisms

Nociplastic pain is a mechanistic term used to describe pain that arises or is sustained by altered nociception, despite the absence of tissue damage. Although nociplastic pain has distinct pathophysiology from nociceptive and neuropathic pain, these pain mechanisms often coincide within individuals, which contributes to the intractability of chronic pain. Key symptoms of nociplastic pain include pain in multiple body regions, fatigue, sleep disturbances, cognitive dysfunction, depression and anxiety. Individuals with nociplastic pain are often diffusely tender - indicative of hyperalgesia and/or allodynia - and are often more sensitive than others to non-painful sensory stimuli such as lights, odours and noises. This Review summarizes the risk factors, clinical presentation and treatment of nociplastic pain, and describes how alterations in brain function and structure, immune processing and peripheral factors might contribute to the nociplastic pain phenotype. This article concludes with a discussion of two proposed subtypes of nociplastic pain that reflect distinct neurobiological features and treatment responsivity.

Association between multisite musculoskeletal pain and disability trajectories among community-dwelling older adults

BACKGROUND

Pain is linked to disability, but how multisite musculoskeletal pain leads to disability over time is not well elaborated.

OBJECTIVE

To examine the associations of multisite musculoskeletal pain with disability among a nationally representative cohort.

DESIGN

We used data from the National Health and Aging Trends Study (NHATS) 2015-22. Disability was assessed by basic activities of daily living (ADL) and instrumental activities of daily living (IADL).

PARTICIPANTS

A total of 5557 individuals with multisite musculoskeletal pain dwelling in the community were included in this study.

METHODS

Group-based trajectory models were applied to identify distinct profiles of disability in ADL and IADL. Design-based logistic regressions were used to examine associations among multisite musculoskeletal pain, disability, and dual trajectory group memberships, adjusted for sociodemographic, health status, behavioral, and mental characteristics.

RESULTS

Persons who experienced multisite musculoskeletal pain were at higher risk of disability in ADL and IADL. We identified five heterogeneous disability trajectories and named them based on baseline levels and rates of increase over time. Approximately, 52.42% of older adults with multisite musculoskeletal pain were in trajectories with ADL and IADL declines, and 33.60% experienced a rapid decline. Multisite musculoskeletal pain was associated with elevated relative risk for the adverse disability trajectories, which generally increases with multisite musculoskeletal pain frequency and number of sites.

CONCLUSIONS

Persons with multisite musculoskeletal pain had a higher risk of disability. It is essential to adopt effective pain management strategies to maintain the independent living ability of older adults and to realize active aging.

Emotion-Focused Psychodynamic Interview for People with Chronic Musculoskeletal Pain and Childhood Adversity: A Randomized Controlled Trial

Childhood adversity and emotional conflicts are associated with the presence and severity of chronic musculoskeletal pain (CMP), yet common treatments for CMP do not address such risk factors. We developed a single session, emotion-focused psychodynamic interview, based on Emotional Awareness and Expression Therapy and Intensive Short-term Psychodynamic Therapy, and we tested the interview's effects on pain-related outcomes and potential psychological mediators in a randomized, controlled trial. Adults (N = 91; ages 21-70, M = 44.64; 87.9% women) reporting CMP and at least 3 adverse childhood experiences completed measures at baseline and 6-week follow-up. Participants were randomized to immediate interview or waitlist control conditions. The 90-minute interview was conducted via videoconference, and the interviewer elicited disclosure of adversities and conflicts, linked these with pain, and encouraged the experience and expression of adaptive emotions. Analyses indicated that conditions did not differ significantly on change in pain severity; however, compared to control, the interview led to a significantly greater reduction in pain interference (P = .016, ηp2 = .05) and a similar trend for anxiety (P = .058, ηp2 = .04). The interview also significantly changed several potential mediators: pain-related anxiety (P = .008, ηp2 = .06), pain controllability (P = .016, ηp2 = .06), and psychological (P < .001, ηp2 = .15) and brain attributions (P = .022, ηp2 = .05) for pain. Participants viewed the interview as very valuable. We conclude that addressing childhood adversities and conflicts in a psychodynamic interview is beneficial for people with CMP. PERSPECTIVE: This study found that, compared to waitlist control, a 90-minute, remotely-administered, emotion-focused, psychodynamic interview improved pain interference, and anxiety among adults with chronic musculoskeletal pain and childhood adversity. Intensive emotional work can be done in a single session to the benefit of patients with chronic musculoskeletal pain.

Autonomic responses to aerobic and resistance exercise in patients with chronic musculoskeletal pain: A systematic review

BACKGROUND

It is unknown whether patients with chronic musculoskeletal pain (CMP) show autonomic dysregulation after exercise, and the interventional effects of exercise on the autonomic dysregulation have not been elucidated. The objectives of this study were to reveal acute autonomic responses after aerobic and resistance exercises and the interventional effects of both exercises on autonomic dysregulation in patients with CMP.

METHODS

A systematic search using nine electronic databases was performed based on three key search terms: "chronic musculoskeletal pain," "autonomic nervous system," and "exercise." Data were extracted from measurements of the autonomic nervous system and pain.

RESULTS

We found a total of 1170 articles; 17 were finally included, incorporating 12 observational and five interventional studies. Although a comparator has not been specified, healthy controls were compared to patients with CMP in observational studies. Three of five interventional studies were pre-post study with healthy controls as a comparator or no controls. The other two interventional studies were randomized controlled trial with a different treatment e.g., stretching. There were four good, 10 fair, and three poor-quality articles. The total number of participants was 617, of which 551 were female. There was high heterogeneity among the five disease conditions and nine outcome measures. Following one-time exposure to aerobic and resistance exercises, abnormal autonomic responses (sympathetic activation and parasympathetic withdrawal), which were absent in healthy controls, were observed in patients with CMP. The effects of aerobic and resistance exercise as long-term interventions were unclear since we identified both positive effects and no change in the autonomic activities in patients with CMP.

CONCLUSIONS

This study indicates dysfunctional autonomic responses following one-time exposure to exercise and inconsistent interventional effects in the autonomic activities in patients with CMP. Appropriate therapeutic dose is necessary for studying the management of autonomic regulation and pain after exercise.

Neurophysiological and Psychosocial Mechanisms of Fibromyalgia: A Comprehensive Review and Call for An Integrative Model

Research into the neurobiological and psychosocial mechanisms involved in fibromyalgia has progressed remarkably in recent years. Despite this, current accounts of fibromyalgia fail to capture the complex, dynamic, and mutual crosstalk between neurophysiological and psychosocial domains. We conducted a comprehensive review of the existing literature in order to: a) synthesize current knowledge on fibromyalgia; b) explore and highlight multi-level links and pathways between different systems; and c) build bridges connecting disparate perspectives. An extensive panel of international experts in neurophysiological and psychosocial aspects of fibromyalgia discussed the collected evidence and progressively refined and conceptualized its interpretation. This work constitutes an essential step towards the development of a model capable of integrating the main factors implicated in fibromyalgia into a single, unified construct which appears indispensable to foster the understanding, assessment, and intervention for fibromyalgia.

The Biology of Stress Intolerance in Patients with Chronic Pain—State of the Art and Future Directions

Stress has been consistently linked to negative impacts on physical and mental health. More specifically, patients with chronic pain experience stress intolerance, which is an exacerbation or occurrence of symptoms in response to any type of stress. The pathophysiological mechanisms underlying this phenomenon remain unsolved. In this state-of-the-art paper, we summarised the role of the autonomic nervous system (ANS) and hypothalamus-pituitary-adrenal (HPA) axis, the two major stress response systems in stress intolerance. We provided insights into such mechanisms based on evidence from clinical studies in both patients with chronic pain, showing dysregulated stress systems, and healthy controls supported by preclinical studies, highlighting the link between these systems and symptoms of stress intolerance. Furthermore, we explored the possible regulating role for (epi)genetic mechanisms influencing the ANS and HPA axis. The link between stress and chronic pain has become an important area of research as it has the potential to inform the development of interventions to improve the quality of life for individuals living with chronic pain. As stress has become a prevalent concern in modern society, understanding the connection between stress, HPA axis, ANS, and chronic health conditions such as chronic pain is crucial to improve public health and well-being.

Reconsidering Fordyce's classic article, "Pain and suffering: what is the unit?" to help make our model of chronic pain truly biopsychosocial

ABSTRACT

The biopsychosocial model (BPS) of chronic pain aspires to be comprehensive, incorporating psychological and social factors omitted from biomedical models. Although psychosocial factors are viewed as highly influential in understanding behavioral and psychological responses to pain, these factors are usually viewed as modifiers of biological causes of the experience of pain itself, rather than as equal contributors to pain. To further advance the BPS model, we re-examine a classic 1994 article by Wilbert "Bill" Fordyce, "Pain and suffering: what is the unit?" In this article, Fordyce suggested that pain-related disability and suffering should be viewed as "transdermal," as having causes both inside and outside the body. We consider Fordyce's article theoretically important because this concept allows us to more fully break free of the medical model of chronic pain than customary formulations of the BPS model. It makes it possible to place psychological and social factors on an equal footing with biological ones in explaining pain itself and to remove distinctions between pain mechanisms and pain meanings. The brain's salience network now offers a platform on which diverse influences on pain experience-from nociception to multisensory indicators of safety or danger-can be integrated, bridging the gap between impersonal nociceptive mechanisms and personal meanings. We also argue that Fordyce's article is practically important because this concept expands the BPS model beyond the bounds of the clinical encounter, opening the door to the full range of social, psychological, and biological interventions, empowering patients and nonmedical providers to tackle chronic pain.

Emotion regulation and the salience network: a hypothetical integrative model of fibromyalgia

Fibromyalgia is characterized by widespread pain, fatigue, sleep disturbances and other symptoms, and has a substantial socioeconomic impact. Current biomedical and psychosocial treatments are unsatisfactory for many patients, and treatment progress has been hindered by the lack of a clear understanding of the pathogenesis of fibromyalgia. We present here a model of fibromyalgia that integrates current psychosocial and neurophysiological observations. We propose that an imbalance in emotion regulation, reflected by an overactive 'threat' system and underactive 'soothing' system, might keep the 'salience network' (also known as the midcingulo-insular network) in continuous alert mode, and this hyperactivation, in conjunction with other mechanisms, contributes to fibromyalgia. This proposed integrative model, which we term the Fibromyalgia: Imbalance of Threat and Soothing Systems (FITSS) model, should be viewed as a working hypothesis with limited supporting evidence available. We hope, however, that this model will shed new light on existing psychosocial and biological observations, and inspire future research to address the many gaps in our knowledge about fibromyalgia, ultimately stimulating the development of novel therapeutic interventions.

Attention deficits in Brazilian health care workers with chronic pain

The impact of COVID-19 on chronic pain (CP) in non-infected vulnerable South American subjects is unknown. Healthcare workers (HCWs) are at increased risk for CP. During the pandemic, many HCWs with CP kept working. Knowing how cognition is affected by CP in these subjects is an important subject for work safety. The attention domain has a pivotal role in cognition. Previously, the Continuous Visual Attention Test (CVAT) was applied to detect specific attention deficits in fibromyalgia patients. The present investigation described CP prevalence in non-infected Brazilian HCWs during the pandemic and assessed HCWs' attentional performance with the aid of the CVAT. This study was carried out at a reference University Hospital in Rio de Janeiro, Brazil. HCWs of both sexes, aged 20 or older, were interviewed from August to December 2020. A 90-second version of the CVAT was performed. The average reaction time to correct responses and the respective intraindividual reaction time variability for correct responses to target (VRT) was determined. Omission and commission errors were also calculated. Then, for each participant we calculated the Z-scores of the CVAT variables based on the distribution of CVAT performance of 211 healthy subjects (reference-comparison group). HCWs with Z-scores > 1.64 were classified as significantly impaired. From the 154 selected HCWs, 72 reported CP during the pandemic (prevalence = 47%). Post hoc ANCOVAs showed that the average correct VRT was significantly higher in the CP group than in the non-CP group (F = 4.99, df = 1/150, p = 0.027, η2 = 0.032). The percentage of participants with impaired VRT performance was 30% (n = 21) in the CP group and 16% (n = 13) in the non-CP group. The difference between these two propositions reached significance (χ2 = 3.96, df = 1, p = 0.047). As VRT is associated with the sustained-attention subdomain, our data suggest that this subdomain is disrupted in the CP group.

Shoulder pain, shoulder disability, and depression as serial mediators between stress and health-related quality of life among middle-aged women

This study analyzed the mediating effects of shoulder pain, disability, and depression on the relationship between stress and health-related quality of life among middle-aged women using a serial mediation model. Methods. Data on stress, health-related quality of life, shoulder pain, shoulder disability, and depression were collected from 565 women aged 35–64 years living in Seoul, South Korea, from May 13 to 23, 2021, using a self-reported, structured survey. SPSS PROCESS macro (Model 6) and serial mediation analysis were used to analyze the relationship between stress and health-related quality of life among participants, with shoulder pain, shoulder disability, and depression as mediators. Results. The results indicate that stress had a statistically direct impact on health-related quality of life. In the serial mediation analysis, shoulder pain, disability, and depression were found to be statistically significant, thus affecting the relationship between stress and health-related quality of life, with an explanatory power of 33%. Therefore, the relationship between stress and health-related quality of life was partially mediated by these variables. Conclusions. Thus, this study suggests the need for healthcare workers to develop methods, such as exercise intervention programs based on various degrees and types of physical activity, to improve health-related quality of life and reduce stress caused by shoulder pain, shoulder disability, and depression among middle-aged women.

Potentially traumatic events, social support and burden of persistent somatic symptoms: A longitudinal study

OBJECTIVE

Psychological trauma is a well-known risk factor for the onset of persistent somatic symptoms (PSS). In contrast, little is known on the relation between potentially traumatic events (PTEs) and the severity of PSS, and on the protective effect of social support. We aimed to: (i) determine whether childhood, adulthood and recent PTEs are associated with burden of PSS over four years of follow-up; (ii) examine associations of multiple and cumulative (in childhood and adulthood) exposure to PTEs with burden of PSS; and (iii) determine whether social support modifies these associations.

METHODS

Longitudinal data of 322 patients with PSS were analyzed. PTEs (Life Events Questionnaire) and social support (Social Support Scale) were assessed at baseline. Burden of PSS was measured in terms of symptom severity (PHQ-15) and physical functioning (RAND-36 PCS) at six repeated measurements over a four-year interval. Associations were analyzed using longitudinal mixed model analysis.

RESULTS

Patients with multiple childhood PTEs reported higher burden of PSS over four-year time. Adulthood PTEs were associated with burden of PSS in patients with, but not in patients without childhood PTEs. Recent PTEs were not associated with burden over time. Social support did not modify any of the associations.

CONCLUSIONS

PTEs are associated with higher burden of PSS over time, in addition to the well-known association with the onset of PSS. PTEs in early life and cumulative exposure to PTEs in childhood and adulthood are associated with higher burden over time in patients with PSS. Social support did not attenuate the associations.

"I Don't Know Why I've Got this Pain!" Allostasis as a Possible Explanatory Model

Explaining the onset and maintenance of pain can be challenging in many clinical presentations. Allostasis encompasses the mechanisms through which humans adapt to stressors to maintain physiological stability. Due to related neuro-endocrine-immune system effects, allostasis and allostatic load (the cumulative effects on the brain and body that develop through the maintenance of physiological stability) offer the potential to explain the development and maintenance of musculoskeletal pain in certain cases. This paper outlines the concept of allostatic load, highlights the evidence for allostatic load in musculoskeletal pain conditions to date, and discusses mechanisms through which allostatic load influences pain, with particular focus on hypothalamic-pituitary-adrenal axis and sympathetic nervous system function and central, brain-driven governance of these systems. Finally, through case examples, consideration is given as to how allostatic load can be integrated into clinical reasoning and how it can be used to help explain pain to individuals and guide clinical decision-making.

IMPACT

Awareness of the concept of allostatic load, and subsequent assessment of physical and psychological stressors potentially contributing to allostatic load, may facilitate a broader understanding of the multidimensional presentations of many people with pain, both acute and persistent. This may facilitate discussion between clinicians and their patients regarding broader influences on their presentations and drive more targeted and inclusive pain management strategies.

Hippocampal volume, FKBP5 genetic risk alleles, and childhood trauma interact to increase vulnerability to chronic multisite musculoskeletal pain

Chronic multisite musculoskeletal pain (CMP) is common and highly morbid. However, vulnerability factors for CMP are poorly understood. Previous studies have independently shown that both small hippocampal brain volume and genetic risk alleles in a key stress system gene, FKBP5, increase vulnerability for chronic pain. However, little is known regarding the relationship between these factors and CMP. Here we tested the hypothesis that both small hippocampal brain volume and FKBP5 genetic risk, assessed using the tagging risk variant, FKBP5rs3800373, increase vulnerability for CMP. We used participant data from 36,822 individuals with available genetic, neuroimaging, and chronic pain data in the UK Biobank study. Although no main effects were observed, the interaction between FKBP5 genetic risk and right hippocampal volume was associated with CMP severity (β = -0.020, praw = 0.002, padj = 0.01). In secondary analyses, severity of childhood trauma further moderated the relationship between FKBP5 genetic risk, right hippocampal brain volume, and CMP (β = -0.081, p = 0.016). This study provides novel evidence that both FKBP5 genetic risk and childhood trauma moderate the relationship between right hippocampal brain volume and CMP. The data increases our understanding of vulnerability factors for CMP and builds a foundation for further work assessing causal relationships that might drive CMP development.

The impact of COVID-19 on patients with chronic pain seeking care at a tertiary pain clinic

Empirical data on the health impacts of the COVID-19 pandemic remain scarce, especially among patients with chronic pain. We conducted a cross-sectional study matched by season to examine patient-reported health symptoms among patients with chronic pain pre- and post-COVID-19 pandemic onset. Survey responses were analyzed from 7535 patients during their initial visit at a tertiary pain clinic between April 2017-October 2020. Surveys included measures of pain and pain-related physical, emotional, and social function. The post-COVID-19 onset cohort included 1798 initial evaluations, and the control pre-COVID-19 cohort included 5737 initial evaluations. Patients were majority female, White/Caucasian, and middle-aged. The results indicated that pain ratings remained unchanged among patients after the pandemic onset. However, pain catastrophizing scores were elevated when COVID-19 cases peaked in July 2020. Pain interference, physical function, sleep impairment, and emotional support were improved in the post-COVID-19 cohort. Depression, anxiety, anger, and social isolation remained unchanged. Our findings provide evidence of encouraging resilience among patients seeking treatment for pain conditions in the face of the COVID-19 pandemic. However, our findings that pain catastrophizing increased when COVID-19 cases peaked in July 2020 suggests that future monitoring and consideration of the impacts of the pandemic on patients' pain is warranted.

Multisite musculoskeletal pain in the general population: a cross-sectional survey

BACKGROUND

Epidemiological studies focusing on multisite musculoskeletal pain have revealed that the prevalence of multisite pain is high in general populations.

OBJECTIVE

To ascertain the prevalence of multisite musculoskeletal pain in the last 12 months and in the last seven days, in a population-based sample and investigate its association with demographic, socioeconomic, behavioral, reported morbidity and ergonomic variables.

DESIGN AND SETTING

Cross-sectional population-based survey in Bauru, São Paulo (Brazil).

METHODS

600 individuals were interviewed. The following data were collected: participants' characteristics, through a precoded questionnaire; physical activity level, through the International Physical Activity Questionnaire; and musculoskeletal symptoms, through the Nordic questionnaire. Descriptive, bivariate and Poisson regression analyses were performed.

RESULTS

The prevalence of multisite musculoskeletal pain was 46.5% (confidence interval, CI 42.5 to 50.5) in the last 12 months and 26.1% (CI 22.8 to 29.8) in the last seven days. The variables associated with multisite pain in the last 12 months were female sex, presence of hypertension, diabetes mellitus or depression, watching TV more than three times a week and working in a seated position. Formerly smoking was a protection factor. The variables associated with multisite pain in the last seven days were female sex, age group 60 years and over, low income, presence of comorbidities of hypertension, diabetes mellitus or depression and working in a seated position.

CONCLUSION

There was high prevalence of multisite musculoskeletal pain, which was associated with demographic, socioeconomic, work-related, electronic device-related and reported morbidity variables.

Characterization of chronic overlapping pain conditions in patients with chronic migraine: A CHOIR study

OBJECTIVE

Chronic overlapping pain conditions (COPCs) represent a co-aggregation of widespread pain disorders. We characterized differences in physical and psychosocial functioning in patients with chronic migraine (CM) and those with CM and COPCs.

BACKGROUND

Patients with CM and COPCs have been identified as a distinct subgroup of patients with CM, and these patients may be vulnerable to greater symptom severity and burden.

METHODS

Data were extracted from Collaborative Health Outcomes Information Registry (an open-source learning health-care system), completed at the patients' first visit at a large tertiary care pain management center and electronic medical records. In 1601 patients with CM, the number of non-cephalic areas of pain endorsed on a body map was used to examine the differences in pain, physical and psychosocial function, adverse life experience, and health-care utilization.

RESULTS

Patients endorsing more body map regions reported significantly worse symptoms and function across all domains. Scored on a t-score metric (mean = 50, SD = 10), endorsement of one additional body map region corresponded with a 0.69-point increase in pain interference (95% CI = 0.55, 0.82; p < 0.001; Cohen's f = 0.328), 1.15-point increase in fatigue (95% CI = 0.97, 1.32; p < 0.001; Cohen's f = 0.432), and 1.21-point decrease in physical function (95% CI = -1.39, -1.03; p < 0.001; Cohen's f = 0.560). Patients with more widespread pain reported approximately 5% more physician visits (95% CI = 0.03, 0.07; p < 0.001), and patients reporting adverse life events prior to age 17 endorsed 22% more body map regions (95% CI = 0.11, 0.32; p < 0.001).

CONCLUSIONS

Patients with CM and other overlapping pain conditions as noted on the body map report significantly worse pain-related physical function, psychosocial functioning, increased health-care utilization, and greater association with adverse life experiences, compared with those with localized CM. This study provides further evidence that patients with CM and co-occurring pain conditions are a distinct subgroup of CM and can be easily identified through patient-reported outcome measures.

The impact of Covid-19-related distress on general health, oral behaviour, psychosocial features, disability and pain intensity in a cohort of Italian patients with temporomandibular disorders

This study aimed to understand the impact of COVID-19 distress on psychological status, features of central sensitization and facial pain severity in people with temporomandibular disorders (TMDs). In this prospective cohort study, 45 adults (19 chronic, 26 acute/subacute TMD) were recruited prior to the COVID-19 outbreak. Baseline assessment took place before the outbreak while a follow-up was performed immediately after the lockdown period. Multiple variables were investigated including age, gender, perceived life quality, sleep quality, anxiety and depression, coping strategies, central sensitization, pain intensity, pain-related disability and oral behaviour. COVID Stress Scales (CSS) were applied at follow-up to measure the extent of COVID-related distress. CSS were significantly higher in those with chronic TMDs compared to those with acute/subacute TMDs (p<0.05). In people with chronic TMD, the variation in anxiety and depression from baseline to follow-up was significantly correlated with scores on the CSS (r = 0.72; p = 0.002). Variations of the central sensitization inventory (r = 0.57; p = 0.020) and graded chronic pain scale (r = 0.59; p = 0.017) were significantly correlated with scores on the CSS. These initial findings indicate that people with chronic TMD were more susceptible to COVID-19 distress with deterioration of psychological status, worsening features of central sensitization and increased chronic facial pain severity. These findings reinforce the role of stress as a possible amplifier of central sensitization, anxiety, depression, chronic pain and pain-related disability in people with TMDs. Trial Registration: ClinicalTrials.gov ID: NCT03990662.

Relationships Between Pain, Life Stress, Sociodemographics, and Cortisol: Contributions of Pain Intensity and Financial Satisfaction

Objective

The relationship between psychosocial stress and chronic pain is bidirectional. An improved understanding regarding the relationships among chronic pain, life stress, and ethnicity/race will inform identification of factors contributing to health disparities in chronic pain and improve health outcomes. This study aims to assess relationships between measures of clinical pain, life stress, sociodemographics, and salivary cortisol levels.

Methods

A cross-sectional analysis involving data from 105 non-Hispanic White (NHW) and non-Hispanic Black (NHB) participants aged 45–85 years old with or at risk for knee osteoarthritis. Data included sociodemographics, clinical pain, psychosocial stress, and salivary cortisol across five time points over an approximate 12-hour period. Non-parametric correlation analysis, sociodemographic group comparisons, and regression analyses were performed.

Results

Clinical pain and psychosocial stress were associated with salivary cortisol levels, particularly morning waking and the evening to morning awakening slope. With the inclusion of recognized explanatory variables, the Graded Chronic Pain Scale characteristic pain intensity and financial satisfaction were identified as the primary pain and psychosocial measures associated with cortisol levels. Sociodemographic group differences were indicated such that NHB participants reported higher pain-related disability, higher levels of discrimination, lower financial and material satisfaction, and showed higher evening salivary cortisol levels compared to NHW participants. In combined pain and psychosocial stress analyses, greater financial satisfaction, lower pain intensity, and lower depression were associated with higher morning waking saliva cortisol levels while greater financial satisfaction was the only variable associated with greater evening to morning awakening slope.

Conclusion

Our findings show relationships among clinical pain, psychosocial stress, sociodemographic factors, and salivary cortisol levels. Importantly, with inclusion of recognized explanatory variables, financial satisfaction remained the primary factor accounting for differences in morning waking cortisol and evening to morning awakening cortisol slope in an ethnic/racially diverse group of middle aged and older adults with or at risk for knee osteoarthritis.

Psychological Therapy for Centralized Pain: An Integrative Assessment and Treatment Model

OBJECTIVE

Chronic pain is a significant health problem that is increasing in prevalence, and advances in treatment are needed.

METHODS

We briefly review the leading evidence-based psychological therapies for chronic pain-cognitive-behavioral and acceptance/mindfulness-based therapies-and examine several limitations and missing perspectives of these approaches. We review six lesser-known interventions that address these limitations, and we describe our integrative model for psychological assessment and treatment of centralized pain. We present a typical patient and describe how we apply this approach, along with challenges to its implementation and possible solutions to these challenges.

RESULTS

Greater pain treatment efficacy may be possible if clinicians: (a) distinguish patients with primarily centralized (i.e., somatoform or nociplastic) pain from those with primarily peripheral (nociceptive, inflammatory, or neuropathic) pain; (b) acknowledge the capacity of the brain not only to modulate pain but also generate as well as attenuate or eliminate centralized pain; (c) consider the powerful role that adverse life experiences and psychological conflicts play in centralized pain; and (d) integrate emotional processing and interpersonal changes into treatment. Our integrative treatment involves delivering a progression of interventions, as needed, to achieve pain reduction: tailored pain neuroscience education, cognitive and mindfulness skills to decrease the pain danger alarm mechanism, behavioral engagement in avoided painful and other feared activities, emotional awareness and expression to reverse emotional avoidance and overcome trauma or psychological conflict, and adaptive communication to decrease interpersonal stress.

CONCLUSIONS

This integrative assessment and treatment model has the potential to substantially reduce and sometimes eliminate centralized pain by changing the cognitive, behavioral, emotional, and interpersonal processes that trigger and maintain centralized pain.

The Physical and the Emotional: Case Report, Mixed-Methods Development, and Discussion

There is a growing recognition that emotional problems are important to physical health outcomes. In response, primary care clinics have introduced self-report checklists to identify patients with emotional disorders such as depression or anxiety. Yet psychodynamic theory posits that certain emotional problems may be unconscious and unspoken, and thus not discernible on self-report checklists, and studies show that checklists do not identify every patient who needs treatment. New clinical tools are needed to identify subtle and complex presentations. We aimed to develop an innovative mixed-methods approach characterizing different types of verbal expression of feelings, drawing on psychodynamic theory and empirical research. We outline the development of the mixed-methods approach, including our theoretical framework and use of semi-structured interview data from Partners in Care (PIC), a randomized controlled trial of quality improvement for depression. We then illustrate the approach with one case: an older female PIC participant who screened positive for depression on all study self-reports. The approach delineates three qualitatively different categories of words-specific feeling words, vague feeling words, and physical words-that were quantified to define a measurable pattern for our participant. Clinicians could be trained to identify these categories of words in the context of a discussion of feelings to better detect and understand subtle emotional problems in patients who have difficulty talking openly about their feelings. Next steps include furthering face and construct validity and test-retest reliability, examining the prevalence of these patterns in a larger sample, and assessing correlates of patterns.

Emotional Awareness and Expression Therapy for Chronic Pain: Rationale, Principles and Techniques, Evidence, and Critical Review

PURPOSE OF REVIEW

Patients with chronic pain, especially primary or centralized pain, have elevated rates of psychosocial trauma and intrapersonal or intrapsychic conflict. To address these risk factors and potentially reduce pain, the authors developed emotional awareness and expression therapy (EAET). This article presents the rationale for EAET, describes its principles and techniques, reviews its development and early testing as well as recent clinical trials, and critically analyzes the evidence base.

RECENT FINDINGS

Four initial trials (between 2006 and 2011) demonstrated the efficacy of earlier versions of EAET. Four recent randomized, controlled trials of different EAET durations (1 to 8 sessions) and formats (individual or group) in patients with fibromyalgia, irritable bowel syndrome, pelvic pain, or medically unexplained symptoms support the earlier findings. EAET reliably reduces pain and interference, although improvements in anxiety and depression are less reliably achieved and may be delayed. The largest and best conducted trial found superiority of EAET over cognitive-behavioral therapy for fibromyalgia. Patient retention in EAET is high, and adverse events are rare. EAET merits inclusion as a treatment option for primary pain conditions, and it may be the preferred treatment for some patients. Research is needed on EAET with other pain conditions and samples, using better controls and comparison conditions, and on additional ways to motivate and help patients engage in successful emotional processing.

The management of post-traumatic stress disorder and associated pain and sleep disturbance in refugees

More than 68 million people worldwide have been forcibly displaced and one-third of these are refugees. This article offers an overview of the current literature and reviews the epidemiology and evidence-based psychological and pharmacological management of post-traumatic stress disorder (PTSD), sleep disturbance and pain in refugees and asylum seekers. It also considers the relationship between sleep disturbance and PTSD and explores concepts of pain in relation to physical and psychological trauma and distress. During diagnosis, clinicians must be aware of ethnic variation in the somatic expression of distress. Treatments for PTSD, pain and sleep disturbance among refugees and asylum seekers are essentially the same as those used in the general population, but treatment strategies must allow for cultural and contextual factors, including language barriers, loss of freedom and threat of repatriation.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Phenotypic Characterization of Paclitaxel-Induced Peripheral Neuropathy in Cancer Survivors

CONTEXT

Although paclitaxel is one of the most commonly used drugs to treat breast, ovarian, and lung cancers, little is known about the impact of paclitaxel-induced peripheral neuropathy (PIPN) on cancer survivors.

OBJECTIVES

The purposes of this study were to evaluate for differences in demographic and clinical characteristics as well as measures of sensation, balance, upper extremity function, perceived stress, symptom burden, and quality of life (QOL) between survivors who received paclitaxel and did (n = 153) and did not (n = 58) develop PIPN.

METHODS

Pain characteristics associated with PIPN are described in detail. Both subjective and objective measures were used to evaluate the impact of PIPN.

RESULTS

Survivors with PIPN were significantly older, had a higher body mass index, and a worse comorbidity profile. The duration of PIPN was almost four years, and pain scores were in the moderate range. Compared with survivors without PIPN, survivors with PIPN had a higher number of upper and lower extremity sites that had lost light touch, cold, and pain sensations. Survivors with PIPN had worse upper extremity function, more problems with balance, a higher symptom burden, and higher levels of perceived stress. In addition, survivors with PIPN had worse QOL scores particularly in the domain of physical functioning.

CONCLUSION

The findings from this large descriptive study are the first to document the impact of PIPN on survivors' symptom burden, functional status, and QOL.

The association between multisite musculoskeletal pain and cardiac autonomic modulation during work, leisure and sleep - a cross-sectional study

Background

The prevention and rehabilitation of multisite musculoskeletal pain would benefit from studies aiming to understand its underlying mechanism. Autonomic imbalance is a suggested mechanism for multisite pain, but hardly been studied during normal daily living. Therefore, the aim of the study is to investigate the association between multisite musculoskeletal pain and cardiac autonomic modulation during work, leisure and sleep.

Methods

This study is based on data from the “Danish Physical activity cohort with objective measurements” among 568 blue-collar workers. Pain intensity scales were dichotomized according to the median of each scale, and the number of pain sites was calculated. No site was regarded as the pain-free, one site was considered as single-site musculoskeletal pain and pain in two or more sites was regarded as multisite musculoskeletal pain. Heart rate variability (HRV) was measured by an electrocardiogram system (ActiHeart) and physical activity using accelerometers (Actigraph). Crude and adjusted linear mixed models were applied to investigate the association between groups and cardiac autonomic regulation during work, leisure and sleep.

Results

There was no significant difference between groups and no significant interaction between groups and domains in the crude or adjusted models for any HRV index. Significant differences between domains were found in the crude and adjusted model for all indices, except SDNN; sleep time showed higher values than leisure and work time, except for LF and LF/HF, which were higher during work.

Conclusion

This cross-sectional study showed that multisite musculoskeletal pain is not associated with imbalanced cardiac autonomic regulation during work, leisure and sleep time.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2312-3) contains supplementary material, which is available to authorized users.

Associations Between Perceived Stress and Chemotherapy-Induced Peripheral Neuropathy and Otoxicity in Adult Cancer Survivors

CONTEXT

The most common adverse effects from neurotoxic chemotherapy are chemotherapy-induced neuropathy (CIPN), hearing loss, and tinnitus. Although associations between perceived stress and persistent pain, hearing loss, and tinnitus are documented, no studies have examined these associations in cancer survivors who received neurotoxic chemotherapy.

OBJECTIVES

In this cross-sectional study, we evaluated for associations between perceived stress and the occurrence of CIPN, hearing loss, and tinnitus, in 623 adult cancer survivors who received platinum and/or taxane compounds.

METHODS

Survivors completed self-report measures of hearing loss, tinnitus, and perceived stress (i.e., Impact of Events Scale-Revised [IES-R]). Separate logistic regression analyses were done for each neurotoxicity to evaluate whether each of the IES-R subscale (i.e., intrusion, avoidance, hyperarousal) and total scores made a significant independent contribution to neurotoxicity group membership.

RESULTS

Of the 623 survivors in this study, 68.4% had CIPN, 34.5% reported hearing loss, and 31.0% reported tinnitus. Older age, higher body mass index, poorer functional status, being born prematurely, cancer diagnosis, and higher intrusion (P = 0.013), hyperarousal (P = 0.014), and total (P = 0.047) IES-R scores were associated with CIPN. Older age, being male, poorer functional status, a worse comorbidity profile, and a higher IES-R hyperarousal (P = 0.007) score were associated with hearing loss. Being male, having less education, a worse comorbidity profile, and a higher IES-R hyperarousal (P = 0.029) score were associated with tinnitus.

CONCLUSION

These findings suggest that increased levels of perceived stress are associated with the most common chemotherapy-induced neurotoxicities.

Brazilian cross-cultural adaptation and validation of the List of Threatening Events Questionnaire (LTE-Q)

Objective:

To perform a construct validation of the List of Threatening Events Questionnaire (LTE-Q), as well as convergence validation by identifying its association with drug use in a sample of the Brazilian population.

Methods:

This is a secondary analysis of the Second Brazilian National Alcohol and Drugs Survey (II BNADS), which used a cross-cultural adaptation of the LTE-Q in a probabilistic sample of 4,607 participants aged 14 years and older. Latent class analysis was used to validate the latent trait adversity (which considered the number of events from the list of 12 item in the LTE experienced by the respondent in the previous year) and logistic regression was performed to find its association with binge drinking and cocaine use.

Results:

The confirmatory factor analysis returned a chi-square of 108.341, weighted root mean square residual (WRMR) of 1.240, confirmatory fit indices (CFI) of 0.970, Tucker-Lewis index (TLI) of 0.962, and root mean square error approximation (RMSEA) score of 1.000. LTE-Q convergence validation showed that the adversity latent trait increased the chances of binge drinking by 1.31 time and doubled the chances of previous year cocaine use (adjusted by sociodemographic variables).

Conclusion:

The use of the LTE-Q in Brazil should be encouraged in different research fields, including large epidemiological surveys, as it is also appropriate when time and budget are limited. The LTE-Q can be a useful tool in the development of targeted and more efficient prevention strategies.

Chronic pain, depression and cardiovascular disease linked through a shared genetic predisposition: Analysis of a family-based cohort and twin study

BACKGROUND

Depression and chronic pain are the two most important causes of disability (Global Burden of Disease Study 2013). They occur together more frequently than expected and both conditions have been shown to be co-morbid with cardiovascular disease. Although shared socio-demographic risk factors (e.g. gender, deprivation) might explain the co-morbidity of these three conditions, we hypothesised that these three long-term, highly prevalent conditions co-occur and may be due to shared familial risk, and/or genetic factors.

METHODS AND FINDINGS

We employed three different study designs in two independent cohorts, namely Generation Scotland and TwinsUK, having standardised, validated questionnaire data on the three traits of interest. First, we estimated the prevalence and co-occurrence of chronic pain, depression and angina among 24,024 participants of a population-based cohort of extended families (Generation Scotland: Scottish Family Health Study), adjusting for age, gender, education, smoking status, and deprivation. Secondly, we compared the odds of co-morbidity in sibling-pairs with the odds in unrelated individuals for the three conditions in the same cohort. Lastly, examination of similar traits in a sample of female twins (TwinsUK, n = 2,902), adjusting for age and BMI, allowed independent replication of the findings and exploration of the influence of additive genetic (A) factors and shared (C) and non-shared (E) environmental factors predisposing to co-occurring chronic widespread pain (CWP) and cardiovascular disease (hypertension, angina, stroke, heart attack, elevated cholesterol, angioplasty or bypass surgery). In the Generation Scotland cohort, individuals with depression were more than twice as likely to have chronic pain as those without depression (adjusted OR 2·64 [95% CI 2·34-2·97]); those with angina were four times more likely to have chronic pain (OR 4·19 [3·64-4·82]); those with depression were twice as likely to have angina (OR 2·20 [1·90-2·54]). Similar odds were obtained when the outcomes and predictors were reversed and similar effects seen among sibling pairs; depression in one sibling predicted chronic pain in the other (OR 1·34 [1·05-1·71]), angina predicted chronic pain in the other (OR 2·19 [1·63-2·95]), and depression, angina (OR 1·98 [1·49-2·65]). Individuals with chronic pain and angina showed almost four-fold greater odds of depression compared with those manifesting neither trait (OR 3·78 [2·99-4·78]); angina showed seven-fold increased odds in the presence of chronic pain and depression (OR 7·76 [6·05-9·95]) and chronic pain nine-fold in the presence of depression and angina (OR 9·43 [6·85-12·98]). In TwinsUK, the relationship between CWP and depression has been published (R = 0.34, p<0.01). Considering the CWP-cardiovascular relationship, the most suitable model to describe the observed data was a combination of A, C and E, with a small but significant genetic predisposition, shared between the two traits (2·2% [95% CI 0·06-0·23]).

CONCLUSION

We found an increased co-occurrence of chronic pain, depression and cardiovascular disease in two independent cohorts (general population-based cohort, twins cohort) suggesting a shared genetic contribution. Adjustment for known environmental influences, particularly those relating to socio-economic status (Generation Scotland: age, gender, deprivation, smoking, education; Twins UK: age,BMI) did not explain the relationship observed between chronic pain, depression and cardiovascular disease. Our findings from two independent cohorts challenge the concept of traditional disease boundaries and warrant further investigation of shared biological mechanisms.

Discordance between tender and swollen joint count as well as patient's and evaluator's global assessment may reduce likelihood of remission in patients with rheumatoid arthritis and psoriatic arthritis: data from the prospective multicentre NOR-DMARD study

Objective

To investigate the predictive value of discordance between (1) tender and swollen joint count and (2) patient's and evaluator's global assessment on remission in patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA).

Methods

From the prospective, multicentre Norwegian-Disease-Modifying Antirheumatic Drug study, we included patients with RA and PsA starting first-time tumour necrosis factor inhibitors and DMARD-naïve patients starting methotrexate between 2000 and 2012. The predictive value of ΔTSJ (tender minus swollen joint counts) and ΔPEG (patient's minus evaluator's global assessment) on remission was explored in prespecified logistic regression models adjusted for age, sex, disease duration and smoking.

Results

A total of 2735 patients with RA and 1236 patients with PsA were included (mean (SD) age 55.0 (13.5)/48.3 (12.4) years, median(range) disease duration 0.7 (0.0–58.0)/1.3 (0.0–48.3) years, 69.7/48.4% females). Baseline ΔTSJ/ΔPEG reduced the likelihood of achieving DAS28<2.6, SDAI≤3.3, CDAI≤2.8, ACR/EULAR Boolean and DAPSA<4 remission after 3 and 6 months in RA (OR 0.95–0.97, p<0.001/OR 0.96–0.99, p≤0.01) and PsA (OR 0.91–0.94, p≤0.004/OR 0.89–0.99, p≤0.002), except for ΔPEG and 6-month DAS28 remission in PsA.

Conclusions

Discordance between patient's and physician's evaluation of disease activity reflected through ΔTSJ and partly ΔPEG may reduce likelihood of remission in RA and PsA. The findings are relevant for use of the treat-to-target strategy in individual patients.

The brain-derived neurotrophic factor pathway, life stress, and chronic multi-site musculoskeletal pain

Introduction

Brain-derived neurotrophic factor (BDNF) disturbances and life stress, both independently and in interaction, have been hypothesized to induce chronic pain. We examined whether (a) the BDNF pathway (val⁶⁶met genotype, gene expression, and serum levels), (b) early and recent life stress, and (c) their interaction are associated with the presence and severity of chronic multi-site musculoskeletal pain.

Methods

Cross-sectional data are from 1646 subjects of the Netherlands Study of Depression and Anxiety. The presence and severity of chronic multi-site musculoskeletal pain were determined using the Chronic Pain Grade (CPG) questionnaire. The BDNF val⁶⁶met polymorphism, BDNF gene expression, and BDNF serum levels were measured. Early life stress before the age of 16 was assessed by calculating a childhood trauma index using the Childhood Trauma Interview. Recent life stress was assessed as the number of recent adverse life events using the List of Threatening Events Questionnaire.

Results

Compared to val⁶⁶val, BDNF met carriers more often had chronic pain, whereas no differences were found for BDNF gene expression and serum levels. Higher levels of early and recent stress were both associated with the presence and severity of chronic pain (p < 0.001). No interaction effect was found for the BDNF pathway with life stress in the associations with chronic pain presence and severity.

Conclusions

This study suggests that the BDNF gene marks vulnerability for chronic pain. Although life stress did not alter the impact of BDNF on chronic pain, it seems an independent factor in the onset and persistence of chronic pain.

A low cortisol response to stress is associated with musculoskeletal pain combined with increased pain sensitivity in young adults: a longitudinal cohort study

Background

In this study, we investigated whether an abnormal hypothalamic-pituitary-adrenal (HPA) axis response to psychosocial stress at 18 years of age is associated with musculoskeletal (MS) pain alone and MS pain combined with increased pain sensitivity at 22 years of age.

Methods

The study sample included 805 participants from the Western Australian Pregnancy Cohort (Raine) Study who participated in the Trier Social Stress Test (TSST) at age 18 years. Number of pain sites, pain duration, pain intensity and pain frequency were assessed at age 22 to measure severity of MS pain. Cold and pressure pain thresholds were determined at age 22. Group-based trajectory modeling was applied to establish cortisol response patterns based on the TSST. Logistic regression was used to study the association of TSST patterns with MS pain alone and MS pain combined with increased cold or pressure pain sensitivity, adjusted for relevant confounding factors. All analyses were stratified by sex.

Results

The mean (standard deviation) age during the TSST was 18.3 (0.3) years, and during MS pain assessment it was 22.2 (0.6). Forty-five percent of the participants were female. Three cortisol response patterns were identified, with cluster 1 (34 % of females, 21 % of males) reflecting hyporesponse, cluster 2 (47 %, 54 %) reflecting intermediate response and cluster 3 (18 %, 24 %) reflecting hyperresponse of the HPA axis. MS pain was reported by 42 % of females and 33 % of males at age 22 years. Compared with females in cluster 2, females in cluster 1 had an increased likelihood of having any MS pain (odds ratio 2.3, 95 % confidence interval 1.0–5.0) and more severe MS pain (2.8, 1.1–6.8) if their cold pain threshold was above the median. In addition, females in cluster 1 had an increased likelihood (3.5, 1.3–9.7) of having more severe MS pain if their pressure pain threshold was below the median. No statistically significant associations were observed in males.

Conclusions

This study suggests that a hyporesponsive HPA axis at age 18 years is associated with MS pain at 22 years in young females with increased pain sensitivity.