The importance of psychosocial influences on chronic pain

Unveiling relevant emotions, cognitions, and behaviours from the viewpoint of people with chronic low back pain: A qualitative study with patient involvement

OBJECTIVE

To gain insight into the emotions, cognitions, and behaviours experienced by people with chronic low back pain (CLBP) undergoing invasive treatment in a pain unit.

DESIGN

A cross-sectional qualitative study based on individual interviews. This study included patient involvement in its design and development.

METHODS

An interpretative phenomenological approach was adopted to understand the multidimensional experience of patients. The interview script was a translated, adapted, and expanded version of the one proposed by Cognitive and Functional Therapy. A mixed coding method was applied to structure the interviews. Three themes were created, with the three most frequently reported emotions, cognitions, and behaviours as subthemes. A patient with CLBP approved the initial protocol and the aim of the study. Subsequently, the patient contributed questions to the interview script, checked the coding process, and approved the final version of the manuscript.

RESULTS

Twenty-two patients undergoing epidural infiltrations in a pain unit were interviewed. (i)"Fears", (ii)"Frustration", and (iii)"Worry" were the three most commonly expressed emotions. Cognitions related to (i)"Pain predictability", (ii)"Pain description and perception", and (iii)"Pain interference/disability" were also widely reported. The theme "Behaviours" was composed of the following subthemes: (i)"Strategies for managing symptoms", (ii)"Social behaviours", and (iii)"Strategies for coping with daily tasks". Noteworthily, cognitions related to the (i)"Diagnosis", (ii)"Health system attention", and (iii)"Medical prescriptions" arose from questions provided by patient involvement.

CONCLUSION

Patients with CLBP expressed a wide variety of emotions, cognitions, and behaviours that must be considered by health professionals with the goal of providing the best patient-centred care.

Probiotic and high-fat diet: effects on pain assessment, body composition, and cytokines in male and female adolescent and adult rats

Obesity in adolescence is increasing in frequency and is associated with elevated proinflammatory cytokines and chronic pain in a sex-dependent manner. Dietary probiotics may mitigate these detrimental effects of obesity. Using a Long-Evans adolescent and adult rat model of overweight (high-fat diet (HFD) - 45% kcal from fat from weaning), we determined the effect of a single-strain dietary probiotic [Lactiplantibacillus plantarum 299v (Lp299v) from weaning] on the theoretically increased neuropathic injury-induced pain phenotype and inflammatory cytokines. We found that although HFD increased fat mass, it did not markedly affect pain phenotype, particularly in adolescence, but there were subtle differences in pain in adult male versus female rats. The combination of HFD and Lp299v augmented the increase in leptin in adolescent females. There were many noninteracting main effects of age, diet, and probiotic on an array of cytokines and adipokines with adults being higher than adolescents, HFD higher than the control diet, and a decrease with probiotic compared with placebo. Of particular interest were the probiotic-induced increases in IL12p70 in female adolescents on an HFD. We conclude that a more striking pain phenotype could require a higher and longer duration caloric diet or a different etiology of pain. A major strength of our study was that a single-strain probiotic had a wide range of inhibiting effects on most proinflammatory cytokines. The positive effect of the probiotic on leptin in female adolescent rats is intriguing and worthy of exploration.NEW & NOTEWORTHY A single-strain probiotic (Lp299v) had a wide range of inhibiting effects on most proinflammatory cytokines (especially IL12p70) measured in this high-fat diet rat model of mild obesity. The positive effect of probiotic on leptin in female adolescent rats is intriguing and worthy of exploration.

Can the Assessment of the Circadian Rhythm of Pain Be Shortened? A Study of Community-Dwelling Participants with Chronic Pain

Purpose

This study aimed to juxtapose the circadian rhythm of pain with the conventional 7-day assessment and ascertain the feasibility of condensing the evaluation of the circadian rhythm of pain into a 3-day timeframe.

Patients and Methods

Seventy-three patients with pain persisting for a minimum of 3 months and a numerical rating scale (NRS) score of ≥2 were recruited from three medical centers. The circadian patterns of pain were appraised over a 7-day period by quantifying the intensity of pain at six temporal junctures each day using a 10-cm visual analog scale (VAS). Cluster analysis was performed using six standardized variables derived from the VAS score of each participant at six designated time points to identify cohorts with analogous circadian rhythms of pain. The clusters were discerned for the 7- and 3-day assessments (Tuesday-Thursday, Friday-Sunday, and Sunday-Tuesday), according to the research objectives. Cohen's kappa coefficient was calculated to gauge the intra-observer variability to assess the consistency between the outcomes of the cluster analysis for the 7-day assessment and each of the 3-day assessments.

Results

The highest Cohen's kappa coefficient was observed for the 3-day evaluation spanning from Friday to Sunday, indicating a substantial concordance with the results of the 7-day assessment.

Conclusion

Our results suggest that it may be prudent to consider implementing a condensed 3-day evaluation of the circadian rhythm of pain that is tailored to individual characteristics. This approach will allow a better understanding of the diurnal rhythms of chronic pain in patients and implement more targeted and specific pain management strategies. Furthermore, it will contribute to increased patient satisfaction through early intervention.

Parent-perceived recurrent pain in children: associations with maternal pain, depressiveness, socioeconomic status, and children's behavioural difficulties

Objectives

The current study aimed to examine the potential transgenerational associations between maternal pain and depressiveness and childhood pain, and to explore the associations between the children's difficulties and recurrent pain (defined as pain occurring at least once a month in the previous 6 month) in healthy children aged 3-13 years.

Methods

We collected Data between 2015 and 2019 as part of the LIFE Child study in Germany and investigated associations of maternal pain and depressiveness, child age, sex, pubertal stage, emotional difficulties, conduct difficulties, hyperactivity/inattention, peer group difficulties, and prosocial skills, and family socioeconomic status with the frequency of parent-perceived headache, backache, and stomachache in a sample of 1,850 children (4,819 documented visits) using logistic and ordinal regression analyses.

Results

Overall, 10.4%, 24.4%, and 45.2% of parents reported their children had recurrent backache, headache, and stomachache, respectively, with 5.5% of children were reported to experience all three types of pain simultaneously. Higher age, female sex, puberty, emotional difficulties, low family socioeconomic status, as well as higher maternal impairment due to pain and maternal depressiveness were significantly associated with more frequent pain.

Conclusions

Our study suggests that maternal pain, maternal depressiveness, and lower family socioeconomic status as well as child's emotional difficulties are significantly associated with a higher frequency of recurrent pain in children perceived by their parents.

Impact of Environment on Pain among the Working Poor: Making Use of Random Forest-Based Stratification Tool to Study the Socioecology of Pain Interference

Pain interferes with one's work and social life and, at a personal level, daily activities, mood, and sleep quality. However, little research has been conducted on pain interference and its socioecological determinants among the working poor. Noting the clinical/policy decision needs and the technical challenges of isolating the intricately interrelated socioecological factors' unique contributions to pain interference and quantifying the relative contributions of each factor in an interpretable manner to inform clinical and policy decision-making, we deployed a novel random forest algorithm to model and quantify the unique contribution of a diverse ensemble of environmental, sociodemographic, and clinical factors to pain interference. Our analyses revealed that features representing the internal built environment of the working poor, such as the size of the living space, air quality, access to light, architectural design conducive to social connection, and age of the building, were assigned greater statistical importance than other more commonly examined predisposing factors for pain interference, such as age, occupation, the severity and locations of pain, BMI, serum blood sugar, and blood pressure. The findings were discussed in the context of their benefit in informing community pain screening to target residential areas whose built environment contributed most to pain interference and informing the design of intervention programs to minimize pain interference among those who suffered from chronic pain and showed specific characteristics. The findings support the call for good architecture to provide the spirit and value of buildings in city development.

Different logics of pain: the gendered dimension of chronic pain in a relational setting

This study aims to increase our understanding of the gendered dimension of living with chronic pain within a relational context. The empirical setting for this study is Sweden, a country widely recognised for its long history of gender equality. Interview responses from 21 women and 12 men were analysed using the feminist notion of the marriage contract, outlining the terms for women and men living together in a relationship. The result shows how living with chronic pain leads to processes of grief and altered priorities. Respondents emphasize the importance of equality. However, men and women apply different logics when deciding which tasks to prioritise. Although there is no distinct pattern regarding whether or not couples share housework equally, the allocation of responsibilities appears to follow a particular pattern: men tend to prioritise their rehabilitation to become good fathers, women are grateful and prioritise the family before her own well-being. The study indicates that while attitudes and the allocation of household chores may have changed in the past few decades, the marriage contract still restricts women from employment and rehabilitation.

A Qualitative Study of Psychosocial Factors in Patients With Knee Osteoarthritis: Insights Learned From an Asian Population

BACKGROUND

A patient's experience with knee osteoarthritis (OA) is influenced by many psychosocial contributors that can influence the impact of pain. Such factors are known to explain some of the discordance between objective clinical parameters and patient-reported levels of disability and treatment effectiveness. However, few data are available to help clinicians understand the psychosocial factors that apply to the world's many Asian populations. Insights gained from a qualitative study in such a population may support targeted interventions.

QUESTIONS/PURPOSES

In this qualitative study involving a group of Asian patients with knee OA in Singapore, we asked: (1) What psychologic factors contribute to patients' experiences, rehabilitation, and recovery? (2) What social factors contribute to patients' experiences, rehabilitation, and recovery?

METHODS

Semistructured interviews eliciting broad patient experiences of managing knee OA were conducted in an urban, referral-based tertiary hospital in central Singapore. Patients were recruited if they met either of the following criteria: Kellgren-Lawrence grade ≥ 3 (minimum of one knee); Knee Injury and Osteoarthritis Outcome Score ≤ 60; or the Pain average (P), interference with Enjoyment of life (E), and interference with General activity (G) (PEG) ≥ 5. All patients had a clinical diagnosis of knee OA, were ambulatory in the community with or without a walking aid, had not undergone partial arthroplasty or TKA, were prescribed nonsurgical treatment, and were conversant in either English or Mandarin. Forty-six patients (30 women and 16 men, mean age 64 years old) were recruited for this study. A thematic analysis with elements of grounded theory and framework analysis was performed using a deductive approach. Psychologic influences specific to patients' behavioral and emotional responses to pain, as well as social factors known to have an impact on the experience of managing knee OA, were identified in the interview transcripts and coded according to established factors from earlier research. An inductive thematic analysis was then applied to the remaining transcripts to identify new themes that emerged from the data. Thematic saturation was attained when study team members agreed data and thematic sufficiency were met in the 46 transcripts. The study team discussed and deemed the 46 transcripts to contain sufficient insights for a reasonably clear understanding of the codes and development of themes to answer the study's research questions.

RESULTS

Six main themes related to psychosocial influences on pain emerged. Psychologic factors were "loss of face" because of knee OA, anticipation and avoidance of pain and suffering, and a vicious cycle of negative emotional experiences. The social factors we identified were social and family support, workplace environment and employment uncertainty, and built environment (patients' ability to navigate manmade structures and facilities).

CONCLUSION

Psychosocial factors have an important impact on patients' physical, psychologic, and social functioning. Although several of our findings have been addressed previously, the phenomenon of loss of face and the wide spectrum of social and family support dynamics found in our Asian patients with knee OA were new findings. With loss of face, patients were concerned about how others would view the change in them, including movement changes because of knee OA. They appeared to associate the use of walking canes with major disability, loss of respect, and being discriminated against by others, motivating patients to "save face" by dissociating themselves from those stigmas, even at the cost of mobility and independence. An interplay of complex cultural processes (perceived social roles and contributions to family, desire to avoid burdening family, help-seeking behavior, and the preference for unsolicited social support) underpinned by the value of collectivism impacted the behaviors and choices patients exhibited.

CLINICAL RELEVANCE

With knowledge about the impact of culturally relevant psychosocial factors on the experience and outcomes of patients with knee OA, clinicians will be able to screen and actively explore these factors more effectively. Especially important themes include pain perception (paying close attention to signs of pain catastrophizing and negative affect), presence of chronic illness shame associated with a diagnosis of knee OA (including the stigma associated with using a walking aid), and level of social support received and contributions of a patient's built environment to kinesiophobia. For patients who are still working, the presence of workplace stressors and management of these stressors should also be explored. Where possible, screening tools that measure psychosocial factors such as pain catastrophizing and emotional distress can also be used as an added layer of screening in busy clinical settings.

Spirituality in Coping with Pain in Cancer Patients: A Cross-Sectional Study

Spirituality has been identified as an adaptive coping strategy and a predictor of better quality of life in cancer patients. Despite the relevance of spirituality in the health-disease process, it is noted that the assessment of the impact of spirituality in coping with pain is still incipient. The objective of this study is to assess the impact of spirituality in coping with pain in cancer patients. This quantitative cross-sectional study was carried out in a medium-sized hospital and a cancer patient support institution located in northeastern Brazil. A questionnaire with sociodemographic and clinical variables was used and the following instruments were applied: Visual Analogue Scale (VAS); Short-Form McGill Pain Questionnaire (SF-MPQ); Neuropathic Pain 4 Questions (DN4); Spiritual Wellbeing Scale (SWBS); WHOQOL Spirituality, Religiousness and Personal Beliefs (WHOQOL-SRPB). Most people with no pain had higher scores on the SWBS. Neuropathic pain was identified in 23 patients and was associated with the highest level of spirituality used as a way of coping with pain. As faith increases, pain decreases in intensity by 0.394 points. On the other hand, as inner peace increases, pain increases by 1.485 points. It is concluded that faith is a strategy for coping with pain, in particular neuropathic pain, minimizing its intensity. On the other hand, greater levels of inner peace allow to increase the awareness of the painful sensation. It is expected that these findings may be useful to integrate spirituality care in healthcare facilities as a resource for positive coping for people in the process of becoming ill, contributing to the therapeutic path and favouring a new meaning to the experience of the disease.

Heterogeneity in patterns of pain development after nerve injury in rats and the influence of sex

The genesis of neuropathic pain is complex, as sensory abnormalities may differ between patients with different or similar etiologies, suggesting mechanistic heterogeneity, a concept that is largely unexplored. Yet, data are usually grouped for analysis based on the assumption that they share the same underlying pathogenesis. Sex is a factor that may contribute to differences in pain responses. Neuropathic pain is more prevalent in female patients, but pre-clinical studies that can examine pain development in a controlled environment have typically failed to include female subjects. This study explored patterns of development of hyperalgesia-like behavior (HLB) induced by noxious mechanical stimulation in a neuropathic pain model (spared nerve injury, SNI) in both male and female rats, and autonomic dysfunction that is associated with chronic pain. HLB was analyzed across time, using both discrete mixture modeling and rules-based longitudinal clustering. Both methods identified similar groupings of hyperalgesia trajectories after SNI that were not evident when data were combined into groups by sex only. Within the same hyperalgesia development group, mixed models showed that development of HLB in females was delayed relative to males and reached a magnitude similar to or higher than males. The data also indicate that sympathetic tone (as indicated by heart rate variability) drops below pre-SNI level before or at the onset of development of HLB. This study classifies heterogeneity in individual development of HLB and identifies sexual dimorphism in the time course of development of neuropathic pain after nerve injury. Future studies addressing mechanisms underlying these differences could facilitate appropriate pain treatments.

Which Psychological Factors Are Involved in the Onset and/or Persistence of Musculoskeletal Pain? An Umbrella Review of Systematic Reviews and Meta-Analyses of Prospective Cohort Studies

OBJECTIVE

The objective of this study was to summarize the current status of knowledge about the longitudinal association between vulnerability or protective psychological factors and the onset and/or persistence of musculoskeletal (MSK) pain.

METHODS

PubMed, CINAHL, PsycINFO, PubPsych, Scopus, Web of Science, gray literature, and manual screening of references were searched from inception to June 15, 2019. Systematic reviews with or without meta-analysis that explored the longitudinal association between psychological factors and the onset and/or persistence of MSK pain were identified. The AMSTAR-2 tool was used to assess the risk of bias.

RESULTS

Fifty-nine systematic reviews that included 286 original research studies were included, with a total of 249,657 participants (127,370 with MSK pain and 122,287 without MSK pain at baseline). Overall, our results found that exposure to many psychological vulnerability factors such as depression, anxiety, psychological distress, and fear, among others, may increase the risk of the onset and persistence of MSK pain across time. In addition, our results also showed that a range of psychological factors considered to be "protective" such as self-efficacy beliefs, better mental health, active coping strategies, or favorable expectations of recovery may reduce the risk of the onset and persistence of MSK pain. However, all these systematic reviews were evaluated to have critically low confidence based on the AMSTAR-2 tool, indicating that findings from these reviews may be informative, but should be interpreted with caution.

DISCUSSION

The large number of methodological flaws found across reviews gives rise to a call to action to develop high-quality systematic reviews in this field.

Assessment and management of chronic pain

Chronic pain can have significant physical, psychological and social effects on a person's life, as well as on their families and friends. However, it is often not well-recognised or understood, which can lead to further harm. Therefore, an individualised, person-centred approach to chronic pain is essential to accurately assess pain and to develop an appropriate treatment plan. This article outlines the biomedical and psychosocial factors that can influence an individual's pain experience that should be considered as part of the assessment and management of chronic pain, and explores the assessment tools available to assist in this process. It also discusses the management options available for chronic pain, including neural blockade and analgesics, as well as non-pharmacological options such as psychological approaches, physical activity and exercise, and complementary and alternative therapies.

Reliability, Construct and Predictive Validity of the Hong Kong Chinese Orebro Musculoskeletal Pain Screening Questionnaire

Purpose The aim of this study was to evaluate the reliability, construct validity and predictive validity of the Hong Kong Chinese version of the Orebro Musculoskeletal Pain Screening Questionnaire (COMPSQ-HK). Methods The COMPSQ-HK was developed using the forward-backward translation. Internal consistency was assessed using Cronbach's alpha and test-retest reliability was examined using intraclass correlation coefficient with one-way random-effects model (ICC_1,1), minimum detectable change (MDC) and 95% limits of agreement (LoA). Construct validity was evaluated by correlating the COMPSQ-HK with the Numeric Pain Rating Scale, Roland-Morris Disability Questionnaire, Northwick Park Neck Pain Questionnaire, Tampa Scale for Kinesiophobia, and Medical Outcomes Study Short Form 12. The predictive validity was investigated using receiver operating characteristics (ROC) curve analyses with sick leave >60 days and return-to-work for ≥4 consecutive weeks as outcomes at 1 year follow-up. The areas under the curve (AUC) were calculated. Results The COMPSQ-HK was administered to 305 patients with acute/subacute low back pain and 160 patients with acute/subacute neck pain. The Cronbach's alphas and ICC_1,1 ranged from 0.83 to 0.84 and 0.81 to 0.92 respectively. The MDC were 32.1 and 21.1. The 95% LoA were -32.4 to 31.8 and -15.4 to 26.7. The Pearson r ranged from 0.333 to 0.697 in absolute value. The AUC for the ROC curve analyses ranged from 0.59 to 0.71. Conclusions The COMPSQ-HK has good internal consistency, moderate test-retest reliability, satisfactory construct validity and predictive validity as a screening tool for patients with back and neck pain at risk of chronic disability.

Masticatory sensory-motor changes after an experimental chewing test influenced by pain catastrophizing and neck-pain-related disability in patients with headache attributed to temporomandibular disorders

Background

Recent research has shown a relationship of craniomandibular disability with neck-pain-related disability has been shown. However, there is still insufficient information demonstrating the influence of neck pain and disability in the sensory-motor activity in patients with headache attributed to temporomandibular disorders (TMD). The purpose of this study was to investigate the influence of neck-pain-related disability on masticatory sensory-motor variables.

Methods

An experimental case–control study investigated 83 patients with headache attributed to TMD and 39 healthy controls. Patients were grouped according to their scores on the neck disability index (NDI) (mild and moderate neck disability). Initial assessment included the pain catastrophizing scale and the Headache Impact Test-6. The protocol consisted of baseline measurements of pressure pain thresholds (PPT) and pain-free maximum mouth opening (MMO). Individuals were asked to perform the provocation chewing test, and measurements were taken immediately after and 24 hours later. During the test, patients were assessed for subjective feelings of fatigue (VAFS) and pain intensity.

Results

VAFS was higher at 6 minutes (mean 51.7; 95% CI: 50.15-53.26) and 24 hours after (21.08; 95% CI: 18.6-23.5) for the group showing moderate neck disability compared with the mild neck disability group (6 minutes, 44.16; 95% CI 42.65-45.67/ 24 hours after, 14.3; 95% CI: 11.9-16.7) and the control group. The analysis shows a decrease in the pain-free MMO only in the group of moderate disability 24 hours after the test. PPTs of the trigeminal region decreased immediately in all groups, whereas at 24 hours, a decrease was observed in only the groups of patients. PPTs of the cervical region decreased in only the group with moderate neck disability 24 hours after the test. The strongest negative correlation was found between pain-free MMO immediately after the test and NDI in both the mild (r = −0.49) and moderate (r = −0.54) neck disability groups. VAFS was predicted by catastrophizing, explaining 17% of the variance in the moderate neck disability group and 12% in the mild neck disability group.

Conclusion

Neck-pain-related disability and pain catastrophizing have an influence on the sensory-motor variables evaluated in patients with headache attributed to TMD.