The Relationship between Cognitive and Emotional Factors and Healthcare and Medication Use in People Experiencing Pain: A Systematic Review

Indication for spinal sensitization in chronic low back pain: mechanical hyperalgesia adjacent to but not within the most painful body area

Introduction

In 85% of patients with chronic low back pain (CLBP), no specific pathoanatomical cause can be identified. Besides primary peripheral drivers within the lower back, spinal or supraspinal sensitization processes might contribute to the patients' pain.

Objectives

The present study conceptualized the most painful area (MP) of patients with nonspecific CLBP as primarily affected area and assessed signs of peripheral, spinal, and supraspinal sensitization using quantitative sensory testing (QST) in MP, a pain-free area adjacent to MP (AD), and a remote, pain-free control area (CON).

Methods

Fifty-nine patients with CLBP (51 years, SD = 16.6, 22 female patients) and 35 pain-free control participants individually matched for age, sex, and testing areas (49 years, SD = 17.5, 19 female participants) underwent a full QST protocol in MP and a reduced QST protocol assessing sensory gain in AD and CON. Quantitative sensory testing measures, except paradoxical heat sensations and dynamic mechanical allodynia (DMA), were Z-transformed to the matched control participants and tested for significance using Z-tests (α = 0.001). Paradoxical heat sensations and DMA occurrence were compared between cohorts using Fisher's exact tests (α = 0.05). The same analyses were performed with a high-pain and a low-pain CLBP subsample (50% quantile).

Results

Patients showed cold and vibration hypoesthesia in MP (all Ps < 0.001) and mechanical hyperalgesia (P < 0.001) and more frequent DMA (P = 0.044) in AD. The results were mainly driven by the high-pain CLBP subsample. In CON, no sensory alterations were observed.

Conclusion

Mechanical hyperalgesia and DMA adjacent to but not within MP, the supposedly primarily affected area, might reflect secondary hyperalgesia originating from spinal sensitization in patients with CLBP.

Pain neuroscience education improves post-traumatic stress disorder, disability, and pain self-efficacy in veterans and service members with chronic low back pain: Preliminary results from a randomized controlled trial with 12-month follow-up

Post-traumatic stress disorder (PTSD) and chronic low back pain (CLBP) are frequently co-morbid. Some research suggests that PTSD and CLBP may share common neurobiological mechanisms related to stress. Traditional biomedical education may be ineffective for PTSD and CLBP, especially when co-morbid. The purpose of this study is to determine if pain neuroscience education (PNE) is more effective than traditional education in reducing PTSD, disability, pain, and maladaptive beliefs in patients with CLBP. Participants with CLBP and possible PTSD/PTSD-symptoms were recruited for this study. Participants were randomly allocated to a PNE group or a traditional education group. The intervention included 30 minutes of education followed by a standardized exercise program once a week for 4-weeks with a 4 and 8-week follow-up and healthcare utilization assessed at 12-months. Forty-eight participants consented for this research study with 39 allocated to treatment (PNE n = 18, traditional n = 21). PNE participants were more likely to achieve a clinically meaningful reduction in PTSD symptoms and disability at short-term follow-up. At 12-months, the PNE group utilized healthcare with 76% lower costs. In participants with CLBP, PNE may reduce hypervigilance toward pain and improve PTSD symptoms. Participants who received PNE were more confident body-tissues were safe to exercise. These beliefs about pain could contribute to a decrease in perceived disability and healthcare consumption for CLBP.

Body constitutions of traditional Chinese medicine caused a significant effect on irritable bowel syndrome

BACKGROUND

According to the theory of traditional Chinese medicine (TCM), all types of body constitutions, except for the Gentleness (ie, the control group in our study), have disease susceptibility and affect the disease development process. This study attempted to investigate the relationship between TCM body constitutions and irritable bowel syndrome (IBS).

METHODS

This cross-sectional study was based on Taiwan Biobank (TWB) and collected clinical data from 13 941 subjects aged 30 to 70. The results of the study showed that subjects with Yang-deficiency (N = 3161 subjects, odds ratio [OR] = 2.654, 95% CI = 1.740-3.910), Ying-deficiency (N = 3331 subjects, OR = 1.096, 95% CI = 0.627-1.782) or Stasis (N = 2335 subjects, OR = 1.680, 95% CI = 0.654-3.520) were more likely to have IBS.

RESULTS

If the subjects with two or more TCM body constitutions: Yang-deficiency + Ying-deficiency (OR = 3.948, 95% CI = 2.742-5.560), Yang-deficiency + Stasis (OR = 2.312, 95% CI = 1.170-4.112), Ying-deficiency + Stasis (OR = 1.851, 95% CI = 0.828-3.567), or Yang-deficiency + Ying-deficiency + Stasis (OR = 3.826, 95% CI = 2.954-4.932) were also prone to IBS.

CONCLUSION

These results confirmed the high correlation between TCM body constitutions and IBS. Because the current treatment for IBS is not entirely satisfactory, integrated traditional Chinese and Western medicine might provide patients with an alternative treatment option to alleviate IBS.

Increased Stress Is Associated With Severe Pain and Decrements in Cognitive Function in Patients Receiving Chemotherapy

OBJECTIVES

Purposes were to identify subgroups of adult oncology patients (n = 1342) with distinct joint profiles of worst pain and cognitive function (CF) and evaluate for differences in demographic and clinical characteristics, as well as the severity of three distinct types of stress, resilience, and coping.

DATA SOURCES

Measures of pain and CF were evaluated six times over two cycles of chemotherapy. The other measures of demographic and clinical characteristics, stress, resilience, and coping were completed at enrollment (ie, prior to the second or third cycle of chemotherapy).

RESULTS

Using latent profile analysis, four distinct profiles were identified (ie, no pain + moderate CF [27.6%], moderate pain + high CF [22.4%] moderate pain and moderate CF [32.4%, both moderate], severe pain and low CF [17.5%, both severe]). Both moderate and both severe classes reported higher global, cancer-specific, and cumulative life stress, lower levels of resilience, and greater use of disengagement coping strategies. The Both severe class had higher occurrence rates for a number of adverse childhood experiences (ie, family violence in childhood, physical abuse at <16 years, forced sex at <16 years). Risk factors associated with membership in the two worst profiles included: being female, having a lower annual income, having a higher comorbidity burden, and having a poorer functional status.

CONCLUSION

Findings suggest that 72.4% of the patients reported pain scores in the moderate to severe range and 77.6% reported low to moderate levels of CF. Clinicians need to assess for both symptoms and various types of stress on a routine basis.

How do people with chronic pain explain their use, or non-use, of pain-related healthcare services? A qualitative study of patient experiences

PURPOSE

This study aims to explore how people with chronic pain explain their use or non-use of pain-related healthcare services and their expectations of the healthcare provider, and explore how explanations and expectations vary between different levels of pain-related healthcare use.

MATERIALS AND METHODS

We conducted 20 individual semi-structured interviews with purposely sampled adults between 39 and 77 years of age with chronic pain. All interviews were audio-recorded, transcribed and analysed using a thematical template analysis approach.

RESULTS

Four key drivers for pain-related healthcare use were identified: (1) the healthcare system facilitates clinical pathways, (2) appraisal of pain-related healthcare initiatives influences future use, (3) autonomy, beliefs and values determine healthcare behaviour, and (4) recommendations from others impact healthcare behaviour. Comparing explanations across different pain-related healthcare user groups (high, medium and low) showed that perceived needs, beliefs and values, and appraisal of previous healthcare experiences differed between these groups.

CONCLUSIONS

Beliefs, pain characteristics, recommendations, and the search for a diagnostic label, often initiate pain-related healthcare use. Healthcare is modified by two interconnected systems: (1) perceived needs, beliefs and values and (2) previous healthcare experiences. Differences related to these systems could explain some of the variance in pain-related healthcare use.Implications for RehabilitationDifferent use of pain-related healthcare services for people with chronic pain could be related to differences in perceived needs, beliefs and values and appraisal of previous healthcare.It may be helpful to explore the perceived needs and beliefs of those seeking healthcare due to chronic pain.Previous healthcare experiences may impact and should be explored.

Reductions in kinesiophobia and distress after pain neuroscience education and exercise lead to favourable outcomes: a secondary mediation analysis of a randomized controlled trial in primary care

ABSTRACT

Pain neuroscience education combined with exercise (PNE + exercise) is an effective treatment for patients with chronic spinal pain. Yet, however, little is known about its underlying therapeutic mechanisms. Thus, this study aimed to provide the first insights by performing a novel mediation analysis approach in a published randomized controlled trial in primary care where PNE + exercise was compared with standard physiotherapy. Four mediators (catastrophizing, kinesiophobia, central sensitization-related distress, and pain intensity) measured at postintervention and 3 outcomes (disability, health-related quality of life, and pain medication intake) measured at 6-month follow-up were included into the analysis. The postintervention measure of each outcome was also introduced as a competing candidate mediator in each respective model. In addition, we repeated the analysis by including all pairwise mediator-mediator interactions to allow the effect of each mediator to differ based on the other mediators' values. Postintervention improvements in disability, medication intake, and health-related quality of life strongly mediated PNE + exercise effects on each of these outcomes at 6-month follow-up, respectively. Reductions in disability and medication intake were also mediated by reductions in kinesiophobia and central sensitization-related distress. Reductions in kinesiophobia also mediated gains in the quality of life. Changes in catastrophizing and pain intensity did not mediate improvements in any outcome. The mediation analyses with mediator-mediator interactions suggested a potential effect modification rather than causal independence among the mediators. The current results, therefore, support the PNE framework to some extent as well as highlight the need for implementing the recent approaches for mediation analysis to accommodate dependencies among the mediators.

Exploring Associations between Healthcare Use and Demographics, Pain and Pain Cognitions in People Scheduled for Surgery for Lumbar Radiculopathy: A Cross-Sectional Study

This cross-sectional study explored associations between demographics, pain intensity and cognitions on the one hand and healthcare use (HCU) on the other hand in people undergoing surgery for lumbar radiculopathy. HCU during the 2 months preceding surgery was evaluated using a retrospective questionnaire. Demographics included sex, age and level of education and equivalent income. Back and leg pain intensity were evaluated using a visual analogue scale. Pain cognitions were assessed with the Tampa scale of kinesiophobia, the pain catastrophizing scale and the pain vigilance and awareness questionnaire. The sample comprised 120 participants (52% males; 49 years (Quartile (Q)1-Q3: 37.3-57.43)). The number of visits to the general practitioner was associated with sex (incidence rate ratio (IRR) for males = 0.811; p = 0.050), pain catastrophizing (IRR = 1.010; p = 0.041), pain magnification (IRR = 1.058; p = 0.004) and leg pain intensity (IRR = 1.004; p = 0.038). The number of neurosurgeon visits was associated with level of education (IRR moderate education = 1.518; p = 0.016 (reference: low education)). Receiving zero physiotherapy visits was associated with higher back pain intensity (Beta = 0.018; p = 0.028). Highest level of analgesics used was associated with sex (IRR for males = 0.502; p = 0.047) and leg pain (IRR = 1.014; p = 0.034). Only the association between general practitioner visits and pain magnification remained significant in multivariable analyses (IRR = 1.061; p = 0.033). The results suggest a rather indirect relationship between HCU and demographics, pain intensity and cognitions, involving a potential interplay between several patient- and healthcare system-related factors.

Pain acceptance predicts healthcare utilization in women with chronic pelvic pain

Background:

Chronic pelvic pain (CPP) in women is common and costly, and little is known about patient characteristics predicting healthcare utilization within this population. The present study examined the role of pain acceptance and pain catastrophizing, assessed prior to treatment initiation, in predicting future uptake of medical and surgical interventions specifically for pain management.

Methods:

Our sample comprised women referred to a tertiary gynecological center. Baseline pain catastrophizing and pain acceptance scores were compared across each major medication class and surgery type, as well as across the total number of medication classes and the total number of surgery types using analysis of variance (ANOVA). We then performed multivariable analyses for the association between pain catastrophizing and pain acceptance and treatment utilization by controlling for potential confounders.

Results:

Three hundred eighteen patients met inclusion criteria. Pain catastrophizing was associated with increased likelihood of neuromodulator prescription, while pain acceptance was associated with reduced likelihood of neuromodulator prescription and fewer medication classes prescribed. Overall, no associations between pain catastrophizing and surgeries were observed, while pain acceptance was significantly associated with lower risk of hysterectomy/oophorectomy.

Conclusion:

Pain acceptance was a robust predictor of number of medication classes prescribed and use of radical surgeries even when controlling stringently for confounders. It is worth considering routine assessment of pain acceptance early in treatment of CPP to identify those more at-risk of higher treatment utilization, and potentially mitigate this through engagement with appropriate behavioral therapies.

A Novel Method for Digital Pain Assessment Using Abstract Animations: Human-Centered Design Approach

Background

Patients with chronic pain face several challenges in using clinical tools to help them monitor, understand, and make meaningful decisions about their pain conditions. Our group previously presented data on Painimation, a novel electronic tool for communicating and assessing pain.

Objective

This paper describes the human-centered design and development approach (inspiration, ideation, and implementation) that led to the creation of Painimation.

Methods

We planned an iterative and cyclical development process that included stakeholder engagement and feedback from users. Stakeholders included patients with acute and chronic pain, health care providers, and design students. Target users were adults with acute or chronic pain who needed clinical assessment and tracking of the course of their pain over time. Phase I (inspiration) consisted of empathizing with users, understanding how patients experience pain, and identifying the barriers to accurately expressing and assessing pain. This phase involved understanding how patients communicate pain symptoms to providers, as well as defining limitations of current models of clinical pain assessment tools. In Phase II (ideate) we conceptualized and evaluated different approaches to expressing and assessing pain. The most promising concept was developed through an iterative process that involved end users and stakeholders. In Phase III (implementation), based on stakeholder feedback from initial designs and prototypes of abstract pain animations (painimations), we incorporated all concepts to test a minimally viable product, a fully functioning pain assessment app. We then gathered feedback through an agile development process and applied this feedback to finalizing a testable version of the app that could ultimately be used in a pain clinic.

Results

Engaging intended users and stakeholders in an iterative, human-centered design process identified 5 criteria that a pain assessment tool would need to meet to be effective in the medical setting. These criteria were used as guiding design principles to generate a series of pain assessment concept ideas. This human-centered approach generated 8 highly visual painimations that were found to be acceptable and useable for communicating pain with medical providers, by both patients with general pain and patients with sickle cell disease (SCD). While these initial steps continued refinement of the tool, further data are needed. Agile development will allow us to continue to incorporate precision medicine tools that are validated in the clinical research arena.

Conclusions

A multiphase, human-centered design approach successfully resulted in the development of an innovation that has potential to improve the quality of medical care, particularly for underserved populations. The use of Painimation may especially benefit the medical care of minority populations with chronic and difficult-to-treat pain, such as adults with SCD. The insights generated from this study can be applied to the development of patient-reported outcomes tools that are more patient-centered, engaging, and effective.

Trajectories of Musculoskeletal Healthcare Utilization of People with Chronic Musculoskeletal Pain - A Population-Based Cohort Study

Background and Aim

Chronic musculoskeletal pain is common and associated with more general healthcare-seeking. However, musculoskeletal-related healthcare utilization is under-explored. This study aimed to explore, describe and profile trajectories of long-term musculoskeletal healthcare for people reporting chronic musculoskeletal pain.

Methods

This exploratory prognostic cohort study combined survey and national health register data from a representative group of adult Danes reporting chronic musculoskeletal pain (N = 2929). Trajectories of long-term musculoskeletal healthcare use were generated using latent class growth analysis. Types of healthcare-seeking, individual, sociodemographic, health, belief and work-related factors were used to describe and profile identified trajectories.

Results

We identified five distinct trajectories of long-term musculoskeletal healthcare utilization (low stable, low ascending, low descending, medium stable and high stable). The low stable trajectory group (no or almost no annual contacts) represented 39% of the sample, whereas the high stable trajectory group (consistent high number of annual contacts) represented 8%. Most healthcare-seeking was in primary healthcare settings (GP/physiotherapy/chiropractor). Opioid consumption was primarily in the high stable trajectory group, and surgery was rare. There were statistically significant differences across the five trajectory groups in individual, sociodemographic, health, belief and work-related profiles.

Conclusion

Long-term use of musculoskeletal healthcare services varied in this chronic musculoskeletal pain population. Almost 40% coped without seeking care, whereas 8% had consistent high use of healthcare services. Chronic musculoskeletal pain was mostly managed in primary care settings, which aligns with musculoskeletal guidelines, as did the use of pain medication and surgery. People with different musculoskeletal healthcare trajectories had different individual, sociodemographic, health, belief and work-related profiles.

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Factors mediating pain-related risk for opioid use disorder

Pain is a complex experience with far-reaching organismal influences ranging from biological factors to those that are psychological and social. Such influences can serve as pain-related risk factors that represent susceptibilities to opioid use disorder. This review evaluates various pain-related risk factors to form a consensus on those that facilitate opioid abuse. Epidemiological findings represent a high degree of co-occurrence between chronic pain and opioid use disorder that is, in part, driven by an increase in the availability of opioid analgesics and the diversion of their use in a non-medical context. Brain imaging studies in individuals with chronic pain that use/abuse opioids suggest abuse-related mechanisms that are rooted within mesocorticolimbic processing. Preclinical studies suggest that pain states have a limited impact on increasing the rewarding effects of opioids. Indeed, many findings indicate a reduction in the rewarding and reinforcing effects of opioids during pain states. An increase in opioid use may be facilitated by an increase in the availability of opioids and a decrease in access to non-opioid reinforcers that require mobility or social interaction. Moreover, chronic pain and substance abuse conditions are known to impair cognitive function, resulting in deficits in attention and decision making that may promote opioid abuse. A better understanding of pain-related risk factors can improve our knowledge in the development of OUD in persons with pain conditions and can help identify appropriate treatment strategies. This article is part of the special issue on 'Vulnerabilities to Substance Abuse.'.

Pain Catastrophizing, Opioid Misuse, Opioid Use, and Opioid Dose in People With Chronic Musculoskeletal Pain: A Systematic Review

The objective of this study was to analyze the cross-sectional and longitudinal association between pain catastrophizing and opioid misuse, opioid use, and opioid dose in people with chronic musculoskeletal pain. For this systematic review, CINAHL, Embase, PsycINFO, PubMed, manual searches, and grey literature were searched from inception to May 2020. Observational studies were included if they evaluated the association between pain catastrophizing and opioid dose, opioid use, and/or opioid misuse in people with chronic musculoskeletal pain. Two reviewers independently performed the study selection, data extraction, risk of bias assessment, and the certainty of the evidence judgment. Seven observational studies (all cross-sectional designs) satisfied the eligibility criteria, with a total sample of 2,160 participants. Pain catastrophizing was associated with opioid misuse. The results were inconsistent regarding the association between pain catastrophizing and opioid use. A lack of association was found considering pain catastrophizing and the opioid dose. However, the presence of risk of bias and imprecision was serious across the included studies, and therefore, the overall certainty of the evidence was judged as very low for all the outcome measures. This report concludes that pain catastrophizing seem to be associated with opioid misuse in people with chronic musculoskeletal pain. However, the very low certainty of the current evidence confers to interpret the finding of this review as exclusively informative. PERSPECTIVE: This article shows that pain catastrophizing seem to be associated with opioid misuse in people with chronic musculoskeletal pain. The overall certainty of the evidence was judged to be very low, thus, these results should be interpreted with caution.