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This study determined the predictive capabilities of pain intensity and disability on health care utilization (number of condition-specific health care visits, incident and chronic opioid use) and costs (total condition-specific and overall medical costs) in the year following an initial evaluation for musculoskeletal pain. We explored pain catastrophizing and spatial distribution of symptoms (i.e., body diagram symptom score) as mediators of these relationships. Two hundred eighty-three military service members receiving initial care for a musculoskeletal injury completed a region-specific disability measure, numeric pain rating scale, Pain Catastrophizing Scale (PCS) and body pain diagram. Pain intensity predicted all outcomes, while disability predicted incident opioid use only. No mediation effects were observed for either opioid use outcome, while pain catastrophizing partially mediated the relationship between pain intensity and number of health care visits. Pain catastrophizing and spatial distribution of symptoms fully mediated the relationship between pain intensity and both cost outcomes. The mediation effects of pain catastrophizing and spatial distribution of symptoms are outcome-specific, and more consistently observed for cost outcomes. Higher pain intensity may drive more condition-specific health care utilization and use of opioids, while higher catastrophizing and larger spatial distribution of symptoms may drive higher costs for services received. Perspective: This article examines underlying characteristics that help explain relationships between pain intensity and disability, and the outcomes of health care utilization and costs. Health care systems can use these findings to refine value-based prediction models by considering factors that differentially influence outcomes for health care use and cost of services.
Learn More >Preoperative anxiety is common in patients undergoing elective surgery and is closely related to postoperative hyperalgesia. In this study, a single prolonged stress (SPS) model was used to induce preoperative anxiety-like behavior in rats 24h before the surgery. We found that SPS exacerbated the postoperative pain and elevated the level of serum corticosterone (CORT). Previous studies have shown that glucocorticoid (GC) is associated with synaptic plasticity, and decreased spinal GABAergic activity can cause hyperalgesia in rodents. Here, SPS rats lumbar spinal cord showed reduced glutamic acid decarboxylase-65 (GAD65), glutamic acid decarboxylase-67 (GAD67), GABA type A receptor alpha 1 subunit (GABAA α1), and GABA type A receptor gamma 2 subunit (GABAA γ2) , indicating an impairment of GABAergic system. Furthermore, Neuronal PAS domain protein 4 (Npas4) was also reduced in rats after SPS stimulation, which has been reported to promote GABAergic synapse development. Then intraperitoneal injection of RU486 (a glucocorticoid receptor antagonist) rather than spironolactone (a mineralocorticoid receptor antagonist) was found to relieve SPS induced hyperalgesia and reverse Npas4 reduction and the impairment of GABAergic system. Further over-expressing Npas4 could also restore the damage of GABAergic system caused by SPS while interfering with Npas4 caused an opposite effect. Finally, after stimulation of rat primary spinal cord neurons with exogenous CORT in vitro, Npas4 and GABAergic markers were also down-regulated, and RU486 reversed that. Together, our results demonstrated that preoperative anxiety led to GABAergic system impairment in spinal cord and thus caused hyperalgesia due to glucocorticoid-induced down-regulation of Npas4.
Learn More >This study aimed to understand the coping strategies used by a group of Black older adults to manage chronic pain. To this end, a focused ethnography was completed within a senior housing facility. Following participant observation, 106 residents completed informal interviews and surveys comprised of a demographic tool, the Brief Pain Inventory, the PROMIS Global Health scale, and the Psychological Stress Measure – 9. Further, a subset of 20 participants that reported daily pain completed formal semi-structured interviews, which were recorded and transcribed. Descriptive statistics were completed on survey data while interviews were analyzed contextually and thematically. The adaptive coping strategies used by participants to manage pain included: remaining positive, remaining active, being engaged in the community, prayer/meditation, and maintaining positive support systems. Effective coping strategies lead to compensated levels of adaptation for participants. A middle range schema of pain is presented that may guide future nursing pain management practice.
Learn More >A growing pediatric and adult literature highlights the role of injustice appraisals in adjustment to pain. However, interpersonal injustice dynamics have remained largely unexplored. The present study investigated the factor structure and criterion validity of parentally-adjusted versions of the Injustice Experience Questionnaire, assessing child-oriented (IEQ-Pc) and self-oriented appraisals (IEQ-Ps) in the context of child pain. Participants were triads of healthy children (N=407, M=12) and both their parents and dyads of children with chronic pain (N=319, M=14) and one parent. In both samples, children completed measures of functional disability and quality of life (physical, emotional, social, academic); parents completed the IEQ-Pc, IEQ-Ps, and a measure of parental catastrophizing about child pain. Across samples, a confirmatory oblique two-factor model (Severity/Irreparability-Blame/Unfairness) provided a better fit to the data compared to a one-factor model; nevertheless, the two-factor solution was considered suboptimal. A post-hoc exploratory factor analysis consistently revealed one factor. In terms of criterion validity, the IEQ-Pc and IEQ-Ps demonstrated differential associations depending on the child's pain vs. healthy status, independent of parental catastrophizing. Further, findings in the healthy sample indicated that fathers' self-oriented injustice appraisals related to lower child social function. In the clinical sample, parental child-oriented injustice appraisals related to greater child functional disability and lower physical, emotional, social, and academic function. Current findings support the unique role of parental injustice appraisals, assessed by the IEQ-Pc and IEQ-Ps, in understanding child pain, but also suggest these may only partially capture the phenomenology of parental injustice appraisals in the context of child pain. PERSPECTIVE: This manuscript presents an examination of the construct and criterion validity of two parentally adjusted versions of the Injustice Experience Questionnaire. These measures could be valuable tools for clinicians in examining how parents respond to their child's pain as it impacts both the child's life as well as the parents'.
Learn More >Pain neuroscience education (PNE) and motivational interviewing (MI) have been widely implemented and tested in the field of chronic pain management, and both strategies have been shown to be effective in the short term (small effect sizes) for the management of chronic pain. PNE uses contemporary pain science to educate patients about the biopsychosocial nature of the chronicity of their pain experience. The goal of PNE is to optimize patients' pain beliefs/perceptions to facilitate the acquisition of adaptive pain coping strategies. MI, on the other hand, is a patient-centered communication style for eliciting and enhancing motivation for behavior change by shifting the patient away from a state of indecision or uncertainty. Conceptually, PNE and MI appear to be complementary interventions, with complementary rather than overlapping effects; MI primarily improves cognitive and behavioral awareness and, potentially, adherence to treatment principles, whereas PNE potentially increases pain knowledge/beliefs, awareness, and willingness to explore psychological factors that are potentially associated with pain. Therefore, combining PNE with MI might lead to improved outcomes with larger and longer-lasting effect sizes. The combined use of PNE and MI in patients having chronic pain is introduced here, along with a description of how clinicians might be able to integrate PNE and MI in the treatment of patients experiencing chronic pain. Clinical trials are needed to examine whether combining PNE with MI is superior to PNE or MI alone for improving pain and quality of life in patients having chronic pain.
Learn More >This study aimed to analyze the associations among depressive/anxiety and pain symptoms in patients diagnosed with chronic pain.
Learn More >Acute stress reduces responses to static evoked pain stimuli (stress-induced analgesia [SIA]). Whether SIA inhibits temporal summation of pain, a dynamic evoked pain measure indexing central sensitization, has been little studied and mechanisms were not evaluated.
Learn More >Non-restorative sleep is a key diagnostic feature of the musculoskeletal pain disorder fibromyalgia, and is robustly associated with poor physical functioning, including activity interference. However, the mechanisms through which non-restorative sleep elicits activity interference among individuals with fibromyalgia at the within-person level remain unclear. The present study tested the following three-path mediation model, using data gathered from a 21-day electronic daily diary in 220 individuals with fibromyalgia: previous night non-restorative sleep → morning pain catastrophizing → afternoon pain severity → end-of-day activity interference. Results of multilevel structural equation modeling supported the three-path mediation model. Previous night's non-restorative sleep and morning pain catastrophizing were also directly related to end-of-day activity interference. Previous night non-restorative sleep did not significantly predict afternoon pain severity while controlling for the effect of morning pain catastrophizing. Greater non-restorative sleep during the previous night and a higher level of morning pain catastrophizing appear to serve as risk factors for experiencing greater daily pain and activity interference later in the day. These findings point to the potential utility of targeted interventions that improve both sleep quality and pain catastrophizing to help individuals with chronic pain engage in important daily activities despite experiencing pain.
Learn More >Depression, anxiety and somatization influence the recovery of people with musculoskeletal pain. A Delphi study was conducted to reach consensus on the most appropriate self-administered questionnaires to assess these psychosocial factors in people at risk of developing persistent musculoskeletal pain. A multidisciplinary panel of international experts was identified via PubReMiner. The experts (N=22) suggested 24 questionnaires in Round 1. In Round 2, experts rated the questionnaires on suitability, considering clinimetrics, content, feasibility, personal experiences and expertise. The highest ranked questionnaires were retained for Round 3, in which the experts made a final assessment of the suitability of the questionnaires. Sensitivity analyses were performed to assess the impact of (1) not all experts having participated in each round, and (2) experts having been involved in relevant questionnaire development. Consensus (i.e., ≥75% agreement) was reached for the following questionnaires. For depression: Patient Health Questionnaire-9, Beck Depression Inventory-II, Center for Epidemiological Studies-Depression Scale, and Depression Subscale of the Depression, Anxiety and Stress Scales. In the sensitivity analyses, consensus was also reached for the Depression Subscale of the Hospital Anxiety Depression Scale. For anxiety: Generalized Anxiety Disorder Scale-7, State and Trait Anxiety Inventory, and Pain Anxiety Symptoms Scale. For somatization: no recommendation could be made. Perspective This study generated a short-list of preferred questionnaires to assess depression, anxiety and somatization in people with musculoskeletal pain. Broad implementation of these questionnaires by clinicians and researchers will facilitate easier comparison and pooling of baseline and outcome data. Some of the recommended questionnaires still require validation in this population.
Learn More >Psychological factors such as adverse childhood experiences, traumatic life events, interpersonal conflicts and psychological distress play an important role in the predisposition, onset and severity of chronic widespread pain (CWP) and fibromyalgia syndrome (FMS). Therefore, psychological therapies might have the potential to reduce disability as well as symptom and economic burden in patients with CWP and FMS. Recent interdisciplinary guidelines have suggested different strengths of recommendation for psychological therapies for FMS. The aims of this narrative review are to summarise: • Mechanisms of actions. • Evidence on efficacy, tolerability and safety. • Knowledge gaps and needs for future research of psychological therapies for CWP and FMS for non-mental health professionals.
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