Both early and late changes in psychological variables relate to treatment outcome for musculoskeletal pain patients at risk for disability

Characterising tibialis posterior tendinopathy using the International Classification of Functioning, Disability and Health: a cross sectional study

BACKGROUND

Tibialis posterior tendinopathy (TPT) is characterised by pain around the medial foot/ankle and difficulties weightbearing.

OBJECTIVE

Compare individuals who have TPT with asymptomatic controls across the International Classification of Functioning, Disability and Health (ICF) domains of body structure and function, activity, participation and personal factors.

METHODS

Twenty-two individuals meeting the selection criteria for TPT (86% female, mean ± SD age:43 ± 13 years; body mass index [BMI]:28 ± 7 kg/m²) were compared to 27 controls (93% female, age:44 ± 16 years, BMI:23 ± 5 kg/m²). Standardised differences (and 95% confidence intervals [CIs]) between groups were estimated for outcomes under each ICF domain using Cliff's delta to allow for comparison of the magnitude of deficits across outcomes (>0.47 considered large).

RESULTS

Impairments in body structure and function in individuals with TPT were accompanied by activity limitations including difficulties due to foot problems (-1.0 (-1.0, -1.0)) and with independent living (-0.8 (-1.0, -0.3)) and greater time to complete stair descent/ascent (-0.6 (-0.8, -0.3)). Considering participation, overall foot-related function (-1.0 (-1.0, -1.0)), ability to participate in activities (-0.7 (-0.08, -0.3)), social restrictions (-0.8 (-1.0, -0.4)) and quality of life (-0.7 (-0.9, -0.5)) were poorer in individuals with TPT.

CONCLUSION

Individuals with TPT have large impairments in body structure and function, activity limitations and participation restrictions, particularly relating to independent living, mental health and pain. Personal factors appear to contribute to a lesser extent to the TPT presentation. Treatment plans should consider activity and participation limitations in addition to body structure and function.

The role of dispositional mindfulness in the fear-avoidance model of pain

OBJECTIVE

The fear-avoidance model of pain posits that a painful stimulus is interpreted through pain catastrophizing, which leads to negative downstream cognitions, emotions, and behaviors that shape the experience of pain. As dispositional mindfulness is associated with less catastrophizing and pain, some researchers have suggested incorporating mindfulness into the fear-avoidance model. Across two studies, we empirically tested dispositional mindfulness as a stand-alone component within the fear-avoidance model of pain.

METHODS

Two independent, online cross-sectional surveys (Ns = 362 and 580 U.S. adults) were conducted. Participants completed validated assessments of mindfulness, pain catastrophizing, fear of pain, pain vigilance, depression, pain intensity, and pain sensitivity. Using structural equation modeling, we tested the inclusion of dispositional mindfulness in the fear-avoidance model of pain. We proposed that greater mindfulness would be associated with less pain catastrophizing, which in turn would be associated with less fear of pain, leading to less depression, and then ultimately less pain intensity and pain sensitivity.

RESULTS

Across both studies, the fear-avoidance model of pain did not fit the data well, with or without mindfulness included. We found that a simplified model fit the data best (Study 1: χ2/df = 1.83; CFI = .981; RMSEA = .049, 90% CI [0.019, 0.076]; SRMR = 0.031; Study 2: χ2/df = 2.23; CFI = .976; RMSEA = .046, 90% CI [0.026, 0.067]; SRMR = .031), such that greater mindfulness was significantly associated with less pain catastrophizing and, in turn, lower levels of pain intensity and pain sensitivity.

CONCLUSION

Our findings suggest that a simplified model, compared to the traditional fear-avoidance model, may partly explain the experience of pain among individuals without chronic pain. Future work should examine the temporal associations among these variables to inform the employment of future empirically supported interventions for pain management.

The effect of exercise engagement on low back disability at 12-months is mediated by pain and catastrophizing in a community sample of people with chronic low back pain

Despite being a first-line treatment recommendation, there is uncertainly for how exercise helps people with chronic low back pain. We designed this study to examine how exercise might help people with chronic low back pain by following a large community sample for 1-year. Qualitative questionnaires and self-report measures were collected every 3-months for 1-year in 400 people with chronic low back pain. People were not provided any specific treatment advice as part of this study but were allowed to engage with any normal physical activity, treatment, or medication as part of their normal life. Exercise engagement was defined from inspection of participant qualitative responses, according to minimum acceptable levels of exercise that elicit symptom reduction. Multiple mediation analysis was performed to examine the effect of exercise engagement on disability through the proposed mediators (pain, fear, catastrophizing, depression, anxiety, self-efficacy). The significant effect of exercise engagement on reductions in disability at 6- and 12-months was explained through pain and catastrophizing. People with chronic low back pain who reported worsening of symptoms over the year had similar reporting of exercise throughout the 12-months to people who had improvements in disability. Exercise can reduce disability through the effect on pain and catastrophizing, but how this effect occurs (i.e., an active or passive component of exercise) is unclear.

The Effect of Literacy-Adapted Psychosocial Treatments on Biomedical and Biopsychosocial Pain Conceptualization

This is a secondary data analysis of a subgroup of participants who received the Learning About My Pain (LAMP) intervention (clinicaltrials.gov identifier NCT01967342). We examined the effects of LAMP on pre-to-post changes in biomedical and biopsychosocial pain conceptualization and whether those changes in pain conceptualization were associated with physical and psychological functioning. Participants were randomized into three conditions: Cognitive Behavioral Therapy (CBT), Pain Psychoeducation (EDU), or Usual Medical Care (UC). Results based on 225 participants who completed the Pain Concepts Questionnaire (PCQ) showed a pre-to-post reduction in biomedical pain conceptualization (BM), an increase in biopsychosocial pain conceptualization (BPS), and an increase in BPS/BM ratio for CBT and EDU but not UC. There were no differences between CBT and EDU in post-treatment PCQ scores. Compared to those with lower BM pain beliefs scores at post-treatment, participants endorsing higher BM pain beliefs scores reported greater pain intensity and greater pain interference. Furthermore, higher BM pain beliefs scores at post-treatment and lower BPS/BM ratio were associated with higher levels of pain catastrophizing. Overall, results of this study suggest the need for targeting specific pain beliefs that influence pain-related outcomes. PERSPECTIVE: This article presents the potential benefits of providing literacy-adapted psychosocial treatments to expand pain conceptualization beyond a biomedical-only understanding and toward a biopsychosocial conceptualization of the experience of pain. Furthermore, the association of changes in pain conceptualization and pain-related functioning argues for its potential clinical relevance.

Avoid or engage? Outcomes of graded exposure in youth with chronic pain using a sequential replicated single-case randomized design

Pain-related fear is typically associated with avoidance behavior and pain-related disability in youth with chronic pain. Youth with elevated pain-related fear have attenuated treatment responses; thus, targeted treatment is highly warranted. Evidence supporting graded in vivo exposure treatment (GET) for adults with chronic pain is considerable, but just emerging for youth. The current investigation represents the first sequential replicated and randomized single-case experimental phase design with multiple measures evaluating GET for youth with chronic pain, entitled GET Living. A cohort of 27 youth (81% female) with mixed chronic pain completed GET Living. For each participant, a no-treatment randomized baseline period was compared with GET Living and 3- and 6-month follow-ups. Daily changes in primary outcomes fear and avoidance and secondary outcomes pain catastrophizing, pain intensity, and pain acceptance were assessed using electronic diaries and subjected to descriptive and model-based inference analyses. Based on individual effect size calculations, a third of participants significantly improved by the end of treatment on fear, avoidance, and pain acceptance. By follow-up, over 80% of participants had improved across all primary and secondary outcomes. Model-based inference analysis results to examine the series of replicated cases were generally consistent. Improvements during GET Living was superior to the no-treatment randomized baseline period for avoidance, pain acceptance, and pain intensity, whereas fear and pain catastrophizing did not improve. All 5 outcomes emerged as significantly improved at 3- and 6-month follow-ups. The results of this replicated single-case experimental phase design support the effectiveness of graded exposure for youth with chronic pain and elevated pain-related fear avoidance.

Predictors of response to foot orthoses and corticosteroid injection for plantar heel pain

Background

Foot orthoses and corticosteroid injection are common interventions used for plantar heel pain, however few studies have investigated the variables that predict response to these interventions.

Methods

Baseline variables (age, weight, height, body mass index (BMI), sex, education, foot pain, foot function, fear-avoidance beliefs and feelings, foot posture, weightbearing ankle dorsiflexion, plantar fascia thickness, and treatment preference) from a randomised trial in which participants received either foot orthoses or corticosteroid injection were used to predict change in the Foot Health Status Questionnaire foot pain and foot function subscales, and first-step pain measured using a visual analogue scale. Multivariable linear regression models were generated for different dependent variables (i.e. foot pain, foot function and first-step pain), for each intervention (i.e. foot orthoses and corticosteroid injection), and at different timepoints (i.e. weeks 4 and 12).

Results

For foot orthoses at week 4, greater ankle dorsiflexion with the knee extended predicted reduction in foot pain (adjusted R² = 0.16, p = 0.034), and lower fear-avoidance beliefs and feelings predicted improvement in foot function (adjusted R² = 0.43, p = 0.001). At week 12, lower BMI predicted reduction in foot pain (adjusted R² = 0.33, p < 0.001), improvement in foot function (adjusted R² = 0.37, p < 0.001) and reduction in first-step pain (adjusted R² 0.19, p = 0.011). For corticosteroid injection at week 4, there were no significant predictors for change in foot pain or foot function. At week 12, less weightbearing hours predicted reduction in foot pain (adjusted R² = 0.25, p = 0.004) and lower baseline foot pain predicted improvement in foot function (adjusted R² = 0.38, p < 0.001).

Conclusions

People with plantar heel pain who use foot orthoses experience reduced foot pain if they have greater ankle dorsiflexion and lower BMI, while they experience improved foot function if they have lower fear-avoidance beliefs and lower BMI. People who receive a corticosteroid injection experience reduced foot pain if they weightbear for fewer hours, while they experience improved foot function if they have less baseline foot pain.

Psychosocial Mechanisms of Cognitive-Behavioral-Based Physical Therapy Outcomes After Spine Surgery: Preliminary Findings From Mediation Analyses

OBJECTIVE

Changing Behavior through Physical Therapy (CBPT), a cognitive-behavioral-based program, has been shown to improve outcomes after lumbar spine surgery in patients with a high psychosocial risk profile; however, little is known about potential mechanisms associated with CBPT treatment effects. The purpose of this study was to explore potential mediators underlying CBPT efficacy after spine surgery.

METHODS

In this secondary analysis, 86 participants were enrolled in a randomized trial comparing a postoperative CBPT (n = 43) and education program (n = 43). Participants completed validated questionnaires at 6 weeks (baseline) and 3 and 6 months following surgery for back pain (Brief Pain Inventory), disability (Oswestry Disability Index), physical health (12-Item Short-Form Health Survey), fear of movement (Tampa Scale for Kinesiophobia), pain catastrophizing (Pain Catastrophizing Scale), and pain self-efficacy (Pain Self-Efficacy Questionnaire). Parallel multiple mediation analyses using Statistical Package for the Social Sciences (SPSS) were conducted to examine whether 3- and 6-month changes in fear of movement, pain catastrophizing, and pain self-efficacy mediate treatment outcome effects at 6 months.

RESULTS

Six-month changes, but not 3-month changes, in fear of movement and pain self-efficacy mediated postoperative outcomes at 6 months. Specifically, changes in fear of movement mediated the effects of CBPT treatment on disability (indirect effect = -2.0 [95% CI = -4.3 to 0.3]), whereas changes in pain self-efficacy mediated the effects of CBPT treatment on physical health (indirect effect = 3.5 [95% CI = 1.2 to 6.1]).

CONCLUSIONS

This study advances evidence on potential mechanisms underlying cognitive-behavioral strategies. Future work with larger samples is needed to establish whether these factors are a definitive causal mechanism.

IMPACT

Fear of movement and pain self-efficacy may be important mechanisms to consider when developing and testing psychologically informed physical therapy programs.

Psychological Subgrouping to Assess the Risk for the Development or Maintenance of Chronic Musculoskeletal Pain: Is This the Way Forward?

BACKGROUND

Because musculoskeletal pain problems are so prevalent, new methods of evaluating and treating patients are needed to increase effectiveness. Subgrouping is a method wherein patients are classified into defined groups on the basis of psychosocial factors with the expectation of more specific and tailored treatments can be prescribed for them. For those seeking care for a new episode, the risk of developing chronic pain-related disability is assessed, whereas, for those with existing pain, the risk for the maintenance of the chronic pain problem is evaluated.

AIM

The purpose of this narrative review is to examine how patients are classified into subgroups with regard to methods of evaluation and to ascertain whether subgrouping actually facilitates treatment.

RESULTS

For the development of disability, screening tools, for example, the Örebro Musculoskeletal Pain Screening Questionnaire, accurately stratify patients into groups (eg, high, medium, low risk) that predict future pain-related work disability. In addition, several studies show that treatments that directly key in on risk groups enjoy enhanced outcomes compared with treatment as usual. For the maintenance of chronic musculoskeletal pain problems, there are several instruments that classify patients into specific groups or profiles, for example, on the basis of the avoidance and endurance model or the International Classification of Functioning, Disability and Health (ICF) assessment. Although some evidence shows that these classifications are related to treatment outcome, we found no study that directly tested a system for providing treatment matched to the subgrouping for maintenance.

CONCLUSIONS

We conclude that it is possible to reliably subgroup patients with musculoskeletal problems. Likewise, treatments that address the risk factors in the screening procedure may enhance outcomes compared with treatment as usual. More work is needed, however, to better understand the mechanism, so that assessment methods can be improved, and treatment specific to subgroups can be developed and evaluated.

Early Changes in Pain Acceptance Predict Pain Outcomes in Interdisciplinary Treatment for Chronic Pain

Studies have shown that pain acceptance is associated with a better pain outcome. The current study explored whether changes in pain acceptance in the very early treatment phase of an interdisciplinary cognitive-behavioral therapy (CBT)-based treatment program for chronic pain predict pain outcomes. A total of 69 patients with chronic, non-malignant pain (at least 6 months) were treated in a day-clinic for four-weeks. Pain acceptance was measured with the Chronic Pain Acceptance Questionnaire (CPAQ), pain outcomes included pain intensity (Numeric Rating Scale, NRS) as well as affective and sensory pain perception (Pain Perception Scale, SES-A and SES-S). Regression analyses controlling for the pre-treatment values of the pain outcomes, age, and gender were performed. Early changes in pain acceptance predicted pain intensity at post-treatment measured with the NRS (B = −0.04 (SE = 0.02); T = −2.28; p = 0.026), affective pain perception at post-treatment assessed with the SES-A (B = −0.26 (SE = 0.10); T = −2.79; p = 0.007), and sensory pain perception at post-treatment measured with the SES-S (B = −0.19 (SE = 0.08); T = −2.44; p = 0.017). Yet, a binary logistic regression analysis revealed that early changes in pain acceptance did not predict clinically relevant pre-post changes in pain intensity (at least 2 points on the NRS). Early changes in pain acceptance were associated with pain outcomes, however, the impact was beneath the threshold defined as clinically relevant.

Evaluating psychosocial contributions to chronic pain outcomes

The biopsychosocial model of pain dominates the scientific community's understanding of chronic pain. Indeed, the biopsychosocial approach describes pain and disability as a multidimensional, dynamic integration among physiological, psychological, and social factors that reciprocally influence one another. In this article, we review two categories of studies that evaluate the contributions of psychosocial factors to the experience of chronic pain. First, we consider general psychosocial variables including distress, trauma, and interpersonal factors. Additionally, we discuss pain-specific psychosocial variables including catastrophizing, expectations, and pain-related coping. Together, we present a diverse array of psychological, social, and contextual factors and highlight the need to consider their roles in the development, maintenance, and treatment of chronic pain conditions.

Impact of Psychiatric Comorbidities on Short-Term Outcomes Following Intervention for Lumbar Degenerative Disc Disease

STUDY DESIGN

Retrospective, observational cohort study.

OBJECTIVE

To investigate the impact of psychiatric diseases on short-term outcomes in patients undergoing fusion surgery for lumbar degenerative disc disease (LDDD).

SUMMARY OF BACKGROUND DATA

Limited literature exists on the prevalence and impact of psychiatric comorbidities on outcomes in patients undergoing surgery for LDDD.

METHODS

Adult patients (>18 yr) registered in the Nationwide Inpatient Sample database (2002-2011) and undergoing an elective spine fusion for LDDD that met inclusion criteria formed the study population. Defined primary outcome measures were discharge disposition, length of stay, hospitalization cost, and short-term postsurgical complications (neurological, respiratory, cardiac, gastrointestinal, wound complication and infections, venous thromboembolism, and acute renal failure). Multivariable regression techniques were used to explore the association of psychiatric comorbidities on short-term outcomes by adjusting for patient demographics, clinical, and hospital characteristics.

RESULTS

Of the 126,044 adult patients undergoing fusion surgery for LDDD (mean age: 54.91 yr, 58% female) approximately 18% had a psychiatric disease. Multivariable regression analysis revealed patients with psychiatric disease undergoing fusion surgery have higher likelihood for unfavorable discharge (odds ratio [OR] 1.41; 95% confidence interval [CI] 1.35-1.47; P < 0.001), length of stay (OR 1.03; 95% CI 1.02-1.04; P < 0001), postsurgery neurologic complications (OR 1.25; 95% CI 1.13-1.37; P < 0.001), venous thromboembolic events (OR 1.38 95% CI 1.26-1.52; P < 0.001), and acute renal failure (OR 1.17; 95% CI 1.01-1.37; P = 0.040). Patients with psychiatric disease were also associated to have higher hospitalization cost (6.3% higher; 95% CI: 5.6%-7.1%; P < 0.001) compared to those without it.

CONCLUSION

Our study quantifies the estimates for presence of concomitant psychiatric comorbid conditions on short outcomes in patients undergoing fusions for LDDD. The data provide supporting evidence for adequate preoperative planning and postsurgical care including consultation for mental health for favorable outcomes.

LEVEL OF EVIDENCE

4.

Work Outcomes in Patients Who Stay at Work Despite Musculoskeletal Pain

Purpose To assess self-reported work impacts and associations between psychosocial risk factors and work impairment amongst workers seeking care for musculoskeletal pain while continuing to work. Methods Patients were recruited from Musculoskeletal Assessment Clinics at 5 hospitals across Ireland. Participants completed questionnaires including assessments of work impairment (Work Productivity and Activity Impairment Questionnaire), work ability (single item from the Work Ability Index) and work performance (Work Role Functioning Questionnaire; WRFQ). Logistic and hierarchical regressions were conducted to analyse the relation between psychosocial variables and work outcomes. Results 155 participants (53.5% female; mean age = 46.50 years) who were working at the time of assessment completed the questionnaires. Absenteeism was low, yet 62.6% were classified as functioning poorly according to the WRFQ; 52.3% reported having poor work ability. Logistic regression analyses indicated that higher work role functioning was associated with higher pain self-efficacy (OR 1.51); better work ability was associated with older age (OR 1.063) and lower functional restriction (OR 0.93); greater absenteeism was associated with lower pain self-efficacy (OR 0.65) and poorer work expectancy (OR 1.18). Multiple regression analysis indicated that greater presenteeism was associated with higher pain intensity (β = 0.259) and lower pain self-efficacy (β = - 0.385). Conclusions While individuals continue to work with musculoskeletal pain, their work performance can be adversely affected. Interventions that target mutable factors, such as pain self-efficacy, may help reduce the likelihood of work impairment.

Longitudinal relationship between onset of physical symptoms and functional impairment

Patients with chronic physical symptoms (e.g., chronic pain) often have significant functional impairment (i.e., disability). The fear avoidance model is the dominant theoretical model of how the relationship between chronic physical symptoms and functional impairment develops and proposes a cyclical/bidirectional relationship. There has never been a definitive test of the proposed bi-directional relationship. The current study followed 767 Operation Enduring Freedom/Operation Iraqi Freedom soldiers from pre-deployment, when they were relatively healthy, to 1 year after deployment, when it was anticipated that symptoms would increase or develop. Over the four assessment time points, physical symptom severity consistently predicted worse functional impairment at the subsequent time point. Functional impairment did not show a consistent relationship with worsening of physical symptom severity. These findings suggest that changes to functional impairment do not have a short-term impact on physical symptom severity.

Resilience and Vulnerability Factors When Pain is Acute as Predictors of Disability: Findings From a Two-Year Longitudinal Study

OBJECTIVE

To investigate the predictive power of resilience and vulnerability factors in relation to pain-related disability.

DESIGN

A two-year prospective study investigated whether back pain-related disability was predicted by the following variables, measured when pain was acute: 1) pain-related disability, 2) pain intensity, 3) depression, 4) fear avoidance beliefs, 5) anxiety sensitivity, and 6) resilience.

METHODS

Two hundred thirty-two patients treated in five primary care centers participated in this study. They were assessed at baseline during an acute back pain episode and at six, 12, 18, and 24 months. Ninety-nine patients completed all the assessment sessions. Linear mixed models were used to examine the trajectory of disability across the measurement occasions and its association with the predictors.

RESULTS

Individuals who had higher scores of disability and pain intensity when pain was acute also had higher scores of disability six months later; moreover, the increase in disability was greater over time in comparison with individuals with lower scores in disability and pain intensity when pain was acute. Individuals who had reported greater levels of fear avoidance beliefs when pain was acute also reported greater scores of disability six months later; however, no differences were found in the rate of change in disability. No associations were found between initial disability or rate of change and resilience, anxiety sensitivity, or depression.

CONCLUSIONS

Patients with acute back pain who show high levels of pain-related disability, pain intensity, and fear avoidance beliefs are at risk of developing back pain-related disability and should be the target of a preventive intervention.

Physical activity and the mediating effect of fear, depression, anxiety, and catastrophizing on pain related disability in people with chronic low back pain

BACKGROUND

Chronic low back pain is a worldwide burden that is not being abated with our current knowledge and treatment of the condition. The fear-avoidance model is used to explain the relationship between pain and disability in patients with chronic low back pain. However there are gaps in empirical support for pathways proposed within this model, and no evidence exists as to whether physical activity moderates these pathways.

METHODS

This was a cross-sectional study of 218 people with chronic low back pain. Multiple mediation analyses were conducted to determine the role of fear, catastrophizing, depression, and anxiety in the relationship between pain and disability. Separate analyses were performed with physical activity as the moderator. Individuals were classified as performing regular structured physical activity if they described on average once per week for > 30-minutes an activity classified at least moderate intensity (≥ 4-6 METs), activity prescribed by an allied health professional for their back pain, leisure time sport or recreation, or self-directed physical activity such as resistance exercise.

RESULTS

Fear, catastrophizing, and depression significantly mediated the relationship between pain and disability (p<0.001). However the mediating effect of catastrophizing was conditional upon weekly physical activity. That is, the indirect effect for catastrophizing mediating the relationship between pain and disability was only significant for individuals reporting weekly physical activity (B = 1.31, 95% CI 0.44 to 2.23), compared to individuals reporting no weekly physical activity (B = 0.21, 95% CI -0.50 to 0.97). Catastrophizing also mediated the relationship between pain and fear (B = 0.37, 95% CI 0.15 to 0.62), with higher scores explaining 53% of the total effect of pain on fear.

CONCLUSIONS

These results support previous findings about the importance of fear and depression as factors that should be targeted in low back pain patients to reduce back pain related disability. We have also extended understanding for the mediating effect of catastrophizing on back pain related disability. Back pain patients engaged with regular physical activity may require counselling with regards to negative pain perceptions.

The association between pain characteristics, pain catastrophizing and health care use – Baseline results from the SWEPAIN cohort

Background and aim

Pain is common and adds to the global burden of disease. However, individuals suffering from pain are a heterogeneous group in terms of pain spreading, intensity and duration. While pain influences overall health care consultation not everyone with pain consult health care. To be able to provide health care matching the patients’ needs increased knowledge about what factors determines the decision to consult health care is essential. The aim of this study was to explore the combined importance of pain spreading, intensity, duration and pain catastrophizing for consulting health care.

Methods

In this cross-sectional study we used population based survey data from southeast Sweden (SWEPAIN) including 7792 individuals’ aged 16–85 reporting pain. We used Modified Poisson regressions to analyse factors of importance related to the decision to consult health care.

Results

High and moderate pain intensity, as compared to low, increases the probability of consulting health care (High PR = 1.7 [95% CI 1.51–1.88], moderate PR = 1.2 [1.15–1.41]). Having widespread pain, as compared to localised pain, increased the probability of consulting health (PR = 1.2 [1.03–1.36). Pain duration was not associated with increased probability of consulting health care (PR = 1.0 CI0.88–1.07). However an interaction (p = 0.05) between pain duration and pain catastrophizing beliefs was seen indicating a combined importance of the two when consulting health care.

Conclusion

Our result suggests that pain intensity, pain spreading and pain catastrophizing independently influence the decision to consult health care while there is an interaction effect between pain duration and pain catastrophizing beliefs where the importance of pain catastrophizing believes differ with pain duration; the importance of pain catastrophizing believes differ with pain duration.

Implications

Treatment and rehabilitation strategies should incorporate this finding in order to meet the individual’s needs focusing on the biopsychosocial model within health care focusing not only on actual pain reliefs but also on for example acceptance and behavioural changes.

The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain

The recently proposed Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)-American Pain Society (APS) Pain Taxonomy (AAPT) provides an evidence-based, multidimensional, chronic pain classification system. Psychosocial factors play a crucial role within several dimensions of the taxonomy. In this article, we discuss the evaluation of psychosocial factors that influence the diagnosis and trajectory of chronic pain disorders. We review studies in individuals with a variety of persistent pain conditions, and describe evidence that psychosocial variables play key roles in conferring risk for the development of pain, in shaping long-term pain-related adjustment, and in modulating pain treatment outcomes. We consider "general" psychosocial variables such as negative affect, childhood trauma, and social support, as well as "pain-specific" psychosocial variables that include pain-related catastrophizing, self-efficacy for managing pain, and pain-related coping. Collectively, the complexity and profound variability in chronic pain highlights the need to better understand the multidimensional array of interacting forces that determine the trajectory of chronic pain conditions.

PERSPECTIVE

The AAPT is an evidence-based chronic pain classification system in which psychosocial concepts and processes are essential in understanding the development of chronic pain and its effects. In this article we review psychosocial processes that influence the onset, exacerbation, and maintenance of chronic pain disorders.

When Matching Fails: Understanding the Process of Matching Pain-Disability Treatment to Risk Profile

PURPOSE

A previous study (Bergbom et al. in J Occup Rehabil, 2013) showed that matching people at risk for pain-related disability to an intervention aimed at targeting their psychological problem profile did not, as hypothesized, improve the effect of the intervention. Methodological issues were suggested to explain the lack of differential effect. It was questioned whether the profiles used to allocate people to treatment were adequate. The aim of this study was to investigate if the risk profiles used to determine matching were sufficiently stable and valid by comparing the original profiles with profiles constructed using other methods.

METHODS

Ninety-five people suffering musculoskeletal problems were screened, profiled, and matched to workplace based early interventions according to profiles. We studied stability and validity of their psychological risk profiles by investigating their concordance at different time points. People were originally assigned to profiles at inclusion, using a brief screening questionnaire. Then, they were profiled just before treatment start, using the same items. Finally, they were profiled again at treatment start, using extensive questionnaires. Concordance among the three sets of profiles was investigated.

RESULTS

Profiles at inclusion were unstable until treatment start. People moved from profiles with more severe elevations in psychological variables, to a profile with moderate elevations. Concordance between the two means of profiling at treatment start was better; the brief screening and the extensive questionnaires assigned people to similar profiles.

CONCLUSIONS

Risk level may be determined with brief instruments at an early stage of problem development. However, profiles and targets for interventions should be determined immediately prior to treatment start, preferably using full questionnaires.

The fear-avoidance model of chronic pain: assessing the role of neuroticism and negative affect in pain catastrophizing using structural equation modeling

BACKGROUND

Previous research on the fear-avoidance model (FAM) of chronic pain suggests that the personality traits of neuroticism and negative affect (NA) influence pain catastrophizing. However, the mechanisms of their influence on pain catastrophizing remain unclear.

PURPOSE

This study examined four possible models of relationships between neuroticism, NA, and pain catastrophizing within the FAM framework using structural equation modeling.

METHOD

A total of 401 patients with chronic musculoskeletal pain completed measures of neuroticism, NA, three core FAM components (pain catastrophizing, pain-related fear, and pain anxiety), and adjustment outcomes (pain-related disability and depression).

RESULTS

Regression analyses refuted the possibility that neuroticism and NA moderated each other's effect on pain catastrophic thoughts (p > 0.05). Results of structural equation modeling (SEM) evidenced superior data-model fit for the collapsed models in which neuroticism and NA were two secondary traits underlying a latent construct, negative emotion (disability: comparative fit index (CFI) = 0.93; depression: CFI = 0.91).

CONCLUSION

The results offer preliminary evidence that patients presenting with more neurotic symptom and heightened NA probably elicit more catastrophic thoughts about pain.

Change in pain, disability and influence of fear-avoidance in a work-focused intervention on neck and back pain: a randomized controlled trial

BACKGROUND

Neck and back pain are among the most common causes of prolonged disability, and development of interventions with effect on pain, disability and return to work is important. Reduction of fear avoidance might be one mechanism behind improvement after interventions. The aim of the present study was to evaluate changes in pain and disability at the 12-month follow-up of patients with neck and back pain treated with a work-focused intervention compared to patients treated with standard interventions, and the influence of improvement fear avoidance beliefs during the interventions on pain, disability and return to work at 12-month follow-up.

METHODS

413 employed patients with back or neck pain referred to secondary care, and sick-listed between 4 weeks and 12 months, were randomized to a work-focused rehabilitation or control interventions. Follow-up was conducted 4 and 12 months after inclusion. The groups were compared (independent sample t-test) regarding differences in disability scores (Oswestry disability index/neck disability index) and pain (numeric rating scale) from baseline to 12-month follow-up. Changes in fear avoidance beliefs (FABQ) from baseline to 4 month follow-up were calculated, and the association between this change and return to work, pain and disability at 12 months were tested in stepwise multiple logistic regression models.

RESULTS

Pain and, disability scores decreased to in both the work-focused and control intervention to 12-month follow-up, and there were no significant differences between the groups. FABQ decreased similarly in both groups to 4 month follow-up. The logistic regression model revealed an association between a reduced FABQ work score at 4 months and return to work within one year (adjusted OR 3.60, 95% CI 1.19 to 10.88). Reduced FABQ physical activity score at 4 months was associated with decreased disability after 12 months (adjusted OR (3.65. 95% CI 1.43 to 9.28).

CONCLUSIONS

Short work-focused rehabilitation had the same effect on pain and disability as control interventions. Reduction in FABQ-W score after treatment seems to be an important predictor for return to work in both groups.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00840697.