Cognitive and physical capacity process variables predict long-term outcome after treatment of chronic pain

Treatment considerations in neuropathic pain

Neuropathy is a relatively common source of acute and chronic pain. Emerging evidence suggests several pathophysiological mechanisms underlying the neuropathic pain associated with various disorders. Antidepressants and anticonvulsants have largely been the mainstay of treatment. Pharmacologic treatment of neuropathy frequently requires use of multiple medications. Ideally, the selection of which medications to use should be based on targeting the multiple pathophysiologic mechanisms contributing to neuropathic pain transmission. Psychological variables may play a role in predisposing patients to chronic neuropathy after acute illness. In addition, comorbid conditions, especially depression, can complicate the presentation, clinical course, and response to treatment of patients with chronic pain. Treatment of depression may be essential to fully enlist the chronic neuropathic pain patient in comprehensive pain management and rehabilitative approaches.

Changes after multidisciplinary pain treatment in patient pain beliefs and coping are associated with concurrent changes in patient functioning

Little is known about how patient functioning changes after completion of multidisciplinary pain programs, and what factors are associated with such changes when they occur; for example, whether improvement or deterioration in functioning corresponds to changes in patient beliefs and coping during this period. The objective of this study was to examine the extent to which changes in patient pain and functioning were associated with changes in beliefs and coping after multidisciplinary pain treatment. Patients with chronic pain (N=141) completed outcome (pain, functioning) and process (beliefs, catastrophizing, coping) measures at the end of multidisciplinary pain treatment and 12 months posttreatment. On average, patients reported similar levels of pain at both times, but showed a small worsening in disability and depression outcomes between posttreatment and follow-up, which were associated significantly with concurrent changes in the process measures. In particular, increased belief in oneself as disabled by pain, catastrophizing, and increased use of resting, guarding and asking for assistance in response to pain were linked with increased disability and depression. Decreased perceived control over pain was also consistently associated with worsening of these outcomes. The results highlight the potential importance of specific pain-related beliefs and coping responses in long-term patient pain and adjustment. Research is needed to determine whether booster interventions after the end of intensive multidisciplinary treatment that target these beliefs and coping responses improve long-term outcomes.

Chronic pain and comorbid depression

For patients with chronic pain, the experience of pain is intimately linked with psychologic distress. Epidemiologic studies indicate that depression is a common comorbidity accompanying chronic pain states. Longitudinal studies also suggest that depression can predict the emergence of chronic pain in selected populations. Emerging evidence suggests numerous pathophysiologic mechanisms that underlie the coexistence of depression and chronic pain states. Comorbid depression can complicate the presentation, clinical course, and response to treatment of patients with chronic pain. The literature reviewed herein focuses on treatment approaches applicable to chronic, nonmalignant pain states predominantly. Although antidepressants offer advantages in simultaneously producing pain relief and mitigating depression, not all antidepressants share equal efficacy; those with noradrenergic and serotonergic influences seem to fare better than agents with single neurotransmitter influences. Treatment of depression may be essential to fully enlist the patient with chronic pain in comprehensive pain management and rehabilitative approaches. Management plans of patients with chronic pain can be designed with specific individual patient needs in mind, and may involve concurrent use of antidepressants, analgesics, and psychotherapeutic approaches.

Pain self-management in the process and outcome of multidisciplinary treatment of chronic pain: evaluation of a stage of change model

For chronic pain patients, acceptance of a self-management approach for pain may influence success in treatment, and adopting such a perspective may be conceptualized as a stage of change model. For 65 chronic pain patients in multidisciplinary treatment programs, we examined whether pretreatment self-management stage, assessed with Pain Stage of Change Questionnaire subscales, affected improvements in outcomes, and whether changes in stage represented a therapeutic process factor. Results showed (a) low precontemplation, high contemplation, and high action attitudes at pretreatment predicted greater improvements in outcomes than the opposite pattern of attitudes; (b) pre- to midtreatment changes in precontemplation and contemplation attitudes predicted mid- to posttreatment changes in pain severity and interference, but not vice versa. Results support the usefulness of a stage model in conceptualizing patients' acquisition of a self-management approach to pain, and suggest that early-treatment progression across stages may lead to reductions in pain severity and lifestyle interference.