Do post-traumatic pain and post-traumatic stress symptomatology mutually maintain each other? A systematic review of cross-lagged studies

The pain of PTSD: integrating persistent or chronic pain within emotional processing theory of posttraumatic stress disorder

Background: Posttraumatic stress disorder (PTSD) and chronic pain are devastating conditions that often co-occur. Current understanding of comorbid PTSD and chronic pain is limited, and treatment options are undereffective.Objective: This paper presents a theoretical basis for conceptualising chronic pain symptoms within Emotional Processing Theory (EPT), the foundation for Prolonged Exposure (PE), an effective treatment for PTSD. EPT conceptualises the development and treatment of PTSD using a trauma structure that strongly overlaps with pain's neurobiology.Method: This paper proposes a model of shared aetiology and treatment of comorbid PTSD and chronic pain, emphasising these shared neurobiological underpinnings. Discussion details how the comorbidity is maintained through parallel avoidance processes focused on: (1) trauma memories and reminders in PTSD preventing reduction of negative affect (extinction) and inhibitory learning, and (2) physical pain in chronic pain fuelling increased pain and reduced function.Results: A conceptualisation is presented on how PTSD and chronic pain symptomology can be addressed within the EPT framework, increasing the confidence of providers and patients while addressing an important gap in the literature. Finally, recommendations for providers using PE with patients with PTSD and pain are provided including a case example and treatment plan based on real patients.Conclusions: This model provides a clinically useful understanding of the underlying neurobiology for the co-occurrence of PTSD and chronic pain and offers direction for future research.

Chronic pain and comorbid posttraumatic stress disorder: Potential mechanisms, conceptualizations, and interventions

Posttraumatic stress disorder (PTSD) is a common comorbidity to chronic pain, among others due to potentially shared posttraumatic origin. There has been growing interest in this field in the past decades, also providing some important studies to support our understanding of this comorbidity and how to address it in clinical practice. However, there are still important questions, particularly regarding the potentially shared vulnerabilities, mutually maintaining mechanisms, and how to best treat this comorbidity. This article provides a brief and up-to-date review of what we argue to be some of the most important studies within the field of chronic pain and comorbid PTSD and will discuss some of the current challenges and ways forward.

The mediating role of posttraumatic stress disorder symptoms in pain cognitions among Veterans with chronic pain

Symptoms of posttraumatic stress disorder (PTSD) are highly prevalent among Veterans with chronic pain. Considerable research has examined the intersection of chronic pain and PTSD symptoms. However, it remains unclear whether changes in PTSD may potentially serve a mechanistic role in improving unhelpful pain cognitions for individuals with chronic pain. The present research contributes to the foundational knowledge by addressing this question. Baseline data from a randomized controlled trial targeting pain-related disability for Veterans (n = 103; mean age 43.66; SD = 10.17) with musculoskeletal pain and depression and/or PTSD symptoms were used. Cross-sectional mediation analyses showed that PTSD symptoms mediated the relationship between pain severity and pain catastrophizing, and between pain severity and pain acceptance. After controlling for depression, the mediation involving pain catastrophizing remained significant, while the mediation for pain acceptance did not. Although limitations exist, results point to several treatment recommendations, including ensuring that depressive affect, PTSD-specific symptoms, and attention to both body and mind are included in treatment. Results also provide preliminary evidence for examining these associations longitudinally to improve our understanding of this population and corresponding treatment recommendations.

The effects of trauma-focused treatment on painful temporomandibular disorders, awake bruxism and sleep bruxism in patients with severe post-traumatic stress disorder

BACKGROUND

Chronic painful temporomandibular disorders (TMD), awake bruxism and sleep bruxism are often comorbid with post-traumatic stress disorder (PTSD), but the implications for treatment are unknown.

OBJECTIVE(S)

To explore the effects of PTSD treatment on these conditions. We hypothesized that chronic painful TMD, pain intensity, pain interference, awake bruxism and sleep bruxism would decrease after evidence-based trauma-focused treatment and that this decrease would be maintained at the 6-month follow-up.

METHODS

Individuals referred for PTSD treatment were assessed for chronic painful TMD (temporomandibular disorder pain screener), pain intensity, pain interference (Graded Chronic Pain Scale 2.0), awake bruxism and sleep bruxism (oral behaviours checklist) pre-, post-treatment and at the 6-month follow-up. Hypotheses were tested using the Friedman test, followed by a post hoc Wilcoxon signed-rank test. Effect sizes (Cohen's r) are reported. Barely any pain interference was reported, therefore these outcomes were not analysed.

RESULTS

In individuals with chronic painful TMD (n = 98), pain intensity, awake bruxism and sleep bruxism decreased across the three time points. Post hoc tests showed that chronic painful TMD (r = 0.59), pain intensity (r = 0.28), awake bruxism (r = 0.51) and sleep bruxism (r = 0.35) decreased between pre- and post-treatment. Between pre-treatment and the 6-month follow-up, chronic painful TMD (r = 0.58), awake bruxism (r = 0.30) and sleep bruxism (r = 0.39) decreased as well.

CONCLUSION

The results provide preliminary support for a trauma-sensitive approach for patients with chronic painful TMD and PTSD and suggest that trauma-focused treatment may be beneficial for chronic painful TMD, awake bruxism and sleep bruxism in patients with PTSD and chronic painful TMD.

Expectation of pain and relief: A dynamical model of the neural basis for pain-trauma co-morbidity

Posttraumatic Stress Disorder (PTSD) is highly co-morbid with chronic pain conditions. When present, PTSD significantly worsens chronic pain outcomes. Likewise, pain contributes to a more severe PTSD as evidenced by greater disability, more frequent use of harmful opioid analgesics and increased pain severity. The biomechanism behind this comorbidity is incompletely understood, however recent work strongly supports the widely-accepted role of expectation, in the entanglement of chronic pain and trauma symptoms. This work has shown that those with trauma have a maladaptive brain response while expecting stress and pain, whereas those with chronic pain may have a notable impairment in brain response while expecting pain relief. This dynamical expectation model of the interaction between neural systems underlying expectation of pain onset (traumatic stress) and pain offset (chronic pain) is biologically viable and may provide a biomechanistic insight into pain-trauma comorbidity. These predictive mechanisms work through interoceptive pathways in the brain critically the insula cortex. Here we highlight how the neural expectation-related mechanisms augment the existing models of pain and trauma to better understand the dynamics of pain and trauma comorbidity. These ideas will point to targeted complementary clinical approaches, based on mechanistically separable neural biophenotypes for the entanglement of chronic pain and trauma symptoms.

Stepped collaborative care for pain and posttraumatic stress disorder after major trauma: a randomized controlled feasibility trial

PURPOSE

To examine feasibility and acceptability of providing stepped collaborative care case management targeting posttraumatic stress disorder (PTSD) and pain symptoms after major traumatic injury.

MATERIALS AND METHODS

Participants were major trauma survivors in Victoria, Australia, at risk of persistent pain or PTSD with high baseline symptoms. Participants were block-randomized, stratified by compensation-status, to the usual care (n = 15) or intervention (n = 17) group (46% of eligible patients). The intervention was adapted from existing stepped collaborative care interventions with input from interdisciplinary experts and people with lived experience in trauma and disability. The proactive case management intervention targeted PTSD and pain management for 6-months using motivational interviewing, cognitive behavioral therapy strategies, and collaborative care. Qualitative interviews explored intervention acceptability.

RESULTS

Intervention participants received a median of 7 h case manager contact and reported that they valued the supportive and non-judgmental listening, and timely access to effective strategies, resources, and treatments post-injury from the case manager. Participants reported few disadvantages from participation, and positive impacts on symptoms and recovery outcomes consistent with the reduction in PTSD and pain symptoms measured at 1-, 3- and 6-months.

CONCLUSIONS

Stepped collaborative care was low-cost, feasible, and acceptable to people at risk of PTSD or pain after major trauma.IMPLICATIONS FOR REHABILITATIONAfter hospitalization for injury, people can experience difficulty accessing timely support to manage posttraumatic stress, pain and other concerns.Stepped case management-based interventions that provide individualized support and collaborative care have reduced posttraumatic stress symptom severity for patients admitted to American trauma centers.We showed that this model of care could be adapted to target pain and mental health in the trauma system in Victoria, Australia.The intervention was low cost, acceptable and highly valued by most participants who perceived that it helped them use strategies to better manage post-traumatic symptoms, and to access clinicians and treatments relevant to their needs.

The impact of parental acceptance and childhood maltreatment on mental health and physical pain in Burundian survivors of childhood sexual abuse

BACKGROUND

Parental support has been suggested to mitigate mental and physical consequences following childhood sexual abuse (CSA). However, many CSA survivors experience parental rejection post-CSA.

OBJECTIVE

We aimed to understand the impact of abuse-specific parental acceptance on post-traumatic stress disorder (PTSD) and physical pain in Burundian CSA-survivors. We further assessed the significance of parental acceptance among known risk factors for predicting PTSD.

METHODS, PARTICIPANTS, AND SETTINGS

Participants (N = 131, 80.9 % female, mean age 16.21 years) were recruited via primary health care centers for survivors of sexual violence which survivors approached post-CSA. Survivors reported on PTSD symptoms, daytime/nighttime pain, and adverse childhood experiences in semi-structured interviews. Parental acceptance levels were categorized (acceptance, no acceptance, no contact) for mothers and fathers separately. Kruskal-Wallis tests assessed group differences. Conditional random forests (CRF) evaluated the significance of parental acceptance in predicting PTSD symptom severity.

RESULTS

No significant differences regarding PTSD symptoms and physical pain between levels of maternal acceptance were obtained. Pairwise comparisons revealed significant differences in PTSD symptom severity between paternal acceptance and no acceptance (d = 1.04) and paternal acceptance and no contact (d = 0.81). The CRF identified paternal acceptance as important variable for the prediction of PTSD symptom severity. Even though results were less conclusive, medium effect sizes hint at less pain perception within the paternal acceptance group.

CONCLUSIONS

The results highlight paternal acceptance as a potential risk or protective factor regarding psychological and possibly physical well-being in the aftermath of CSA, even in the context of other known risk factors.

High level of post-traumatic stress symptoms in patients with chronic neck pain is associated with poor mental health but does not moderate the outcome of a multimodal physiotherapy programme

INTRODUCTION

Chronic traumatic neck pain has a high prevalence of post-traumatic stress symptoms (PTSS). However, whether PTSS moderates treatment effects is unknown. This study investigated: 1) whether PTSS was associated with patient-reported outcomes and clinical test results at baseline; 2) whether PTSS moderated the effect of a multimodal physiotherapy intervention of exercise therapy and patient education; and 3) whether adherence to the intervention differed across PTSS groups.

METHODS

Secondary data analysis from a randomized controlled trial on chronic neck pain with 12-month follow-up was conducted. Patients were divided into three groups (NT = non-traumatic, LT = traumatic low PTSS, HT = traumatic high PTSS) based on self-reported onset of pain and the Impact of Event Scale. The baseline data were used to analyze the association of PTSS with patient demographics and scores of physical and mental health-related quality of life, depression, neck-related disability, kinesiophobia, and clinical tests. Baseline, 4-month and 12-month follow-up data were analyzed to investigate possible moderating effects on outcomes. Data on adherence were collected at four months.

RESULTS

115 participants were included (NT n = 45; LT n = 46; HT n = 24). The HT group reported lower mental health scores and more depressive symptoms at baseline. PTSS did not significantly moderate the treatment effect on any outcomes. The HT group tended to have lower adherence to the multimodal physiotherapy intervention than the LT group.

CONCLUSION

For patients with traumatic neck pain, high levels of PTSS are associated with poorer psychological outcomes but do not affect the outcomes of multimodal physiotherapy intervention.

Gray Matter Adaptations to Chronic Pain in People with Whiplash-Associated Disorders are Partially Reversed After Treatment: A Voxel-based Morphometry Study

Gray matter (GM) changes are often observed in people with chronic spinal pain, including those with chronic whiplash-associated disorders (CWAD). These GM adaptations may be reversed with treatment, at least partially. Pain neuroscience education combined with exercise (PNE+Exercise) is an effective treatment, but its neural underlying mechanisms still remain unexplored in CWAD. Here, we performed both cross-sectional and longitudinal voxel-based morphometry to 1) identify potential GM alterations in people with CWAD (n = 63) compared to age- and sex-matched pain-free controls (n = 32), and 2) determine whether these GM alterations might be reversed following PNE+Exercise (compared to conventional physiotherapy). The cross-sectional whole-brain analysis revealed that individuals with CWAD had less GM volume in the right and left dorsolateral prefrontal cortex and left inferior temporal gyrus which was, in turn, associated with higher pain vigilance. Fifty individuals with CWAD and 29 pain-free controls were retained in the longitudinal analysis. GM in the right dorsolateral prefrontal cortex increased after treatment in people with CWAD. Moreover, the longitudinal whole-brain analysis revealed that individuals with CWAD had decreases in GM volumes of the left and right central operculum and supramarginal after treatment. These changes were not specific to treatment modality and some were not observed in pain-free controls over time. Herewith, we provide the first evidence on how GM adaptations to CWAD respond to treatment. PERSPECTIVE: This article presents which gray matter adaptations are present in people with chronic pain after whiplash injuries. Then, we examine the treatment effect on these alterations as well as whether other neuroplastic effects on GM following treatment occur.

Trajectories of post-traumatic stress in sepsis survivors two years after ICU discharge: a secondary analysis of a randomized controlled trial

BACKGROUND

Post-traumatic stress has been identified as a frequent long-term complication in survivors of critical illnesses after sepsis. Little is known about long-term trajectories of post-traumatic stress and potentially modifiable risk factors following the ICU stay. Study objective was to explore and compare different clinical trajectories of post-traumatic stress symptoms in sepsis survivors up to two years after discharge from ICU.

METHODS

Data on post-traumatic stress symptoms by means of the Post-traumatic Symptom Scale (PTSS-10) were collected in sepsis survivors at one, six, 12 and 24 months after discharge from ICU. Data on chronic psychiatric diagnoses prior ICU were derived from the primary care provider's health records, and data on intensive care treatment from ICU documentation. Trajectories of post-traumatic symptoms were identified ex post, discriminating patterns of change and k-means clustering. Assignment to the trajectories was predicted in multinomial log-linear models.

RESULTS

At 24 months, all follow-up measurements of the PTSS-10 were completed in N = 175 patients. Three clusters could be identified regarding clinical trajectories of PTSS levels: stable low symptoms (N = 104 patients [59%]), increasing symptoms (N = 45 patients [26%]), and recovering from symptoms (N = 26 patients [15%]). Patients with initially high post-traumatic symptoms were more likely to show a decrease (OR with 95% CI: 1.1 [1.05, 1.16]). Females (OR = 2.45 [1.11, 5.41]) and patients reporting early traumatic memories of the ICU (OR = 4.04 [1.63, 10]) were at higher risk for increasing PTSS levels.

CONCLUSION

Post-traumatic stress is a relevant long-term burden for sepsis patients after ICU stay. Identification of three different trajectories within two years after ICU discharge highlights the importance of long-term observation, as a quarter of patients reports few symptoms at discharge yet an increase in symptoms in the two years following. Regular screening of ICU survivors on post-traumatic stress should be considered even in patients with few symptoms and in particular in females and patients reporting traumatic memories of the ICU.

Perceived Injustice as a Determinant of the Severity of Post-traumatic Stress Symptoms Following Occupational Injury

BACKGROUND

The present study assessed the role of perceived injustice in the experience and persistence of post-traumatic stress symptoms (PTSS) following work-related musculoskeletal injury.

METHODS

The study sample consisted of 187 individuals who were absent from work as a result of a musculoskeletal injury. Participants completed measures of pain severity, perceived injustice, catastrophic thinking, post-traumatic stress symptoms, and disability on three occasions at three-week intervals.

RESULTS

Consistent with previous research, correlational analyses revealed significant cross-sectional relations between pain and PTSS, and between perceived injustice and PTSS. Regression analysis on baseline data revealed that perceived injustice contributed significant variance to the prediction of PTSS, beyond the variance accounted for by pain severity and catastrophic thinking. Sequential analyses provided support for a bi-directional relation between perceived injustice and PTSS. Cross-lagged regression analyses showed that early changes in perceived injustice predicted later changes in PTSS and early changes in PTSS predicted later changes in perceived injustice.

CONCLUSIONS

Possible linkages between perceived injustice and PTSS are discussed. The development of effective intervention techniques for targeting perceptions of injustice might be important for promoting recovery of PTSS consequent to musculoskeletal injury.

Treatment of Comorbid Disorders, Syndromes, and Symptoms of Posttraumatic Stress Disorder Related to Childhood Maltreatment with STAIR-NT

Abstract. Background: Early interpersonal traumatic events, such as childhood maltreatment, increase the risk of developing complex posttraumatic stress symptoms. The biphasic treatment program STAIR-NT (Skills Training for Affective and Interpersonal Regulation with Narrative Therapy), developed specifically for this patient group, combines interventions to improve emotion regulation and interpersonal skills with narrative therapy. Objective: Many affected patients with PTSD after childhood maltreatment also suffer from various comorbid mental disorders and symptoms that can affect and impede the course and outcome of treatment with STAIR-NT. Method: Based on experience from a current treatment study, we provide recommendations for integrating treatment of comorbid mental symptoms into STAIR-NT. Results / Conclusion: Training affective and interpersonal regulation skills in the first treatment phase offers various interventions to efficiently adapt transdiagnostic mechanisms such as emotion dysregulation. In cases of severe comorbid mental disorders or symptoms, adding disorder-specific interventions to STAIR-NT may be indicated.

The role of post-trauma stress symptoms in the development of chronic musculoskeletal pain and disability: A systematic review

BACKGROUND AND OBJECTIVE

Traumatic injuries are amongst the leading causes of death and disability in the world across all age groups. This systematic review aimed to (1) describe the role of post-traumatic stress symptoms (PTSS) on the development of chronic pain and/or pain-related disability following musculoskeletal trauma and (2) report pain and or pain-related disability by injury severity/type.

DATABASE AND DATA TREATMENT

Electronic databases were searched, from inception to 31 November 2021 and updated on 10 May 2022, to identify studies in which: participants were adults aged ≥16 years sustaining any traumatic event that resulted in one or more musculoskeletal injuries; an outcome measure of PTSS was used within 3 months of a traumatic event; the presence of pain and/or pain-related disability was recorded at a follow-up of 3 months or more. Two reviewers independently screened papers and assessed the quality of included studies.

RESULTS

Eight studies were included. Owing to between-study heterogeneity, the results were synthesized using a narrative approach. Five studies investigated the relationship between PTSS and pain. Participants with PTSS were more likely to develop persistent pain for at least 12 months post-injury. Six studies assessed the relationship between PTSS and pain-related disability. The results suggest that patients with PTSS had significantly higher disability levels for at least 12 months post-injury.

CONCLUSION

Findings from this comprehensive systematic review support a clear relationship between PTSS post-injury and future pain/disability, with the potential importance of certain PTSS clusters (hyper-arousal and numbing).

SIGNIFICANCE

The findings of this systematic review indicate an association between PTSS reported within 3 months of a traumatic musculoskeletal injury and the development of longer-term pain and disability. The PTSS clusters of 'hyper-arousal' and 'numbing' appear to be of particular importance in this relationship.

PROSPERO REGISTRATION NUMBER

CRD42021285243.

Postoperative opioid administration and post-traumatic stress symptoms in preschool children after cardiac surgery

PURPOSE

The purpose of this study was to explore relationships between postoperative opioid administration and posttraumatic stress symptoms (PTSS) in preschool-aged children surviving cardiac surgery.

DESIGN AND METHODS

This was a cross-sectional, descriptive study using survey administration and medical chart review. Primary caregivers of children aged three to six years who underwent cardiac surgery at our institution between 2018 and 2020 were invited to participate. Opioid administration was calculated according to morphine milligram equivalents and indexed to the child's body weight. Caregivers completed the Young Child Posttraumatic Stress Disorder Checklist to explore child PTSS. We used correlational methods to assess the strength and direction of relationships between postoperative opioid administration and child PTSS.

RESULTS

We did not find a statistically significant relationship between total postoperative opioid administration and child PTSS. When analyzing individual opioid agents, morphine did show a significant inverse relationship to YCPC scores (r_s = -.57, p = .017) in children with single ventricle physiology.

CONCLUSIONS

Total postoperative opioid administration was not statistically significantly related to child PTSS in our sample. Differing patterns of association were noted among children with single- versus bi-ventricular physiology. Postoperative morphine administration was favorably associated with PTSS in children with single-ventricle physiology.

PRACTICE IMPLICATIONS

Nurses caring for preschool children who undergo cardiac surgery should anticipate the potential development of PTSS in their patients. Studies using larger sample sizes and longitudinal design are needed to replicate the significant relationship between morphine administration and PTSS in preschoolers with single-ventricle physiology.

Role of burn severity and posttraumatic stress symptoms in the co-occurrence of itch and neuropathic pain after burns: A longitudinal study

Itch and pain are common after burns. Neuropathic mechanisms may underlie both modalities but remain not well-understood. This study aims to prospectively document neuropathic pain symptoms and to identify potential itch symptom profiles that differ regarding duration and co-occurrence with neuropathic pain which may inform underlying pathophysiological mechanisms and respond to different treatments. Adult burn survivors (n = 192) self-reported itch and neuropathic pain at 2 weeks post-discharge, 3, 6, 12, and 18 months post-burn. Based on the presence of itch and pain symptoms over time, participants were allocated to one itch profile: transient itch/pain, chronic itch, or chronic itch & pain. Profiles were compared on itch intensity over time using General Linear Modeling. Age, gender, burn severity, posttraumatic stress (PTS) symptoms and baseline itch intensity were examined as potential predictors of the profiles in a Multi-nominal regression analysis. Neuropathic pain occurred in 54% after discharge which decreased to 24% 18 months later. Itch intensity was highest in the chronic itch & pain profile. Compared to the transient itch profile, the chronic itch & pain profile was associated with higher burn severity and more PTS symptoms. Compared to the chronic itch profile, the chronic itch & pain profile was associated with more PTS symptoms. Findings suggest that biological and psycho-dermatological processes underlie both chronic neuropathic pain and itch processes in burn scars. Further research should elucidate the mechanisms underlying the different itch profiles, with specific focus on skin innervation and psychological factors.

Chronicity of posttraumatic stress disorder and comorbid pain as predictors of treatment response for trauma-affected refugees

Predictors of treatment outcomes have received limited attention in the field of trauma-affected refugees. Symptom chronicity is potentially a particularly relevant predictor, as it would instruct earlier interventions for a population less familiar with psychiatric treatment options, and its identification may also reduce or delay the onset of comorbidities, such as chronic pain. Accordingly, this study examined the impacts of posttraumatic stress disorder (PTSD) chronicity and baseline comorbid pain on treatment response in trauma-affected refugees. Multiple regression was used to analyze data from a randomized controlled trial of 318 trauma-affected refugees with PTSD that was conducted at a specialized psychiatric clinic in Denmark. Treatment response was measured by changes in symptoms of PTSD (Harvard Trauma Questionnaire) and depression (Hopkins Symptom Checklist-25). Duration of functional impairment was found to be a significant predictor of PTSD outcomes, p = .003, ΔR²  = .02, f²  = .03; it was not predictive of outcomes for depression. Baseline pain severity was a significant predictor of outcomes for both PTSD, p = .009, ΔR²  = .02, f²  = .02, and depression, p = .041, ΔR²  = .01, f² = .01. These findings suggest that trauma-affected refugees with long-lasting functional impairment and a high pain score are likely to show less improvement from treatments for PTSD and depression. This points to a need for early intervention to prevent chronic functional impairment and suggests comorbid pain is an important therapeutic target.

Bidirectional relationship between cognitive function and loss hierarchy of activities of daily living among older adults with disabilities in urban China: a cross-lagged analysis

OBJECTIVES

The present study aimed to determine the bidirectional relationship between cognitive function and the loss hierarchy of activities of daily living (ADL) among older adults in China.

DESIGN

Data were derived from the Longitudinal Study on Family Caregivers for Frail Older Adults Aged 75 or Above in Shanghai (2010-2013).

SETTING

Community-dwelling older adults and their primary caregivers were invited to participate in this research.

PARTICIPANTS

The inclusion criteria for the older adults were as follows: (a) have a Shanghai urban household registration status, (b) be 75 years old or older, (c) have no fewer than two limitations in ADLs or equivalent, and (d) have one primary caregiver aged 18 years or older. 469 older adults cared by their spouses or children were included in the final analytical sample of this research.

PRIMARY AND SECONDARY OUTCOME MEASURES

Cognitive function was assessed using the Chinese version of the Short Portable Mental Status Questionnaire and ADLs were measured by self-reports of having difficulty or needing help with basic daily activities.

RESULTS

Cognitive function in 2010 was a significant predictor of intermediate loss of ADLs in 2013 (β=-0.13, p<0.05) and late loss of ADLs in 2013 (β=-0.17, p<0.01). The loss hierarchy of ADLs among older adults was not shown to be significant as a risk factor of cognitive function in 2013.

CONCLUSIONS

Practitioners are encouraged to adopt the ADL loss hierarchy as a supplementary needs assessment tool to make the social service delivery process more effective, economical and tailored. Cognitive function change monitoring programmes and services providing education on nutrition and encouraging social participation of older individuals were also helpful in promoting the quality of life of the older adults.

Cervical Motor and Nociceptive Dysfunction After an Acute Whiplash Injury and the Association With Long-Term Non-Recovery: Revisiting a One-Year Prospective Cohort With Ankle Injured Controls

Aims

To explore the development of cervical motor and nociceptive dysfunction in patients with whiplash (WPs) and non-recovery based on injury-related work disability 1-year after injury when compared with ankle-injured controls (ACs).

Methods

A 1-year observational prospective study examining consecutive WPs and age- and sex-matched ACs at 1 week,3 months, 6 months, and 1 year post-injury using semi-structured interviews; global pain rating (VAS0-10) and the pain rating index (PRI-T) and number-of-words-chosen (NWC) from the McGill Pain Questionnaire; examining nociceptive functioning using the cold pressor test (CPT), pressure algometry, and methodic palpation, and central pain processing using counter-stimulation; and examining motor functioning by active cervical range-of-motion (CROM), and neck strength [maximal voluntary contraction flexion/extension (MVC)]. One-year work disability/non-recovery was determined using a semi-structured interview.

Results

A total of 141 WPs and 40 ACs were included. Total pain rating index (PRI-T) NWC were higher in ACs after 1 week but higher in WPs after 3 months, 6 months, and 1 year. Ongoing global pain was higher in WPs after 1 week and after 3 and 6 months but not after 1 year. Pressure pain thresholds were reduced, and palpation was higher in the neck and jaw in WPs after 1 week but was not consistently different afterward from ACs. Cervical mobility was reduced in WPs after 1 week, 3 months, and 6 months but not after 1 year, and MVC was significantly reduced in WPs when compared with ACs after 1 week and 1 year but not after 3 and 6 months. One-year non-recovery was only encountered in 11 WPs and not in the AC group. Non-recovered WPs (N-WPs) had consistently significantly higher VAS₀₋₁₀, PRI-T, NWC, reduced pressure pain thresholds, raised muscle-tenderness, reduced active cervical range-of-motion, reduced active-neck-flexion/extension, and reported higher neck disability scores than recovered WPs. Of special interest, there was increasing tenderness in trigeminal-derived muscles based on palpation scores, and marked reduction of PPDT was most pronounced in N-WPs when compared with recovered WPs and ACs.

Conclusion

Cervical motor dysfunction and segmental nociceptive sensitization were present from early after injury in WPs and prolonged in N-WPs. Differences in trigeminal and cervical motor and sensory function in N-WPs could be of interest for future treatment studies.

Reciprocal relationships between employment status and psychological symptoms: findings from the Building a New Life in Australia study

BACKGROUND

Finding work is an important priority for many refugees in the initial years following settlement in a host country. Difficulties in finding work could conceivably both contribute to and be a consequence of symptoms of posttraumatic stress disorder (PTSD) and psychological distress commonly reported by refugees.

PURPOSE

We sought to determine the direction of these relationships and the possibility of a reciprocal association between employment status on one hand, and symptoms of PTSD and psychological distress on the other, in a large refugee sample.

METHODS

A secondary analysis of three face-to-face interview assessments conducted across 5 years with 894 adult refugee participants (M = 39.9 years, SD = 12.8) from the Building a New Life in Australia study was conducted. Symptoms of psychological distress, posttraumatic stress, and employment status were assessed on each occasion. Preliminary analysis identified the cross-sectional relationships between psychological distress, PTSD symptoms, and employment status, while cross-lagged models were used to identify the longitudinal relationships between these respective symptoms.

RESULTS

Symptoms of psychological distress and not being in paid work were significantly correlated with each other at each time point (ranging 0.09-0.25) and they reciprocally influenced each other over time. Likewise, PTSD symptoms and not being in paid work were correlated with each other after 3 years and 5 years (r = 0.21 and 0.23 respectively), and a reciprocal relationship between these was found over time.

CONCLUSION

The current findings indicate that interventions which target either mental health or work opportunities could have multiple downstream benefits for refugees.

Bio-Psychological Predictors of Acute and Protracted Fatigue After Burns: A Longitudinal Study

Objective

Fatigue after burns is often attributed to the hyperinflammatory and hypermetabolic response, while it may be best understood from a bio-psychological perspective, also involving the neuro-endocrine system. This longitudinal multi-center study examined the course of fatigue up to 18 months postburn. The contribution of bio-psychological factors, including burn severity, pain, and acute PTSD symptoms, to the course and persistence of fatigue was studied in a multifactorial model.

Methods

Participants were 247 adult burn survivors. Fatigue symptoms were assessed with the Multidimensional Fatigue Inventory during the acute phase and subsequently at 3, 6, 12, and 18 months postburn, and were compared to population norms. Age, gender, burn severity, acute PTSD symptoms and pain were assessed as potential predictors of fatigue over time in a latent growth model.

Results

At 18 months postburn, 46% of the burn survivors reported fatigue, including 18% with severe fatigue. In the acute phase, higher levels of fatigue were related to multiple surgeries, presence of pain, and higher levels of acute PTSD symptoms. Fatigue gradually decreased over time with minor individual differences in rate of decrease. At 18 months, pain and acute PTSD symptoms remained significant predictors of fatigue levels.

Conclusions

Protracted fatigue after burns was found in almost one out of five burn survivors and was associated with both pain and acute PTSD symptoms. Early detection of PTSD symptoms and early psychological interventions aimed at reducing PTSD symptoms and pain may be warranted to reduce later fatigue symptoms.

The association of probable PTSD at baseline and pain-related outcomes after chronic pain rehabilitation: A comparison of DSM-5 and ICD-11 criteria for PTSD

BACKGROUND

There is a high prevalence of posttraumatic stress disorder (PTSD) in patients with chronic pain. However, different patients are identified depending on the diagnostic system used. Moreover, it is unclear if the conceptualizations of PTSD are differently associated with outcomes of pain rehabilitation. Hence, the aims of the present study were first to explore the prevalence rates and diagnostic agreement of probable PTSD according to the ICD-11 and the DSM-5 screening tools (International Trauma Questionnaire [ITQ] vs. PTSD Checklist [PCL-5]), and secondly, to explore the associations of probable PTSD determined by ITQ and PCL-5 with psychological distress measures at baseline, and thirdly, the associations with pain and disability after pain rehabilitation adjusting for psychological covariates.

METHODS

A consecutive cohort of patients with chronic non-malignant pain (n = 152) referred to a Danish interdisciplinary pain center was assessed at baseline prior to their first visit and at follow-up three days after completed treatment.

RESULTS

The estimated probable PTSD baseline prevalence rates were 15.8% (ITQ) and 16.4% (PCL-5). However, the diagnostic agreement between the PCL-5 and the ITQ was only moderate (k = 0.64). Overall, compared to the ITQ probable PTSD according to the PCL-5 correlated more strongly with psychological distress. Only the ITQ was associated with poorer outcomes after rehabilitation, explaining alone 7-8% of the variance in disability and pain intensity adjusted for covariates.

CONCLUSIONS

The results underline the importance of taking the conceptualization and assessment of PTSD into consideration when investigating the impact of PTSD on pain rehabilitation.

SIGNIFICANCE

There is a high prevalence of probable PTSD in patients with chronic pain. However, different patients with probable PTSD are identified depending on the diagnostic system used. Although similar probable PTSD prevalence rates (about 16%) were found using DSM-5 and ICD-11 PTSD screening tools (PCL-5 and ITQ, respectively), the diagnostic agreement between the systems was only moderate (k = 0.64). At the same time, only probable PTSD estimated according to the ITQ and not the PCL-5 was a significant predictor of disability after pain rehabilitation.

Pain-related disability, PTSD symptoms, and mood among a comorbid chronic pain and PTSD sample prior to and during the COVID-19 pandemic

There is a knowledge gap when treating comorbid chronic pain and posttraumatic stress disorder (PTSD) during the COVID-19 pandemic. Addressing this gap, 169 individuals (57.4% female), aged 39.8 years were recruited based on levels of pain-related disability and PTSD symptoms. Participants were assessed prior to, and during, the COVID-19 pandemic. Improvements in pain-related disability were marginally attenuated for the comorbid group, compared to the chronic pain group. Results show that some condition-specific symptoms may not have been affected by the COVID-19 pandemic. Cautious interpretation is warranted due to only two time points and the lack of a diverse sample.

A Systematic Review of the Prospective Relationship between Child Maltreatment and Chronic Pain

Objective: The present systematic review aimed to evaluate the association between childhood maltreatment and chronic pain, with specific attention to the temporal nature of the relationship and putative moderators, including, the nature (type), timing of occurrence, and magnitude of maltreatment; whether physical harm or injury occurred; and whether post-traumatic stress disorder (PTSD) subsequently developed. Method: We included studies that measured the prospective relationship between child maltreatment and pain. Medline, EMBASE, PsycINFO, and CINAHL were searched electronically up to 28 July 2019. We used accepted methodological procedures common to prognosis studies and preregistered our review (PROSPERO record ID 142169) as per Cochrane review recommendations. Results: Nine studies (17,340 participants) were included in the present review. Baseline participant age ranged from 2 years to more than 65 years. Follow-up intervals ranged from one year to 16 years. Of the nine studies included, three were deemed to have a high risk of bias. With the exception of one meta-analysis of three studies, results were combined using narrative synthesis. Results showed low to very low quality and conflicting evidence across the various types of maltreatment, with the higher quality studies pointing to the absence of direct (non-moderated and non-mediated) associations between maltreatment and pain. PTSD was revealed to be a potential mediator and/or moderator. Evidence was not found for other proposed moderators. Conclusions: Overall, there is an absence of evidence from high quality studies of an association between maltreatment and pain. Our results are limited by the small number of studies reporting the relationship between child maltreatment and pain using a prospective design. High quality studies, including prospective cohort studies and those that assess and report on the moderators described above, are needed to advance the literature.

Self-reported traumatic etiology of pain and psychological function in tertiary care pain clinic patients: a collaborative health outcomes information registry (CHOIR) study

Background and aims A sizable body of research has elucidated the significant role of psychological reactions to trauma on pain coping and outcomes. In order to best inform intervention development and clinical care for patients with both trauma and pain at the tertiary care level, greater clarity is needed regarding the magnitude of these effects and the specific pathways through which they may or may not function at the time of first presentation to such a treatment setting. To achieve this, the current study examined the cross-sectional relationships between traumatic etiology of pain, psychological distress (anger, depressive symptoms, and PTSD symptoms), and pain outcomes (pain catastrophizing, physical function, disability status). Methods Using a structural path modeling approach, analyses were conducted using a large sample of individuals with chronic pain (n = 637) seeking new medical evaluation at a tertiary pain management center, using the Collaborative Health Outcomes Information Registry (CHOIR). We hypothesized that the relationships between traumatic etiology of pain and poorer pain outcomes would be mediated by higher levels of psychological distress. Results Our analyses revealed modest relationships between self-reported traumatic etiology of pain and pain catastrophizing, physical function, and disability status. In comparison, there were stronger relationships between indices of psychological distress and pain catastrophizing, but a weaker pattern of associations between psychological distress and physical function and disability measures. Conclusions To the relatively small extent that self-reported traumatic etiology of pain correlates with pain-related outcomes, these relationships appear to be due primarily to the presence of psychiatric symptoms and manifest most notably in the context of psychological responses to pain (i.e. catastrophizing about pain). Implications Findings from this study highlight the need for early intervention for patients with traumatic onset of pain and for clinicians at tertiary pain centers to include more detailed assessments of psychological distress and trauma as a component of comprehensive chronic pain treatment.

Post-injury benzodiazepine and opioid use among older adults involved in road traffic crashes: A Swedish register-based longitudinal study

AIM

Psychotropic drugs like opioids and benzodiazepines are prescribed for traumas resulting from road traffic crashes and the risk of developing an addiction deserves consideration. This study aims to shed light on how the consumption of those drugs evolves over time among older road traffic injury (RTI) victims.

METHODS

We conducted a nationwide Swedish register-based longitudinal study to identify trajectories of post-RTI psychotropic drug use. All individuals aged 50 years and older who had a hospital visit for an RTI from 2007 to 2015 were followed up during a 2-year period; those who used the drugs prior to the RTI were excluded. Trajectories were identified by performing latent class trajectory analysis on drug dispensation data for opioids and benzodiazepines separately (66 034 and 66 859 adults, respectively, in total).

RESULTS

Three trajectories were identified for opioids and four for benzodiazepines. The largest group in both instances included people with no-use/minimal use throughout the follow-up (81.3% and 92.8%). "Sporadic users" were more frequent among users of opioids (16.7%) than benzodiazepines (4.3%), whereas "chronic users" were found in similar proportions (2.0% and 1.8%). "Delayed chronic use" characterized the fourth group of benzodiazepine users (1.0%).

CONCLUSION

Several trajectories of psychotropic drug use were identified after RTI, from limited to chronic. Although chronic use was uncommon, a better understanding of the factors likely to increase that risk is warranted given the seriousness of the problem.

Military veterans with and without post-traumatic stress disorder: results from a chronic pain management programme

BACKGROUND AND AIMS

There is very little published evaluation of the treatment of military veterans with chronic pain, with or without post-traumatic stress disorder. Few clinical services offer integrated treatment for veterans with chronic pain and PTSD. Such veterans experience difficulty in accessing treatment for either condition: services may consider each condition as a contraindication to treatment of the other. Veterans are therefore often passed from one specialist service to another without adequate treatment. The veteran pain management programme (PMP) in the UK was established to meet the needs of veterans suffering from chronic pain with or without PTSD; this is the first evaluation.

METHODS

The PMP was advertised online via veteran charities. Veterans self-referred with accompanying information from General Practitioners. Veterans were then invited for an inter-disciplinary assessment and if appropriate invited onto the next PMP. Exclusion criteria included; current severe PTSD, severe depression with active suicidal ideation, moderate to severe personality disorder, or who were unable to self-care in the accommodation available. Treatment was by a team of experienced pain management clinicians: clinical psychologist, physiotherapist, nurse, medical consultant and psychiatrist. The PMP was delivered over 10 days: five residential days then five single days over the subsequent 6 months. The PMP combines cognitive behavioural treatment, which has the strongest evidence base, with more recent developments from mindfulness-based CBT for pain and compassion-focused therapy. Standard pain management strategies were adapted to meet the specific needs of the population, recognising the tendency to use demanding activity to manage post-traumatic stress symptoms. Domains of outcome were pain, mood, function, confidence and changes in medication use.

RESULTS

One hundred and sixty four military veterans started treatment in 19 programmes, and 158 completed. Results from those with high and low PTSD were compared; overall improvements in all domains were statistically significant: mood, self-efficacy and confidence, and those with PTSD showed a reduction (4.3/24 points on the IES-6). At the end of the programme the data showed that 17% reduced opioid medication and 25% stopped all opioid use.

CONCLUSIONS

Veterans made clinically and statistically significant improvements, including those with co-existing PTSD, who also reduced their symptom level. This serves to demonstrate the feasibility of treating veterans with both chronic pain and PTSD using a PMP model of care.

IMPLICATIONS

Military veterans experiencing both chronic pain and PTSD can be treated in a PMP adapted for their specific needs by an experienced clinical team.

Pain and Posttraumatic Stress Symptom Clusters: A Cross-Lagged Study

Pain and posttraumatic stress disorder (PTSD) frequently co-occur but underlying mechanisms are not clear. This study aimed to test the development and maintenance of pain and PTSD symptom clusters, i.e., intrusions, avoidance, and hyperarousal. The longitudinal study included 216 adults with burns. PTSD symptom clusters, indexed by the Impact of Event Scale-Revised (IES-R), and pain, using a graphic numerical rating scale (GNRS), were measured during hospitalization, 3 and 6 months post-burn. Cross-lagged panel analysis was used to test the relationships between pain and PTSD symptom clusters. Cross-lagged results showed that in-hospital intrusions predicted pain and avoidance 3 months post-burn. In-hospital pain predicted intrusions and avoidance 3 months post-burn and a trend was found for hyperarousal (90% CI). In the second wave, intrusions predicted pain and hyperarousal. Pain predicted hyperarousal. This study provides support for an entangled relationship between pain and PTSD symptoms, and particularly subscribes the role of intrusions in this bidirectional relationship. To a lesser extent, hyperarousal was unidirectionally related to pain. These results may subscribe the driving role of PTSD, particularly intrusions, which partly supports the Perpetual Avoidance Model.

There's Nothing Broken. You've Had a Whiplash, That's It: A Qualitative Study of Comorbid Posttraumatic Stress Disorder and Whiplash Associated Disorders

BACKGROUND

Posttraumatic stress disorder (PTSD) symptoms are common in chronic Whiplash associated disorders (WAD) and have been found to be associated with higher levels of pain and disability. Theoretical frameworks have suggested that PTSD and pain not only coexist, but also mutually maintain one another. Although the comorbidity has been subject to increasing quantitative research, patients' experiences of the comorbidity and symptom interaction remain largely uninvestigated using qualitative methods.

OBJECTIVE

The present study set out to explore the potential relationship of PTSD and pain in people with WAD and properly assessed PTSD after motor vehicle accidents.

METHODS

A qualitative explorative study of eight individual face-to-face semistructured interviews were conducted. Interviews were recorded and transcribed verbatim and analyzed using framework analysis.

RESULTS

Through the analysis, we developed three overarching themes. The first theme illustrated the complex and burdensome comorbidity with overlapping and transdiagnostic symptoms, whereas the second theme highlighted how several circumstances, some related to the health care system, could extend and amplify the traumatic response. The final theme illustrated symptom associations and interactions, particularly between pain and PTSD, both supporting and rejecting parts of the mutual maintenance framework.

CONCLUSIONS

These findings underlined the great complexity and variability of the comorbidity and the traumatic event, but also emphasized how experiences of psyche and soma seem closely connected in these patients. The results provide support for the importance of thorough assessment by multidisciplinary teams, minimizing distress post-injury, and a critical approach to the idea of mutual maintenance between pain and PTSD.

Trajectories of depression in sepsis survivors: an observational cohort study

BACKGROUND

Advances in critical care medicine have led to a growing number of critical illness survivors. A considerable part of them suffers from long-term sequelae, also known as post-intensive care syndrome. Among these, depressive symptoms are frequently observed. Depressive symptom trajectories and associated factors of critical illness survivors have rarely been investigated. Study objective was to explore and compare different trajectories of depressive symptoms in sepsis survivors over 1 year after discharge from ICU.

METHODS

Data of a randomized controlled trial on long-term post-sepsis care were analyzed post hoc. Depressive symptoms were collected at 1, 6 and 12 months post-ICU discharge using the Major Depression Inventory (MDI), among others. Statistical analyses comprised descriptive analysis, univariate and multivariate, linear and logistic regression models and Growth Mixture Modeling.

RESULTS

A total of 224 patients were included into this analysis. We identified three latent classes of depressive symptom trajectories: Over the course of 1 year, 152 patients recovered from mild symptoms, 27 patients showed severe persistent symptoms, and 45 patients recovered from severe symptoms. MDI sum scores significantly differed between the three classes of depressive symptom trajectories at 1 and 6 months after ICU discharge (p < 0.024 and p < 0.001, respectively). Compared with other classes, patients with the mild recovered trajectory showed lower levels of chronic pain (median sum score of 43.3 vs. 60.0/53.3 on the Graded Chronic Pain Scale, p < 0.010) and posttraumatic stress (4.6% with a sum score of ≥ 35 on the Posttraumatic Stress Scale 10 vs. 48.1%/33.3%, p < 0.003); and higher levels of health-related quality of life (HRQOL) using the Short Form-36 scale within 1 month after ICU discharge (p < 0.035).

CONCLUSIONS

In the first year after discharge from ICU, sepsis survivors showed three different trajectories of depressive symptoms. Course and severity of depressive symptoms were associated with chronic pain, posttraumatic stress and reduced HRQOL at discharge from ICU. Regular screening of sepsis survivors on symptoms of depression, chronic pain and posttraumatic stress within 1 year after ICU may be considered. Trial registration ISRCTN, ISRCTN 61744782. Registered April 19, 2011-Retrospectively registered, http://www.isrctn.com/ISRCTN61744782 .

Validation of the Danish International Trauma Questionnaire for posttraumatic stress disorder in chronic pain patients using clinician-rated diagnostic interviews

Background: The estimated prevalence rate of comorbid posttraumatic stress disorder (PTSD) is high in trauma-exposed chronic pain patients. At the same time, self-report measures of PTSD tend to be over-inclusive within this specific population due to the high symptom overlap resulting in potential false positives. There is a need for an updated PTSD screening tools with a proper validation against clinical interviews according to the recently published 11^th revision of the World Health Organization's International Classification of Diseases (ICD-11). Objective: The present study aimed to validate the Danish International Trauma Questionnaire (ITQ) PTSD part in a sample of trauma-exposed chronic pain patients. Method: The ITQ was validated using a clinician-rated diagnostic interview of ICD-11 PTSD among chronic pain patients exposed to accident or work-related trauma (N = 40). Construct validity, concurrent and discriminant validity was investigated using confirmatory factor analyses (CFA) and correlation analysis, respectively. Three CFA models of ITQ PTSD part were tested in a sample of trauma-exposed chronic pain patients (N = 1,017) and a subsample of chronic pain patients exposed to accident or work-related trauma only (n = 367). Results: Diagnostic consistency between the six ICD-11 PTSD symptoms derived from the ITQ and the clinical interview (κ = .59) and the overall accuracy of the scale (AUC = .90) were good. The Danish ITQ showed excellent construct, concurrent and discriminant validity. The ICD-11 three factor PTSD model had excellent fit in both the full sample and the subsample of traffic and work-related accidents. Conclusions: The results indicate that the ITQ also has good psychometric properties in patients with chronic pain.

Different Patterns of Mental Health Outcomes among Road Traffic Crash Survivors: A Prospective Cohort Study

This study aimed to investigate factors associated with the symptoms of mental disorders following a road traffic crash (RTC). A prospective cohort of 200 people was followed for 6 months after experiencing an RTC. The cohort was comprised of uninjured survivors and injured victims with all levels of road traffic injury (RTI) severity. Multivariable logistic regression analyses were performed to evaluate the associations between the symptoms of depression, posttraumatic stress disorder and anxiety one and six months after the RTC, along with sociodemographic factors, health status before and after the RTC, factors related to the RTI and factors related to the RTC. The results showed associations of depression, anxiety, and posttraumatic stress disorder symptoms with sociodemographic factors, factors related to the health status before and after the RTC and factors related to the RTC. Factors related to the RTI showed associations only with depression and posttraumatic stress disorder symptoms. Identifying factors associated with mental disorders following an RTC is essential for establishing screening of vulnerable individuals at risk of poor mental health outcomes after an RTC. All RTC survivors, regardless of their RTI status, should be screened for factors associated with mental disorders in order to successfully prevent them.

Neurophysiological relationship of neuromuscular fatigue and stress disorder in PTSD patients

INTRODUCTION

Apart from mental disorders, other complications that have been reported in some patients with Post-Traumatic Stress Disorder (PTSD), include physical pain and being quick to fatigue, which can severely affect the patients' daily life. Therefore, this study aims to evaluate the relationship between PTSD and physical fatigue in people with PTSD.

METHOD

18 military men with (n = 9) and without PTSD (n = 9), with an age range of 45-60 years, volunteered to participate. They were randomly assigned into two groups: PTSD and non-PTSD groups. Recording of the surface electromyography (EMG) in a specific muscle was conducted twice in both groups, once at baseline and then again after a single session of fatiguing exercise. Data were analyzed by ANOVA with repeated measure (2✕2) at the significance level of 0.05.

RESULTS

Results showed that there was a significant main effect of intervention on electrical activity and neural conduction variables in the PTSD group (p = 0.04, p = 0.02). There was also an effect of time for the both variables (P < 0.001).

CONCLUSION

Stress disorders may affect the time to fatigue in PTSD patients and subsequently cause some difficulties in their daily life.

Autonomic Rehabilitation: Adapting to Change

Adaption to changes of external environment or internal health, the body-mind connection, or autonomic nervous system must be flexible and healthy. Population health studies with wearable technology and remote monitoring will lead to paradigm shifts in how to approach the physiology of emotion. Heart rate variability as a whole health biomarker could emerge as a foundation for a process beginning with objective habits and skills of real-time modulation with focused breathing for healthier decision making and autonomic health trajectory change. Physical medicine and rehabilitation is uniquely poised to refine an autonomic rehabilitation process in an integrative manner to help individuals adapt.

Body therapy versus treatment as usual among Danish veterans with PTSD: Study protocol for a randomised controlled trial combined with a qualitative study

BACKGROUND

Many veterans suffer from Post-Traumatic Stress Disorder (PTSD) after returning from military missions. This implies complex physical and psychosocial problems for veterans and their families. Treatment options today are primarily medically and psychologically founded but treatment response is incomplete. Body therapy for PTSD is scarcely researched though subject of increased attention. In 2015, a Danish pilot study was conducted exploring body therapy for PTSD. The study showed positive results and formed basis for a randomised controlled trial. This paper outlines the protocol for this trial.

METHODS

The intervention will be evaluated in a two-arm randomised controlled trial (1:1). The trial will include 42 veterans with PTSD recruited by the Danish Military Psychiatric Centre. The intervention group receives treatment as usual and weekly body therapy treatment as add-on. The control group receives treatment as usual (TAU). Participants will complete four questionnaires assessing PTSD, depression, quality of life, function level and body awareness: at baseline, and at 3 months, 6 months and 12 months post baseline. Linear regression models and mixed effects models will be used to assess intervention effects. Furthermore, an ethnographic study will examine how the participants experience the treatment and changes in their everyday life. The ethnographic study is based on in-depth interviews, participant observations and focus groups. A mixed method, convergent parallel design will be applied.

DISCUSSION

This study examines the efficacy of body therapy for veterans with PTSD and how the treatment is experienced and affects daily life. The study will contribute with important knowledge on an alternative treatment for PTSD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03777800.

Somatic Experiencing® for patients with low back pain and comorbid posttraumatic stress symptoms - a randomised controlled trial

BACKGROUND

Low back pain (LBP) and comorbid post-traumatic stress symptoms (PTSS) are common after traumatic injuries, and a high level of PTSS is associated with more severe pain and pain-related disability. Few randomised controlled trials (RCT) exist targeting comorbid PTSS and chronic pain, and only one has assessed the effect of Somatic Experiencing®.

OBJECTIVE

The aim of this study was to assess the effect of Somatic Experiencing® (up to 12 sessions) + physiotherapeutic intervention (4-8 sessions) (SE+PT) compared with the physiotherapeutic intervention alone (4-8 sessions) (PT) for pain-related disability in LBP with comorbid PTSS.

METHODS

The study was a two-group RCT in which participants (n = 114) were recruited consecutively from a large Danish Spine Centre. Patients were randomly allocated to either SE+PT or PT alone. Outcomes were collected at baseline before randomisation, 6 and 12-month post-randomisation. The primary outcome was pain-related disability as measured with the modified version of the Roland Morris Disability Questionnaire at 6-month post-randomisation. Secondary outcomes were PTSS, pain intensity, pain-catastrophising, kinesiophobia, anxiety and depression.

RESULTS

No significant group differences were found on any of the outcomes at any timepoints. Both groups achieved a significant reduction in pain-related disability (20-27%) as measured by the Roland Morris Disability Questionnaire at 6 and 12-month follow up. Also, both groups achieved a small reduction in PTSS.

CONCLUSIONS

Although significant effects were achieved for both groups, the additional SE intervention did not result in any additional benefits in any of the outcomes.

Association of fear-avoidance and self-efficacy on pain disability in individuals with co-morbid post-traumatic stress and chronic pain

This study investigated relationships between post-traumatic stress symptoms (PTSS) and pain disability. Fifty people with chronic pain (probable PTSD, n = 22) completed measures assessing pain interference, PTSS, fear avoidance, and pain self-efficacy. We hypothesized that people with probable PTSD would have higher fear avoidance and lower pain self-efficacy; and that PTSS would be indirectly associated with pain disability via fear avoidance and self-efficacy. People with probable PTSD had higher fear avoidance, but there were no differences in self-efficacy, pain severity or disability. There was an indirect association between PTSS and pain disability via fear avoidance, but not via self-efficacy.

How are pain and traumatic stress symptoms related in acute whiplash-associated disorders? An investigation of the role of pain-related fear in a daily diary study

Comorbidity of pain and posttraumatic stress disorder is well recognized, but the reason for this association is unclear. This study investigated the direction of the relationship between pain and traumatic stress and the role that pain-related fear plays, for patients with acute whiplash-associated disorder. Participants (n = 99) used an electronic diary to record hourly ratings of pain, traumatic stress, and fear of pain (FOP) symptoms over a day. Relationships between pain, traumatic stress, and pain-related fear symptoms were investigated through multilevel models including variables lagged by 1 hour. Traumatic stress was associated with previous pain, even after controlling for previous traumatic stress and current pain; current pain was not associated with previous traumatic stress. The relationship between traumatic stress and previous pain became negligible after controlling for FOP, except for traumatic stress symptoms of hyperarousal that were driven directly by pain. Overall, these results support a pain primacy model, and suggest that pain-related fear is important in the maintenance and development of comorbid pain and traumatic stress symptoms. They also confirm that traumatic stress symptoms of hyperarousal are central in this relationship. Differences between this study and others that reported mutual maintenance can be understood in terms of different stages of whiplash-associated disorder and different intervals between repeated measurements. Traumatic stress may affect pain over longer time intervals than measured in this study. Future research could explore how relationships between traumatic stress symptoms, pain, and FOP change over time, and whether previous experiences of traumatic stress influence these relationships.

Different clinical phenotypes of persistent post-traumatic headache exhibit distinct sensory profiles

INTRODUCTION

Persistent post-traumatic headache remains a poorly understood clinical entity. Although there are currently no accepted therapies for persistent post-traumatic headache, its clinical symptoms, which primarily resemble those of migraine or tension-type headache, often serve to guide treatment. However, evidence-based justification for this treatment approach remains lacking given the paucity of knowledge regarding the characteristics of these two major persistent post-traumatic headache phenotypes and their etiology.

METHODS

We compared clinical features and quantitative sensory testing profiles between two distinct cohorts of persistent post-traumatic headache subjects that exhibited symptoms resembling either migraine (n = 15) or tension-type headache (n = 13), as well as to headache-free subjects that had suffered traumatic brain injury (n = 19), and to healthy controls (n = 10). We aimed to determine whether the two persistent post-traumatic headache subgroups could be discriminated based on additional clinical features, distinct quantitative sensory testing profiles, or the interaction of pain severity with the level of post-traumatic stress disorder.

RESULTS

Persistent post-traumatic headache subjects with migraine-like symptoms reported that bright light and focused attention aggravated their pain, while stress and nervousness were reported to aggravate the headache in subjects with tension-type headache-like symptoms. Quietness was better in alleviating migraine-like persistent post-traumatic headache, while anti-inflammatory medications provided better relief in tension-type headache-like persistent post-traumatic headache. The two persistent post-traumatic headache subgroups exhibited distinct quantitative sensory testing profiles with subjects exhibiting tension-type headache-like persistent post-traumatic headache displaying a more pronounced cephalic and extracephalic thermal hypoalgesia that was accompanied by cephalic mechanical hyperalgesia. While both persistent post-traumatic headache subgroups had high levels of post-traumatic stress disorder, there was a positive correlation with pain severity in subjects with tension-type headache-like symptoms, but a negative correlation in subjects with migraine-like symptoms.

CONCLUSIONS

Distinct persistent post-traumatic headache symptoms and quantitative sensory testing profiles may be linked to different etiologies, potentially involving various levels of neuropathic and inflammatory pain, and if confirmed in a larger cohort, could be used to further characterize and differentiate between persistent post-traumatic headache subgroups in studies aimed to improve treatment.

Challenges in anaesthesia and pain management for burn injuries

Burn-injured patients provide unique challenges to those providing anaesthesia and pain management. This review aims to update both the regular burn anaesthetist and the anaesthetist only occasionally involved with burn patients in emergency settings. It addresses some aspects of care that are perhaps contentious in terms of airway management, fluid resuscitation, transfusion practices and pharmacology. Recognition of pain management failures and the lack of mechanism-specific analgesics are discussed along with the opioid crisis as it relates to burns and nonpharmacological methods in the management of distressed patients.

Post-Traumatic Stress Disorder Symptoms from Multiple Stressors Predict Chronic Pain in Cancer Survivors

Background: Despite the association between chronic pain and post-traumatic stress disorder (PTSD), little is known about the longitudinal course of pain and PTSD during cancer treatment. Objectives: We examined the prevalence of PTSD and chronic pain at three time periods in veterans with a diagnosis of cancer, and the relationship between the experience of pain and PTSD. Methods: Participants (N = 123) with oral-digestive cancers were recruited from the Veterans Healthcare System (age M = 65.31 and SD = 9.13; 98.4% male) and completed face to face interviews at 6, 12, and 18 months post-diagnosis. Measures included the Post-traumatic Stress Disorder Checklist-Stressor-Specific version (PCL-S), Primary care PTSD (PC-PTSD), and the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Impact Scale. Results: About one-third (26.8%) of the sample had chronic pain, defined as elevated pain at two time periods. About one-fifth (20.3%) endorsed symptoms of combat-related PTSD at 6 months, and 22.8% endorsed symptoms of cancer-related PTSD, exceeding a clinical cutoff for older adults (12 months = 21.1%, 18 months = 23.1%). Changes over time were observed for cancer-related PTSD symptom clusters of hyperarousal (F = 3.85 and p = 0.023) and emotional numbing (F = 4.06 and p = 0.018) with a statistically significant quadratic function increasing at 18 months. In logistic regression, individuals with both combat and cancer-related PTSD symptoms at six months had 8.49 times higher odds of experiencing chronic pain (χ² = 25.91 and p < 0.001; R² = 0.28). Conclusions: Persisting pain may be a concern in veterans with cancer. Individuals who have experienced traumatic events with persisting PTSD symptoms may be at elevated risk for chronic pain. Veterans with PTSD symptoms from both cancer and combat are at the highest risk to experience chronic pain.

Predictors of Mental Health Outcomes in Road Traffic Accident Survivors

Mental health outcomes of road traffic accidents (RTAs) are always investigated in assessments of those involved. The aim of this study was to investigate the psychological consequences and associated factors in all RTA survivors, irrelevant of their injury status. A cohort of 155 people was assessed one month after experiencing a RTA using self-reported measures for posttraumatic stress disorder (PTSD), depression, and anxiety. Associations between mental health outcomes and sociodemographic factors, pre-RTA health status, injury-related factors, and RTA details were analyzed. RTA survivors reported substantial rates of PTSD (32.3%) and depression (17.4%) symptoms, and low rates of anxiety (5.8%). Symptoms of depression were associated with below-average self-perceived economic status, irreligiousness, medication use, psychiatric medication use, and injury-related factors. PTSD symptoms were associated with female gender, below-average self-perceived economic status, previous psychiatric illness, medication use, psychiatric medication use, not being at fault in the relevant RTA, claiming compensation, and injury-related factors. Anxiety symptoms were associated with previous chronic or psychiatric illness, previous permanent pain, psychiatric medication use, and self-perceived threat to life, but not with sustaining injury. Along with the evaluation and treatment of RTA injuries, health care providers should evaluate the pre-RTA health status of all RTA victims. Psychological support to those at risk may prevent psychological disorders after RTAs.

Heightened risk of pain in young adult women with a history of childhood maltreatment: a prospective longitudinal study

A child maltreatment history is reported more frequently among adults with chronic pain compared with the general population; unfortunately, studies have primarily relied upon retrospective maltreatment reports by adults with chronic pain. This prospective study assessed pain symptoms in a cohort of young adult women with a documented history of child maltreatment, compared with a matched cohort of women who did not experience childhood maltreatment. Young women (N = 477) were recruited between ages 14 to 17 years and followed annually to age 19. Of these women, 57% experienced maltreatment (ie, physical, sexual, or emotional abuse, neglect; n = 273) substantiated by child welfare record. Maltreated women were demographically matched to nonmaltreated women, also confirmed by child welfare record. In adolescence, post-traumatic stress was assessed. Women were contacted as young adults (Mage = 24.76; n = 383) and surveyed about their pain experiences, including the presence of pain in the past week, pain severity (0-10), and number of body areas with pain. Mediation path analyses examining the impact of maltreatment and adolescent post-traumatic stress on young adult pain were estimated through structural equation modeling. As adults, women who had experienced child maltreatment reported higher pain intensity, a greater number of pain locations, and were more likely to experience pain in the previous week than nonmaltreated women. Adolescent post-traumatic stress partially explained the effects of maltreatment on pain. Young adult women who experienced child maltreatment are at higher risk of pain, particularly when they also experienced post-traumatic stress as adolescents.