The biopsychosocial model of pain 40 years on: time for a reappraisal?

Pain-on-a-Chip: A microfluidic device for neuron differentiation and functional discrimination in animal models of chronic pain

Chronic pain is a global health issue that is poorly understood and challenging to treat. Improving pain classification and treatment requires new strategies that objectively discriminate between pain conditions and minimise subjectivity associated with the perception of pain. To address this, we have developed a microfluidic biosensor - termed 'pain-on-a-chip' - that leverages recent advancements in biocompatible microfluidic technology with on-chip differentiation of nociceptor-like cells, enabling small sample volumes to be used. Following neuronal differentiation, we used on-chip live cell Ca2+ imaging to functionally validate the system. This includes characterising excitation responses in cells challenged with microfluidic perfusion of known nociceptive stimuli and biological fluids collected from different preclinical pain models. Our results demonstrate that this platform has the potential to discriminate between serum samples from distinct chronic pain models. This system has potential as an objective, and minimally invasive method for distinguishing between different subtypes of chronic pain.

"I am not pain, I have pain": A pilot study examining iRest yoga nidra as a mind-body intervention for persistent pain

PURPOSE

This pilot study was the first of its kind to examine the experiences of people with persistent pain engaging in a six-week iRest for Pain group program as part of multidisciplinary pain care.

METHOD

The present study used a qualitative, phenomenological design and reflexive thematic analysis to gain an understanding of the firsthand experience of patients who participated in the iRest for Pain group program. This program was offered in a specialist outpatient pain management service within a regional public hospital in Victoria, Australia.

RESULTS

Participants reported they experienced iRest Yoga Nidra as personal and therapeutic, that the practice facilitated deep relaxation and restoration; for some participants trauma reprocessing and integration; improved pain self-management and self-efficacy, as well as dis-identification from persisting pain as personal identity. Additionally, some participants reported motivation and confidence to use iRest instead of medication, to reduce dependence on opioid medications.

CONCLUSION

The iRest for Pain group program presents a personally therapeutic and innovative mind-body intervention, which could be offered at various phases from primary to tertiary specialised pain care.

Exploring Pain-Severity and Psychological-Flexibility Trajectories During Group-Based Psychotherapy for Chronic Pain

This study aimed to identify subgroups of patients sharing similar outcome trajectories during group-based psychotherapy for chronic pain, to explore baseline predictors of trajectories, and to describe clinical outcomes as a function of these trajectories. Participants (n = 71) underwent eight weekly sessions of group psychotherapy for chronic pain at a tertiary care multidisciplinary pain treatment center. Pain outcomes, psychological distress, sleep, pain acceptance, and psychological inflexibility were assessed before, during, directly after, and 3 months after the intervention. Using growth mixture modeling, three to four trajectories were identified for pain-severity and psychological-flexibility symptoms during treatment; baseline levels of depression, pain severity, and psychological flexibility predicted trajectory membership. More research is needed to better understand the mechanisms underlying patients' variability in trajectories of symptom change across treatment.

The Relationship Between Pain Catastrophizing and Spiritual Well-Being in Adult Cancer Patients: A Cross-Sectional Observational Study

CONTEXT

Chronic cancer-related pain adversely affects patients' physical and psychological well-being. Pain catastrophizing intensifies pain perception and emotional distress, whereas spiritual well-being may provide essential coping mechanisms. The interplay between spiritual well-being and pain catastrophizing in cancer patients is not thoroughly studied.

OBJECTIVES

To investigate the relationship between spiritual well-being and pain catastrophizing in cancer patients experiencing chronic pain.

METHODS

A cross-sectional observational study was conducted from June 2023 to June 2024 at cancer center enrolling patients with cancer and pain intensity ≥4/10. Participants completed the Pain Catastrophizing Scale and the FACIT-Spiritual Well-being Scale (FACIT-Sp-12) including the domains Meaning, Peace, Faith. Demographic data, symptom burden, and Karnofsky performance status were also collected. A Generalized Additive Model was employed to assess associations between scores of Pain Catastrophizing Scale and spiritual well-being domains, controlling for symptom burden and demographic variables.

RESULTS

Ninety-seven patients, mostly male, with gastrointestinal cancer, a mean age of 62.9 years and mean Karnofsky score 44.4 (SD 7.7) completed the study. Higher levels of Peace (β = -1.96, p = 0.004) and Faith (β = -0.99, P = 0.031) were significantly associated with lower pain catastrophizing, while meaning was not significantly associated (β = 0.87, P = 0.237). Increased symptom burden was positively correlated with higher pain catastrophizing (β = 0.16, P = 0.005). The model explained 38.9% of the variance in pain catastrophizing scores (Adjusted R² = 0.389).

CONCLUSION

Spiritual well-being, specifically the Peace and Faith domains, is inversely related to pain catastrophizing in cancer patients. Integrating spiritual care into pain management strategies may enhance coping mechanisms and reduce emotional distress, thereby improving patients' quality of life.

Understanding the individual's transition from acute to chronic disabling pain: Opportunities for improved care

When acute pain persists, it is said to become chronic after 3 months. Considerable interest has focused on why acute pain appears to transition to chronic pain in some cases, but not all, especially when it becomes disabling. We examine our current understanding of the processes involved in the progression from an acute injury to disabling chronic pain. Rather than viewing this progression as a time dependent transition with specific static risk factors, we consider whether it might be more helpful to understand this evolution in terms of unique individual pathways. While brief self-report screening questionnaires assessing risk factors may enable us to stratify patients into risk levels, they do not provide information on the unique context and factors contributing to the disabling pain for each person. It is proposed that a 2-step process combining screening and individual assessment of those at high risk will enhance the prospect of both early identification and individually relevant interventions before more lasting changes emerge. Rather than being concerned with arbitrary time limits, it is argued that by aiming to understand the unique developmental pathway for those individuals identified as high risk, early, preventive interventions will be both viable and effective. Even so, there are barriers to the implementation of early assessment and matched treatments, and these remain a challenge for future research.

Living successfully with chronic pain: Identifying the pivotal conditions needed to make it happen

Chronic pain is associated with many negative consequences for individuals and society. Given the burden it represents, many studies have focused on the risk factors involved, but very few have aimed to explain why some people live well with chronic pain, beyond the psychological realm. Thus, this study collected and analyzed different individual experiences to identify the pivotal conditions that help some individuals achieve quality of life despite chronic pain, with an emphasis on social considerations. We conducted a qualitative study using a narrative inquiry approach to unpack the participants' stories on these pivotal conditions. We carried out 25 individual interviews with persons who considered they had been living well with their pain for a minimum of 6 months. Data were analyzed using the inductive narrative method. Most participants were women (64%), White (88%), with a high level of education, and having low back or generalized pain (56%). Three main themes were identified: 1) a care partnership, 2) a nurturing environment, and 3) breaking free from previous life to move forward. These themes were then divided into 11 sub-themes, providing an in-depth understanding of the pivotal conditions needed to live well with chronic pain. The data collected suggest that to enable people to have a favorable evolution in the presence of chronic pain, a socio-ecological approach could be necessary to counteract painogenic environments. However, these results need to be validated and adapted to different populations. Perspective This study highlights the importance of a socio-ecological approach to living well with chronic pain, emphasizing that care partnerships, a nurturing environment and the ability to break with the past are essential to improve the quality of life of those affected.

Oral pain and comorbidities in an edentulous older population: A k-prototypes cluster analysis

Non-odontogenic oral pain is prevalent among the older people and significantly impacts their quality of life. Non-odontogenic oral pain is usually persistent and accompanied by comorbidities such as psychosocial distress and sleep-related problems, which further complicate pain management. The relationship between non-odontogenic oral pain and comorbidities in the older people, however, has not been well documented. This study aimed to identify the factors associated with non-odontogenic oral pain in an edentulous older population and to subgroup this population based on the patterns of oral pain and its associated factors. In this cross-sectional study, data from completely edentulous individuals in the National Health and Nutrition Examination Survey for the period from 2017 to 2020 March (pre-pandemic) were analysed. Associations and correlations between oral pain and 46 other variables, including demographic, questionnaire, examination and laboratory data, were investigated using Pearson's chi-squared test and Spearman's rank correlation test. A p value of < 0.05 was considered statistically significant. Clustering of the data was performed using the k-prototypes algorithm, an unsupervised machine learning. Approximately 42% of the edentulous older people experienced oral pain. 'Having been told to take daily low-dose aspirin' was significantly associated with oral pain. Oral pain was positively correlated with depressive symptoms and excessive daytime sleepiness (EDS), and negatively correlated with diastolic blood pressure, red blood cell count, haemoglobin level and haematocrit. The k-prototypes algorithm identified a cluster characterised by frequent oral pain, depression and EDS. This study identified distinct patterns of comorbidities among edentulous older people living with oral pain.

Supported biopsychosocial self-management for back-related leg pain: a randomized feasibility study integrating a whole person perspective

BACKGROUND

There is limited high-quality research examining conservative treatments for back-related leg pain (BRLP). This feasibility study was done in preparation for a full-scale trial comparing a whole-person supported self-management intervention to medical care for chronic BRLP.

METHODS

Participants were randomized to 12 weeks of individualized supported self-management delivered by physical therapists and chiropractors or medical care consisting of guideline-based pharmacologic care. Supported self-management was based on a behavioral model that used a whole person approach to enhance participants capabilities, opportunities, and motivations to engage in self-care. It combined BRLP education with psychosocial strategies (e.g., relaxed breathing, progressive muscle relaxation, guided imagery, communication skills) and physical modalities such as exercise and spinal manipulation therapy. Providers were trained to address participants' individualized needs and use behavior change and motivational communication techniques to develop a therapeutic alliance to facilitate self-management. Feasibility was assessed using pre-specified targets for recruitment and enrollment, intervention delivery, and data collection over the six-month study period. In addition, areas for potential refinement and optimization of processes and protocols for the full-scale trial were assessed.

RESULTS

We met or exceeded nearly all feasibility targets. Forty-two participants were enrolled over a six-month period in 2022 and very few individuals declined participation due to preferences for one treatment. All but one participant received treatment and 95% of participants attended the minimum number of visits (self-management = 6, medical care = 2). At 12 weeks, 95% of participants in the self-management group reported engaging in self-management practices learned in the program and 77% of medical care participants reported taking medications as prescribed. Satisfaction with the self-management intervention was high with 85% of participants reporting satisfaction with the program overall. Self-management intervention providers delivered all required activities at 72% of visits. Providers also noted some challenges navigating the shared decision-making process and deciding what self-management tools to prioritize. Over the six-month study period, completion rates were 91% for monthly surveys and 86% for weekly surveys.

CONCLUSION

We were able to demonstrate that a full-scale randomized trial comparing a whole-person supported self-management intervention to medical care for chronic BRLP is feasible and identified important areas for optimization.

Examining the Effectiveness and Acceptability of Internet-Delivered Psychological Pain Management for Regional and Rural Australians With Chronic Pain

OBJECTIVE

To examine the characteristics, satisfaction levels and clinical outcomes of rural and remote Australians with chronic pain completing an internet-delivered psychological pain management program (PMP).

DESIGN

Longitudinal routine care cohort study.

SETTING

An Australian national digital psychology service.

PARTICIPANTS

Patients in inner regional locations (n = 401), outer regional and remote locations (n = 198), and major cities (n = 968), who used the service over a 6-year period.

MAIN OUTCOME MEASURES

Demographic and clinical data, patient-reported satisfaction and improvements, and meaningful clinical improvements (≥ 30% improvement).

RESULTS

Clinical improvements were observed from pre-treatment to post-treatment in pain-related disability (32% [95% CI: 29, 34]), depression symptoms (44% [95% CI: 39, 49]), anxiety symptoms (43% [95% CI: 39, 47]), and average pain intensity (23% [95% CI: 21, 26]), which were maintained to 3-month follow-up. High levels of satisfaction and treatment completion were also observed. Minor demographic and clinical differences were observed. However, there were similar rates of clinical improvement, treatment satisfaction and treatment completion in all groups.

CONCLUSIONS

The current findings further highlight the value of internet-delivered psychological PMPs for Australians with chronic pain living in regional and remote parts of the country. Further work is needed to raise awareness about the availability of these effective programmes and to integrate their use with traditional pain management services.

Experiences of cross-sectoral collaboration between social security service and healthcare service for patients with chronic pain - a qualitative study

OBJECTIVES

Patients with chronic pain need healthcare services for pain management. Many also require social security services due to potential negative influence of chronic pain on social and work-related issues. The aim of this study was therefore to investigate the experiences of taking part in cross-sectoral collaborative meetings between social security service and healthcare service for chronic pain patients.

METHODS

A qualitative study using semi-structured individual interviews with 15 informants, including healthcare providers, patients, and social security supervisors who had taken part in 8 different meetings, was conducted. The focus of the interviews was how the informants experienced cross-sectoral collaborative meetings. The data were analyzed following the systematic text condensation method, including the steps of total impression, identifying meaning units, condensation, and synthesizing.

RESULTS

The findings were categorized into four themes: "Joining the meeting with preconceptions," which showed how some informants experienced that negative preconceptions toward the social security service were addressed in the cross-sectoral collaborative meetings and solved in some cases. "Get to know each other," which highlighted that the meetings provided opportunities for participants to increase their knowledge about the involved actors. "Access to detailed health information?" indicated that although concerns about whether sensitive health information should be shared with social security supervisors were raised by healthcare providers, the supervisors found this issue to be less concerning. Finally, "Who has the final word?", which showed that unclarity over decision-making processes during the meetings was experienced to create disagreement between participants.

CONCLUSIONS

The informants experienced that cross-sectoral collaborative meetings between patients, social security supervisors, and healthcare providers, while challenging, can play a significant role in managing the needs of patients with chronic pain. The study highlights the need for clarification over the roles of the actors and a jointly agreed-upon agenda for the meetings to ensure effective collaboration.

A pain research strategy for Europe: A European survey and position paper of the European Pain Federation EFIC

BACKGROUND

Pain is the leading cause of disability and reduced quality of life worldwide. Despite the increasing burden for patients and healthcare systems, pain research remains underfunded and under focused. Having stakeholders identify and prioritize areas that need urgent attention in the field will help focus funding topics, reduce 'research waste', improve the effectiveness of pain research and therapy and promote the uptake of research evidence. In this study, the European Pain Federation (EFIC) developed a Pain Research Strategy for Europe.

METHODS

The study used multiple methods, including literature searches, multidisciplinary expert debate, a survey and a final consensus meeting. The cross-sectional survey was conducted among 628 European pain researchers, clinicians, educators and industry professionals to obtain the rating and hierarchy of pain research priorities. The final consensus meeting involved a multidisciplinary expert panel including people with lived experience from 23 countries. The survey results guided discussions where top priorities were agreed.

RESULTS

Content analysis identified nine survey themes, of which five emerged as top priorities: (i) understand the pathophysiology of pain; (ii) understand and address comorbidities; (iii) critically assess current therapies; (iv) develop new treatments; and (v) explore the biopsychosocial impacts of pain. Physical, psychological and social approaches were prioritized at the same level as pharmacological treatments. The top priorities were endorsed by a multidisciplinary expert panel. The panel emphasized the importance of also clearly communicating the concepts of prediction, prevention self-management and personalized pain management in the final strategy.

CONCLUSIONS

The content of the final top research priorities' list reflects a holistic approach to pain management. The equal importance given to physical, psychological and social aspects alongside pharmacological treatments highlights the importance of a comprehensive biopsychosocial-orientated research strategy. The expert panel's endorsement of five top priorities, coupled with an emphasis on communicating the concepts of prediction, prevention, self-management and personalized pain management, provides a clear direction for future basic, translational and clinical research.

SIGNIFICANCE

EFIC has developed a Pain Research Strategy for Europe that identifies pain research areas deserving the most focus and financial support. Implementation and wide dissemination of this Strategy is vital to increase the conduct of urgent pain projects, pain research funding and the implementation of research findings into practice, to ultimately decrease the personal, societal and financial burden of pain.

Stratified health care for low back pain using the STarT Back approach: holy grail or doomed to fail?

ABSTRACT

There have been at least 7 separate randomised controlled trials published between 2011 and 2023 that have examined primary care for nonspecific low back pain informed by the STarT Back approach to stratified care based on risk prediction, compared with care not informed by this approach. The results, across 4 countries, have been contrasting-some demonstrating effectiveness and/or efficiency of this approach, others finding no benefits over comparison interventions. This review considers possible explanations for the differences, particularly whether this is related to poor predictive performance of the STarT Back risk-prediction tool or to variable degrees of success in implementing the whole STarT Back approach (subgrouping and matching treatments to predicted risk of poor outcomes) in different healthcare systems. The review concludes that although there is room for improving and expanding the predictive value of the STarT Back tool, its performance in allocating individuals to their appropriate risk categories cannot alone explain the variation in results of the trials to date. Rather, the learning thus far suggests that challenges in implementing stratified care in clinical practice and in changing professional practice largely explain the contrasting trial results. The review makes recommendations for future research, including greater focus on studying facilitators of implementation of stratified care and developing better treatments for patients with nonspecific low back pain at high risk of poor outcomes.

A technology-enabled collaborative learning model (Project ECHO) to upskill primary care providers in best practice pain care

Background The South Australian (SA) Chronic Pain Extension for Community Healthcare Outcomes (ECHO) Network was established to upskill primary care providers in best practice pain care aligned to a patient-centred, biopsychosocial approach using didactic and case-based virtual mentoring sessions. The aims of this study were to assess: (a) participation, satisfaction (relevance, satisfaction with format and content, perceptions of the mentorship environment), learning (perceived knowledge gain, change in attitudes), competence (self-confidence) and performance (intention to change practice, perceived practice change) of the ECHO Network clinician participants; and (b) self-perceived barriers at the clinical, service and system level to applying the learnings. Methods A mixed methods, participatory evaluation approach was undertaken. Data sources included analysis of program records (learning needs assessment, enrolment survey data, program participation data and online surveys of healthcare professionals including a satisfaction survey after each ECHO session (n=106 across the ECHO series of 10 sessions; average response rate=46%), a case presenters survey (n=7, response rate=78%) and an outcome survey after all 10 ECHO sessions (n=11, response rate=25%). Results Forty-four healthcare professionals participated in the ECHO Network from a range of career stages and professional disciplines (half were general practitioners). One-third of participants practised in regional SA. Participants reported that the ECHO sessions met their learning needs (average=99% across the series), were relevant to practice (average=99% across the series), enabled them to learn about the multidisciplinary and biopsychosocial approach to pain care (a verage=97% across the series) and provided positive mentorship (average=96% across the series). Key learnings for participants were the importance of validating the patient experience and incorporating psychological and social approaches into pain care. More than one-third of participants (average=42% across the series) identified barriers to applying the learnings such as limited time during a consultation and difficulty in forming a multidisciplinary team. Conclusions The ECHO Network model was found to be an acceptable and effective interdisciplinary education model for upskilling primary care providers in best practice pain care aligned to a patient-centred, biopsychosocial approach to pain managment. However, participants perceived barriers to translating this knowledge into practice at the clinical, service and system levels.

Could Relationship-Based Learnt Beliefs and Expectations Contribute to Physiological Vulnerability of Chronic Pain? Making a Case to Consider Attachment in Pain Research

Pain is an interpersonal and inherently social experience. Pain perception and administration of medical treatment all occur in a particular environmental and social context. Early environmental influences and early learning experiences and interactions condition the body's response to different threats (like pain), ultimately shaping the underlying neurophysiology. These early interactions and experiences also determine what situations are perceived as threatening, as well as our belief in our own ability to self-manage, and our belief in others to offer support, during perceived threats. These beliefs intrinsically drive the combination of behaviors that emerge in response to perceived threats, including pain. Such behaviors can be categorized into attachment styles. In this interdisciplinary review, we synthesize and summarize evidence from the neurobiological, psychobiological, psychosocial, and psychobehavioral fields, to describe how these beliefs are embedded in the brain's prediction models to generate a series of expectations/perceptions around the level of safety/threat in different contexts. As such, these beliefs may predict how one experiences and responds to pain, with potentially significant implications for the development and management of chronic pain. Little attention has been directed to the effect of adult attachment style on pain in research studies and in the clinical setting. Using interdisciplinary evidence, we argue why we think this interaction merits further consideration and research. PERSPECTIVE: This review explores the influence of attachment styles on pain perception, suggesting a link between social connections and chronic pain development. It aligns with recent calls to emphasize the social context in pain research and advocates for increased focus on adult attachment styles in research and clinical practice.

Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

Psychosocial factors in knee osteoarthritis: Scoping review of evidence and future opportunities

OBJECTIVE

Identify, describe and produce an evidence map of studies investigating psychosocial factors association with, or effect on, clinical outcomes for people with knee osteoarthritis.

METHODS

Scoping review of interventional and observational studies was performed. Medline (Ovid), Embase (Ovid), Cumulated Index in Nursing and Allied Health Literature, PsycInfo and Web of Science were searched on the 15th May 2023. Screening, data extraction and analysis was performed by two independent researchers. Extracted information included characteristics of studies plus which psychosocial factors were used to investigate association with, or effect on, clinical outcome(s). Descriptive statistics summarized the study design, temporal trend, geographic distribution, frequency of each psychosocial factor and whether associations/effects were observed.

RESULTS

23,065 records were screened, with 108 studies selected. Eighty-two percent of studies (n = 89/108) were cross-sectional in design. Number of studies increased over time and spanned 28 countries. Most research originated from the Americas region (55 %, 59/108). Twenty-four psychosocial factors (11 psychological, 13 social) were identified. Depression (47 %, n = 48/102) and education (28 %, n = 29/102) were the most frequently reported psychological and social factors, respectively. Psychological factors were often reported to have an association with/effect on pain (81 %, n = 71/88) and physical function (75 %, n = 56/74). Social factors were less frequently reported to have an association with or effect on pain (57 %, n = 46/81) and physical function (50 %, n = 18/36).

CONCLUSION

Psychosocial factors are often associated with clinical outcomes for people with knee osteoarthritis. High-quality longitudinal studies examining a wide range of psychosocial factors across diverse cultural and geographical settings are key to continue informing the development of biopsychosocial models of care.

Methods for pragmatic randomized clinical trials of pain therapies: IMMPACT statement

ABSTRACT

Pragmatic, randomized, controlled trials hold the potential to directly inform clinical decision making and health policy regarding the treatment of people experiencing pain. Pragmatic trials are designed to replicate or are embedded within routine clinical care and are increasingly valued to bridge the gap between trial research and clinical practice, especially in multidimensional conditions, such as pain and in nonpharmacological intervention research. To maximize the potential of pragmatic trials in pain research, the careful consideration of each methodological decision is required. Trials aligned with routine practice pose several challenges, such as determining and enrolling appropriate study participants, deciding on the appropriate level of flexibility in treatment delivery, integrating information on concomitant treatments and adherence, and choosing comparator conditions and outcome measures. Ensuring data quality in real-world clinical settings is another challenging goal. Furthermore, current trials in the field would benefit from analysis methods that allow for a differentiated understanding of effects across patient subgroups and improved reporting of methods and context, which is required to assess the generalizability of findings. At the same time, a range of novel methodological approaches provide opportunities for enhanced efficiency and relevance of pragmatic trials to stakeholders and clinical decision making. In this study, best-practice considerations for these and other concerns in pragmatic trials of pain treatments are offered and a number of promising solutions discussed. The basis of these recommendations was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) meeting organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks.

The experience of occupational therapists and physiotherapists using a prototype, evidence-informed online knowledge translation resource to learn about patient-defined, personally-meaningful chronic pain rehabilitation

Purpose

Chronic pain is a complex biopsychosocial experience, and rehabilitation helps people to manage pain, and restore valued life roles. Evidence suggests that more positive outcomes occur when clients perceive their rehabilitation to be meaningful. People with chronic pain describe rehabilitation as personally-meaningful when they develop a genuine connection with a credible therapist who they see as a guiding partner, and when rehabilitation holds personal value, is self-defined, and relevant to their sense of self-identity. This paper presents a qualitative study of therapists' experience using an e-learning package on patient-defined, personally-meaningful rehabilitation.

Methods

A qualitative descriptive design was used to explore rehabilitation therapists' experience of a prototype evidence-informed, online resource developed on the basis of eLearning and web-design principles. Semi-structured interviews and focus groups were conducted with a purposive sample of occupational therapists and physiotherapists, and inductive coding and thematic analysis of transcripts was completed.

Findings

Twenty-four therapists (12 occupational therapists, 12 physiotherapists) participated, representing a mix of gender and experience (early career; experienced; and specialist). Four themes and 12 sub-themes emerged from the analysis. The resource delivered a positive user experience, which added (translational) value to enhance learning, and participants were highly positive about the future potential of the resource to translate chronic pain rehabilitation research for early career, experienced, and specialist rehabilitation therapists.

Conclusion

Results suggest that the disparate learning needs of rehabilitation therapists from diverse professional backgrounds and experience, may be addressed through the one resource. Participant feedback provides evidence that the resource fits with current models of learning and behaviour change. This study demonstrates the importance of basing online resources on eLearning and web-design principles to translate complex biopsychosocial chronic pain rehabilitation research for rehabilitation therapists.

Full-Body Harness versus Waist Belt: An Examination of Force Production and Pain during an Isoinertial Device Maximal Voluntary Isometric Contraction

BACKGROUND/OBJECTIVES

This study examined the differences in participant force production and pain between a squat maximal voluntary isometric contraction (IMVIC) performed with either a waist belt (WB) or full-body harness (FBH) on the Desmotec D.EVO isoinertial device (D.EVO). Agreement between FBH IMVIC and a traditional force plate squat MVIC (TMVIC) was also assessed.

METHODS

Twenty adults completed FBH, WB, and TMVIC assessments on two separate occasions. Two-way treatment x time ANOVAs were conducted to compare force outputs and pain between treatments (FBH vs. WB) across time. Test-retest reliability was assessed using intraclass correlation coefficients. Associations between outcomes were determined using Pearson's r. Standard error of estimate, constant error, total error, and Bland-Altman plots were used to assess agreement between IMVIC and TMVIC.

RESULTS

FBH and WB IMVIC exhibited good to excellent reliability (ICC2,1 = 0.889-0.994) and strong associations (r = 0.813 and 0.821, respectively) when compared to TMVIC. However, agreement between FBH and TMVIC was poor. No significant interaction or main effects were observed for pain. FBH maximum isometric force (MIF) was significantly higher than WB MIF. WB IMVIC was the only significant predictor of TMVIC (R2 = 0.674).

CONCLUSIONS

Our findings indicate that the D.EVO should not be utilized as a replacement for a traditional MVIC setup.

Uncovering moderators of pain perception by women with endometriosis from Latin America and Spain: the roles of sociodemographics, racial self-identity, and pain catastrophizing

ABSTRACT

A cross-sectional multinational collaborative study on women with endometriosis from Latin America and Spain uncovered high levels of painful symptomatology and high pain catastrophizing scores. Associations between pain perception/catastrophizing and race/ethnicity have been documented. This study was conducted to uncover factors moderating pelvic pain severity, including socioeconomic variables, self-identified race, and pain catastrophizing in women with endometriosis from Latin America and Spain, a population encompassing diverse racial and sociocultural contexts. Self-reported data on demographics, clinical history, Ob-Gyn history, pelvic pain intensity, and pain catastrophizing were collected with the Spanish World Endometriosis Research Foundation (WERF) Endometriosis Phenome Project (EPhect) Clinical Questionnaire (ECQ). Multiple logistic regression was conducted to analyze effects of self-identified race, demographic clusters (defined as countries with similar racial population distribution), socioeconomic factors, and pain catastrophizing on reporting severe vs moderate-mild levels of dysmenorrhea, dyspareunia, and pelvic pain. Self-identified race did not affect the likelihood of reporting severe pelvic pain; however, there were significant differences in reporting severe dysmenorrhea at worst among demographic clusters. Older age was associated with severe dyspareunia at worst and recent pelvic pain. Pain catastrophizing score was highly predictive of reporting most types of severe pelvic pain, regardless of race and demographic cluster. These results negate a role of racial categories as moderator of pain in women from Latin America and Spain and support integration of pain catastrophizing assessments and psychological interventions into the pain management plan to enhance therapeutic outcomes and QoL for patients with endometriosis.

A systematic review with meta-analyses of the association between stigma and chronic pain outcomes

ABSTRACT

Stigma is common in people experiencing chronic pain and there are indications that it may adversely affect pain outcomes. However, to date, there is no systematic review exploring the impact of stigma on chronic pain-related outcomes. This systematic review and meta-analysis aimed to examine the association between stigma and key chronic pain outcomes and differences in stigma between pain conditions. Seven databases were searched for studies reporting a measure of association between stigma and at least one pain outcome in adults with chronic pain. Studies were screened by 2 independent researchers. Nineteen studies met eligibility criteria and data were extracted, quality-assessed, and narratively synthesised and meta-analysed where possible. Meta-analyses of bivariate cross-sectional correlations demonstrated significant positive correlations between stigma and pain intensity, disability, and depression, with small to moderate effects. Data from 2 prospective studies and those only reporting multivariate analyses that were not included in meta-analyses further supported these findings. There was some evidence that individuals who experience pain conditions with less clear pathophysiology may report greater stigma, although more research is needed. The review highlights that there is a growing number of studies on stigma in the pain field showing an adverse association between stigma and chronic pain outcomes.

Measuring Pain-related Behavioral Inhibition and Behavioral Activation System Responses: Further Validity Evidence for the Pain Responses Scale

OBJECTIVES

The Pain Responses Scale and its Short Form (PRS-SF) were recently developed to assess the affective, behavioral, and cognitive responses to pain based on the behavioral inhibition system (BIS) and behavioral activation system (BAS) model of chronic pain. The purpose of this study was to provide additional tests of the psychometric properties of the PRS-SF in a new sample of individuals with chronic pain.

METHODS

A sample of Spanish adults (N = 190) with chronic non-cancer pain completed a translated version of the PRS-SF and a battery of questionnaires measuring validity criteria hypothesized the be associated with BIS and BAS activation, including measures of sensitivity to punishment, sensitivity to reward, pain intensity, pain interference, catastrophizing, and pain acceptance.

RESULTS

Confirmatory factor analysis supported a 4-factor structure for the PRS-SF assessing despondent, escape, approach, and relaxation responses (S-B χ 2 [5] = 1.49, Comparative Fit Index = 0.99, Non-Normed Fit Index = 0.99, root-mean-square error of approximation = 0.051, Akaike Information Criterion = 4113.66), with marginal internal consistency for 1 scale (relaxation) and adequate to good internal consistency for the others. The pattern of associations found between the PRS-SF Scale scores and the validity criterion supports the validity of the instrument.

CONCLUSION

The results provide additional support for the validity of the 4 PRS-SF Scale scores, and the reliability of 3 of the scales. If these findings are replicated in future research, investigators may wish to administer more items from the original Relaxation Scale when assessing this domain to ensure adequate reliability for this scale. The other items from the PRS-SF assessing despondent, escape, and approach responses appear to provide at least adequate reliability. When used in this way, the PRS-SF may be used to measure BIS and BAS responses to pain to: (1) provide further tests of the BIS-BAS model of chronic pain and/or (2) understand the potential mediating effects of BIS and BAS responses on the effects of psychological pain treatments to help determine which specific responses are most responsible for the benefits of treatment, and, therefore, which responses should be specifically targeted to enhance treatment response.

Deprescribing NSAIDs: The Potential Role of Community Pharmacists

Non-steroidal anti-inflammatory drugs (NSAIDs) are largely used for controlling various pain conditions and are widely available in community pharmacies, with and without prescription. Despite their effectiveness, NSAIDs can pose significant risks due to potential side effects and drug interactions, particularly in polypharmacy and comorbidity contexts and for vulnerable users. This study investigated whether and how NSAIDs deprescribing can be conducted at the community pharmacy level by assessing pharmacists' confidence, attitudes, and potential barriers and facilitators. Additionally, we aimed to identify any deprescribing guidelines that pharmacists could use. A literature search and a cross-sectional digital questionnaire targeting community pharmacists in Norway were conducted. Results showed that study participants (N = 73) feel confident in identifying needs for deprescribing NSAIDs but barriers such as time constraints, lack of financial compensation, and communication challenges were noted. Participants reported positive attitudes toward deprescribing but highlighted a need for better guidelines and training. This study highlights a gap in specific guidelines for deprescribing NSAIDs and a potential for enhancing pharmacists' roles in the deprescribing process, for example, through training and improved financial incentives. Further research is encouraged to develop concrete strategies for an effective implementation where community pharmacists can be involved in the deprescribing of NSAIDs.

Do threats and reassurances reside in the biological, psychological or social domain? A qualitative study in adults and young people with chronic pain

Objective

Understanding biopsychosocial contributions to a sensitised pain system is a key target of many pain management programs. The 'Protectometer' is a freely available educational tool that guides people with chronic pain to explore their personal threats and reassurances, identifying them as 'DIMs' (danger in me) or 'SIMs' (safety in me), to guide personalised pain management. This study aimed to explore common types of DIMs and SIMs, and examine differences between adults and young people.

Materials and Methods

A retrospective qualitative study was conducted. Written DIMs (n = 504) and SIMs (n = 711) were collected from 96 participants with chronic pain (77 adults aged 18-85 years; 19 young people aged 9-17 years) across 15 multidisciplinary pain management groups. DIMs and SIMs were transcribed and analysed using deductive content analysis.

Results

Four overarching themes were identified: 'Engaging with the environment', 'In my body', 'My emotional health', and 'Activities and behaviours'. Similarities in SIMs were found, with the greatest proportion of SIMs in the social domain (49% adults; 47% young people). While adult DIMs were fairly evenly spread across the biological (37%), psychological (27%) and social domains (36%), young people's DIMs were predominantly in the psychological (44%) and social (43%) domains.

Discussion

These findings provide insights into common threats and reassurances people in pain perceive, and revealed age-related differences in biopsychosocial contributions to pain and pain relief. Findings also highlight the importance of social-based interventions as part of pain management therapies for both adults and young people.

Global trends and hotspots in pain associated with bipolar disorder in the last 20 years: a bibliometric analysis

Purpose

The prevalence of comorbid pain and Bipolar Disorder in clinical practice continues to be high, with an increasing number of related publications. However, no study has used bibliometric methods to analyze the research progress and knowledge structure in this field. Our research is dedicated to systematically exploring the global trends and focal points in scientific research on pain comorbidity with bipolar disorder from 2003 to 2023, with the goal of contributing to the field.

Methods

Relevant publications in this field were retrieved from the Web of Science core collection database (WOSSCC). And we used VOSviewer, CiteSpace, and the R package "Bibliometrix" for bibliometric analysis.

Results

A total of 485 publications (including 360 articles and 125 reviews) from 66 countries, 1019 institutions, were included in this study. Univ Toront and Kings Coll London are the leading research institutions in this field. J Affect Disorders contributed the largest number of articles, and is the most co-cited journal. Of the 2,537 scholars who participated in the study, Stubbs B, Vancampfort D, and Abdin E had the largest number of articles. Stubbs B is the most co-cited author. "chronic pain," "neuropathic pain," "psychological pain" are the keywords in the research.

Conclusion

This is the first bibliometric analysis of pain-related bipolar disorder. There is growing interest in the area of pain and comorbid bipolar disorder. Focusing on different types of pain in bipolar disorder and emphasizing pain management in bipolar disorder are research hotspots and future trends. The study of pain related bipolar disorder still has significant potential for development, and we look forward to more high-quality research in the future.

Psychologically based interventions for adults with chronic neuropathic pain: a scoping review

OBJECTIVE

As psychologically based interventions have been shown to have clinical utility for adults with chronic pain generally, a similar benefit might be expected in the management of chronic neuropathic pain (NeuP). However, to date, this has not been established, with existing systematic reviews on this topic being hampered by the scarcity of randomized controlled trials (RCTs). This review aimed to identify the type of psychologically based interventions studied for adults with chronic NeuP. It also aimed to assess whether there are enough RCTs to justify undertaking an updated systematic review.

METHODS

Seven databases and 2 clinical trial registries were searched for NeuP and psychologically based interventions from database inception to December 2021, and the search was updated in February 2023. The search was broadened by reviewing the reference list of included studies and contacting field experts. Predetermined study characteristics were extracted.

RESULTS

Of 4682 records screened, 33 articles (less than 1%) met the eligibility criteria. Four broad intervention approaches were observed, including cognitive-behavioral approaches (n = 16), mindfulness/meditation (n = 10), trauma-focused therapy (n = 4), and hypnosis (n = 3). Thirteen RCTs were identified, and of these, 9 retained 20 participants in each arm after treatment.

CONCLUSIONS

Cognitive-behavioral therapy was the most common therapeutic approach identified, whereas mindfulness/meditation was the most frequently used technique. Almost half to two-thirds of the studies reported significant improvements in pain, disability, or distress, which suggests that psychologically based interventions are potentially beneficial for adults with chronic NeuP. An updated systematic review seems warranted.

STUDY REGISTRATION

Open Science Framework (https://osf.io) (December 6, 2021; DOI: 10.17605/OSF.IO/WNSTM).

Occupations associated with treatment seeking and biopsychosocial functioning at a tertiary orofacial pain clinic: A cross-sectional study

BACKGROUND

The aim of this study was to describe whether certain occupations were over- or underrepresented and to compare biopsychosocial functioning by types of occupation and employment status among adults seeking orofacial pain (OFP) treatment.

METHODS

The authors extracted self-reported employment status, occupation, and biopsychosocial functioning from initial appointment records of 444 treatment-seeking adults at a university-affiliated OFP clinic. The authors categorized occupations in major and minor occupational groups according to the 2018 Standard Occupational Classification. The authors compared proportions between their sample and the corresponding state level, using a ratio and 95% CI (1.00 = equal representation in sample vs state, < 1.00 = underrepresentation, > 1.00 = overrepresentation).

RESULTS

Among major occupational categories, health care practitioners and technical occupations were the most common in the study sample (22.4%) and the second most overrepresented (ratio, 3.20; 95% CI, 2.59 to 3.97) after the arts, design, entertainment, sports, and media occupations (ratio, 3.95; 95% CI, 2.15 to 7.26). Among minor occupational categories, teachers and instructors were the most common in the study sample (11.2%) and the most overrepresented (ratio, 90.71; 95% CI, 65.67 to 125.30), followed by managers (ratio, 43.87; 95% CI, 29.61 to 64.99) and photographers (ratio, 40.89; 95% CI, 10.23 to 163.4). No differences were observed in biopsychosocial functioning between major occupational categories. However, those not working due to health reasons or disability had worse biopsychosocial functioning (insomnia, anxiety and depression, life satisfaction, sleep health, pain intensity, pain-related interference; all P < .034) than those who were employed.

CONCLUSIONS

Several occupations are strongly over- and underrepresented among adults seeking OFP treatment. Differences were not explained by biopsychosocial functioning.

PRACTICAL IMPLICATIONS

Future research should attempt to identify and address the underlying mechanisms of association between occupation and seeking care for OFP.

Beyond numbers: integrating qualitative analysis into quantitative sensory testing for neuropathic pain

This article investigates the benefits of adopting qualitative and quantitative sensory testing (QQST) in sensory assessment, with a focus on understanding neuropathic pain. The innovative QQST method combines participant qualitative experiences with quantitative psychophysical measurements, offering a more varied interpretation of sensory abnormalities and normal sensory function. This article also explores the steps for the optimization of the method by identifying qualitative signs of sensory abnormalities and standardizing data collection. By leveraging the inherent subjectivity in the test design and participant responses, the QQST method contributes to a more holistic exploration of both normal and abnormal sensory experiences. This article positions the QQST approach as a foundational element within the Sensory Evaluation Network, uniting international experts to harmonize qualitative and quantitative sensory evaluation methods.

Eating habits and the desire to eat healthier among patients with chronic pain: a registry-based study

Healthcare professionals often meet pain patients with a poor nutritional status such as obesity, unhealthy dietary behaviors, and a suboptimal dietary intake. A poor nutritional status may play a significant role in the occurrence, development, and prognosis of chronic pain. This study investigated eating habits in a specialized pain rehabilitation center using data (N = 2152) from the Swedish quality registry for pain rehabilitation during the period 2016-2021. Patients answered a lifestyle questionnaire regarding their eating habits and desire to modify their lifestyle. The mean (SD) patient age was 46.1 (14.6) years, with 24.8% classified as obese. Suboptimal eating habits included irregular mealtimes (27.2%), weekly consumption of fast-food (20.3%) and nearly daily consumption of confectionery (33.3%). Approximately 20% (n = 426) reported a desire to eat healthier. Frequent confectionery intake (Odds ratio [OR] 1.23, 95% Confidence Interval (CI) 1.04-1.47) and fast-food consumption (OR 1.58, 95% CI 1.24-2.02) increased the likelihood to desire healthier eating. Younger patients (18-29 years), those classified as obese, and those with more extended spatial pain were more likely to express a desire to eat healthier. Eating habits should be addressed in pain management and interdisciplinary pain rehabilitation teams are encouraged to provide nutritional care tailored to the patient's needs.

SOMAScience: A Novel Platform for Multidimensional, Longitudinal Pain Assessment

Chronic pain is one of the most significant health issues in the United States, affecting more than 20% of the population. Despite its contribution to the increasing health crisis, reliable predictors of disease development, progression, or treatment outcomes are lacking. Self-report remains the most effective way to assess pain, but measures are often acquired in sparse settings over short time windows, limiting their predictive ability. In this paper, we present a new mobile health platform called SOMAScience. SOMAScience serves as an easy-to-use research tool for scientists and clinicians, enabling the collection of large-scale pain datasets in single- and multicenter studies by facilitating the acquisition, transfer, and analysis of longitudinal, multidimensional, self-report pain data. Data acquisition for SOMAScience is done through a user-friendly smartphone app, SOMA, that uses experience sampling methodology to capture momentary and daily assessments of pain intensity, unpleasantness, interference, location, mood, activities, and predictions about the next day that provide personal insights into daily pain dynamics. The visualization of data and its trends over time is meant to empower individual users' self-management of their pain. This paper outlines the scientific, clinical, technological, and user considerations involved in the development of SOMAScience and how it can be used in clinical studies or for pain self-management purposes. Our goal is for SOMAScience to provide a much-needed platform for individual users to gain insight into the multidimensional features of their pain while lowering the barrier for researchers and clinicians to obtain the type of pain data that will ultimately lead to improved prevention, diagnosis, and treatment of chronic pain.

Pain-sensorimotor interactions: New perspectives and a new model

How pain and sensorimotor behavior interact has been the subject of research and debate for many decades. This article reviews theories bearing on pain-sensorimotor interactions and considers their strengths and limitations in the light of findings from experimental and clinical studies of pain-sensorimotor interactions in the spinal and craniofacial sensorimotor systems. A strength of recent theories is that they have incorporated concepts and features missing from earlier theories to account for the role of the sensory-discriminative, motivational-affective, and cognitive-evaluative dimensions of pain in pain-sensorimotor interactions. Findings acquired since the formulation of these recent theories indicate that additional features need to be considered to provide a more comprehensive conceptualization of pain-sensorimotor interactions. These features include biopsychosocial influences that range from biological factors such as genetics and epigenetics to psychological factors and social factors encompassing environmental and cultural influences. Also needing consideration is a mechanistic framework that includes other biological factors reflecting nociceptive processes and glioplastic and neuroplastic changes in sensorimotor and related brain and spinal cord circuits in acute or chronic pain conditions. The literature reviewed and the limitations of previous theories bearing on pain-sensorimotor interactions have led us to provide new perspectives on these interactions, and this has prompted our development of a new concept, the Theory of Pain-Sensorimotor Interactions (TOPSMI) that we suggest gives a more comprehensive framework to consider the interactions and their complexity. This theory states that pain is associated with plastic changes in the central nervous system (CNS) that lead to an activation pattern of motor units that contributes to the individual's adaptive sensorimotor behavior. This activation pattern takes account of the biological, psychological, and social influences on the musculoskeletal tissues involved in sensorimotor behavior and on the plastic changes and the experience of pain in that individual. The pattern is normally optimized in terms of biomechanical advantage and metabolic cost related to the features of the individual's musculoskeletal tissues and aims to minimize pain and any associated sensorimotor changes, and thereby maintain homeostasis. However, adverse biopsychosocial factors and their interactions may result in plastic CNS changes leading to less optimal, even maladaptive, sensorimotor changes producing motor unit activation patterns associated with the development of further pain. This more comprehensive theory points towards customized treatment strategies, in line with the management approaches to pain proposed in the biopsychosocial model of pain.

The "future" pain clinician: Competencies needed to provide psychologically informed care

BACKGROUND & OBJECTIVE

Psychologically informed care has been proposed to improve treatment outcomes for chronic pain and aligns with a person-centered approach. Yet implementation lags behind, and studies suggest that a lack of competency leads to poor results. It is unclear what training clinicians require to deliver this care. We examine how we might improve psychologically informed care guided by the needs of the patient and in congruence with the scientific literature with a particular focus on how competencies might be upgraded and implementation enhanced.

METHODS

We selectively review the literature for psychologically informed care for pain. The patient's view on what is needed is contrasted with the competencies necessary to meet these needs and how treatment should be evaluated.

RESULTS

Patient needs and corresponding competencies are delineated. A number of multi-professional skills and competencies are required to provide psychologically informed care. Single-subject methodologies can determine whether the care has the desired effect for the individual patient and facilitate effectiveness. We argue that becoming a competent "pain clinician" requires a new approach to education that transcends current professional boundaries.

CONCLUSIONS

Providing person-centered care guided by the needs of the patient and in line with the scientific literature shows great potential but requires multiple competencies. We propose that training the pain clinician of the future should focus on psychologically informed care and the competencies required to meet the individual's needs. Single-subject methodology allows for continual evaluation of this care.

[Transitional pain service in surgery as an optimal strategy for the treatment and prevention of chronic postoperative pain]

The problem of chronic postoperative pain (CPP) has remained relevant over the past decades, despite the active development of anesthesiology and surgery. Existing approaches to the treatment of acute postoperative pain do not provide effective prevention of CPP. The analysis of the results of studies on this problem was carried out. It was shown that the introduction of an interdisciplinary transitional pain service in surgery allows to increase the effectiveness of prevention and treatment of CPP, accompanying patients with high risks of pain chronization at each stage of surgical treatment (surgery planning, perioperative and outpatient, after discharge up to full recovery after surgery). The interdisciplinary nature of the transitional pain service in surgery ensures the timeliness and multimodality of the pain treatment methods used. It can be concluded that the development of a transitional pain service is an optimal strategy for the prevention and treatment of CPP.

Cancer-related pain experienced in daily life is difficult to communicate and to manage - for patients and for professionals

OBJECTIVES

The aim of this study was to gain qualitative insight into cancer patients' experiences, explanations, and management strategies regarding their cancer-related pain (CP).

METHODS

Seventeen patients with CP were interviewed using a semi-structured interview approach. Braun and Clarke's thematic analysis method was used to analyze the transcribed interviews. The patients all participated in cancer rehabilitation courses arranged by the research clinic at The Danish Knowledge Centre for Rehabilitation and Palliative Care.

RESULTS

Three themes were identified: (1) Explaining CP: Patients found it difficult to explain how they experienced their pain. They lacked words, and they frequently used invasive metaphors such as "Pain feels like a heart attack" (2). Strategies and barriers to the management of CP: Initiatives provided by healthcare professionals (HCPs) were perceived as insufficient, and the patients missed guidance in both pharmacological and non-pharmacological approaches to pain management. Several saw medicine as unnatural for their body, and they focused on side effects and the medicine affecting their quality of life. (3) Responsibility for managing CP: A lack of responsiveness from the HCPs and taking on responsibility for pain management were experienced by several of the patients. The patients expressed uncertainty about whom to contact for help with the management of their CP.

CONCLUSION

The patients' difficulties in explaining, understanding, and communicating their pain and pain management contributed to insufficient pain management. They were also uncertain about who had the responsibility to help them to achieve pain relief. These results share the evidence drawn from studies on patients with chronic non-cancer pain. This qualitative study highlights the need for having more focus on a common language and shared understanding between patients and HCPs. It also underpins the importance of HCPs to assume their responsibility to help patients manage their pain conditions.

Pain and the Non-Pharmacological Management of Pain in People with Parkinson's Disease

Pain is a distressing and universal experience, yet everyone's pain experience is influenced by a complex array of biological, psychological, and social factors. For people with Parkinson's disease (PwP), these biopsychosocial factors include neurodegeneration and the psychological and social factors that accompany living with a chronic, neurodegenerative condition in addition to the factors experienced by those in the general population (e.g., living with co-morbidities such as osteoarthritis). The way these factors influence each individual is likely to determine which pain management strategies are optimal for them. This review first describes pain and the biopsychosocial model of pain. It explores how pain is classified in Parkinson's disease (PD) and describes the three main types of pain: nociceptive, neuropathic, and nociplastic pain. This background provides context for a discussion of non-pharmacological pain management strategies that may aid in the management of pain in PwP; exercise, psychological strategies, acupuncture and massage. While there is little PD-specific research to inform the non-pharmacological management of pain, findings from current PD research are combined with that from chronic pain research to present recommendations for clinical practice. Recommendations include assessment that incorporates potential biopsychosocial contributors to pain that will then guide a holistic, multi-modal approach to management. As exercise provides overall benefits for PwP, those with chronic pain should be carefully monitored with exercise prescribed and adjusted accordingly. Research is needed to develop and evaluate multi-modal approaches to pain management that are delivered in a biopsychosocial framework.

The effect of psychological factors on pain outcomes: lessons learned for the next generation of research

Big data and machine learning techniques offer opportunities to investigate the effects of psychological factors on pain outcomes. Nevertheless, these advances can only deliver when the quality of the data is high and the underpinning causal assumptions are considered. We argue that there is room for improvement and identify some challenges in the evidence base concerning the effect of psychological factors on the development and maintenance of chronic pain. As a starting point, 3 basic tenets of causality are taken: (1) cause and effect differ from each other, (2) the cause precedes the effect within reasonable time, and (3) alternative explanations are ruled out. Building on these tenets, potential problems and some lessons learned are provided that the next generation of research should take into account. In particular, there is a need to be more explicit and transparent about causal assumptions in research. This will lead to better research designs, more appropriate statistical analyses, and constructive discussions and productive tensions that improve our science.

Adolescents' Experience of Pain: A Focus Group Study in Sweden

The purpose of this study was to describe experiences of pain among students at upper secondary schools (adolescents aged 16-19 years) in Sweden. Focus group (n = 9) interviews with 41 adolescents were conducted in southern Sweden in 2021. The interviews were analyzed by qualitative content analysis, which identified four categories encompassing the theme how pain expressed itself: (1) a warning bell-the body's way of saying that something is wrong; (2) school- and work-related pain; (3) interpersonal physical and emotional pain; and (4) heartache-a sign of humanity; and four categories describing the theme ways of dealing with pain: (1) turn your attention elsewhere; (2) "bite the bullet" and endure the pain; and (3) use painkillers or complementary treatments; and (4) ask for help from others. Findings are linked to the crucial role of school nurses in supporting students who experience pain.

The role of evolving concepts and new technologies and approaches in advancing pain research, management, and education since the establishment of the International Association for the Study of Pain

ABSTRACT

The decades since the inauguration of the International Association for the Study of Pain have witnessed major advances in scientific concepts (such as the biopsychosocial model and chronic primary pain as a disease in its own right) and in new technologies and approaches (from molecular biology to brain imaging) that have inspired innovations in pain research. These have guided progress in pain management and education about pain for healthcare professionals, the general public, and administrative agencies.

Beyond biopsychosocial: The keystone mechanism theory of pain

Pain is a deeply personal experience, with interindividual differences in its chronification and treatment presenting a formidable healthcare challenge. The biopsychosocial model (BPSm) has been hugely influential within nascent attempts at precision pain medicine, steering the field away from a reductionist biomechanical viewpoint and emphasising complex interactions of biological, psychological, and social factors which shape the individuality of pain. However, despite offering a strong theoretical foundation and holistic perspective, we contend that the BPSm remains limited in its capacity to deliver truly mechanistically informed treatment of pain. We therefore propose the keystone model of pain which offers a pragmatic balance between the dimensionality expansive BPSm and overly reductive approaches, providing both theoretical and practical advantages for the transition from treating populations to individual people.

Is there a geographic and gender divide in Europe regarding the biopsychosocial approach to pain research? An evaluation of the 12th EFIC congress

OBJECTIVES

All pain research combined advances the different domains of the biopsychosocial model and its interactions. However, there may be discrepancies between individual countries in their biomedical, psychological or social focus to pain research. As a proxy for this possible discrepancy, we analysed the biopsychosocial orientation of presentations at a recent major international pain conference.

METHODS

The primary aim was to investigate whether there are geographical differences across Europe regarding the biopsychosocial orientation of workshop presentations at the 12th EFIC congress. The secondary aim was to investigate whether there were differences between female and male presenters regarding the biopsychosocial focus of their presentations. All available workshop abstracts were blinded and categorised by two independent reviewers as biomedical, psychosocial, biopsychosocial, or not applicable. Psychosocial and biopsychosocial were merged to non-biomedical.

RESULTS

Of the 140 available abstracts, 126 abstracts could be categorised (biomedical: 51 %; non-biomedical: 49 %). Three clusters of countries emerged: (1) countries with a clear majority (≥80 %) of non-biomedical presentations (The Netherlands and Belgium); (2) countries with a balance between biomedical and non-biomedical presentations (United Kingdom, Denmark, Norway, Sweden and Finland); and (3) countries with a clear majority (71-100 %) of biomedical presentations (Italy, Germany, Switzerland and France). Overall, women delivered more presentations than men (70 vs. 56 presentations), and delivered proportionally more non-biomedical presentations (57 %) whereas men delivered proportionally more biomedical presentations (61 %).

CONCLUSIONS

Analysis of the 12th EFIC congress revealed geographical and gender differences in biopsychosocial orientation. Whether this reflects established differences in pain research requires further investigation.

Incorporating personal narratives in positive psychology interventions to manage chronic pain

In this perspective paper, we argue for incorporating personal narratives in positive psychology interventions for chronic pain. Narratives refer to the telling and retelling of events. Narratives detail accounts of events and provide rich, in-depth information on human interactions, relationships, and perspectives. As such, narratives have been used to understand people's experiences with pain and pain coping mechanisms-as well as to facilitate therapeutic outcomes. Furthermore, narrative research has shown that narration can help restore and promote relief, calm, hope, self-awareness, and self-understanding in chronic pain sufferers. Positive psychology interventions have been successful in improving the lives of people living with chronic pain, but these psychology interventions do not typically incorporate personal narratives. Still, narrative, and positive psychology scholarship foci overlap, as both aim to enhance people's quality of life, happiness, and well-being, and to promote the understanding of psychosocial strengths and resources. In this article, we provide a rationale for incorporating personal narratives as an agentic form of positive psychology intervention. To that aim, we outline areas of convergence between positive psychology and narrative research and show how combining positive psychology exercises and narration can have additive benefits for pain sufferers. We also show how integrating narration in positive psychology intervention research can have advantages for healthcare research and policy.

Animal-Assisted Psychotherapy for Pediatric Chronic Pain: Case Series of an Open Pilot Study to Test Initial Feasibility and Potential Efficacy

Objective

Chronic pain is a common complaint in children and adolescents, placing an enormous burden on individuals, their families, and the healthcare system. New innovative approaches for the treatment of pediatric chronic pain (PCP) are clearly warranted, as drop-out rates in intervention studies are high and it can be difficult to engage patients with PCP in therapy. Here, animal-assisted interventions (AAIs) might be promising, since there is preliminary evidence for the approach in adults with chronic pain, and AAIs are generally known to foster the therapeutic motivation of patients. To date, however, AAIs have not been examined in pediatric chronic pain.

Methods

The aim of this open pilot study was to examine the initial feasibility of recruitment and potential efficacy of an animal-assisted group psychotherapy (including horses, rabbits, chickens, goats, and a dog), providing case reports of three children with chronic pain. We applied a mixed-methods approach, including the conductance of semi-structured interviews and assessment of quantitative pre-post data with a focus on pain severity, avoidance behavior, pain acceptance, and ability to defocus from the pain.

Results

The three participating girls (age: 9-12 years) reported chronic pain in the head and abdomen. The process of recruitment turned out to be challenging. All three children reported reduced pain-related disability and pain-related distress, as well as an increased ability to accept pain and to defocus from the pain. The qualitative data revealed that patients and their parents had a positive attitude towards AAIs.

Conclusion

Our initial open pilot study is the first to investigate AAIs in the context of pediatric chronic pain. Notably, we had difficulties in the recruitment procedure, mostly due to the Covid-19 situation. Based on three case reports, we found some first indication that AAI approaches might be associated with symptom changes. Future randomized-control studies with larger sample sizes are clearly warranted.

Clinicaltrialsgov Identifier

NCT04171336.

Applying the behavioural change wheel to guide the implementation of a biopsychosocial approach to musculoskeletal pain care

Achieving high value, biopsychosocial pain care can be complex, involving multiple stakeholders working synergistically to support the implementation of quality care. In order to empower healthcare professionals to assess, identify and analyse biopsychosocial factors contributing to musculoskeletal pain, and describe what changes are needed in the whole-of-system to navigate this complexity, we aimed to: (1) map established barriers and enablers influencing healthcare professionals' adoption of a biopsychosocial approach to musculoskeletal pain against behaviour change frameworks; and (2) identify behaviour change techniques to facilitate and support the adoption and improve pain education. A five-step process informed by the Behaviour Change Wheel (BCW) was undertaken: (i) from a recently published qualitative evidence synthesis, barriers and enablers were mapped onto the Capability Opportunity Motivation-Behaviour (COM-B) model and Theoretical Domains Framework (TDF) using "best fit" framework synthesis; (ii) relevant stakeholder groups involved in the whole-of-health were identified as audiences for potential interventions; (iii) possible intervention functions were considered based on the Affordability, Practicability, Effectiveness and Cost-effectiveness, Acceptability, Side-effects/safety, Equity criteria; (iv) a conceptual model was synthesised to understand the behavioural determinants underpinning biopsychosocial pain care; (v) behaviour change techniques (BCTs) to improve adoption were identified. Barriers and enablers mapped onto 5/6 components of the COM-B model and 12/15 domains on the TDF. Multi-stakeholder groups including healthcare professionals, educators, workplace managers, guideline developers and policymakers were identified as target audiences for behavioural interventions, specifically education, training, environmental restructuring, modelling and enablement. A framework was derived with six BCTs identified from the Behaviour Change Technique Taxonomy (version 1). Adoption of a biopsychosocial approach to musculoskeletal pain involves a complex set of behavioural determinants, relevant across multiple audiences, reflecting the importance of a whole-of-system approach to musculoskeletal health. We proposed a worked example on how to operationalise the framework and apply the BCTs. Evidence-informed strategies are recommended to empower healthcare professionals to assess, identify and analyse biopsychosocial factors, as well as targeted interventions relevant to various stakeholders. These strategies can help to strengthen a whole-of-system adoption of a biopsychosocial approach to pain care.

A Qualitative Study of Psychosocial Factors in Patients With Knee Osteoarthritis: Insights Learned From an Asian Population

BACKGROUND

A patient's experience with knee osteoarthritis (OA) is influenced by many psychosocial contributors that can influence the impact of pain. Such factors are known to explain some of the discordance between objective clinical parameters and patient-reported levels of disability and treatment effectiveness. However, few data are available to help clinicians understand the psychosocial factors that apply to the world's many Asian populations. Insights gained from a qualitative study in such a population may support targeted interventions.

QUESTIONS/PURPOSES

In this qualitative study involving a group of Asian patients with knee OA in Singapore, we asked: (1) What psychologic factors contribute to patients' experiences, rehabilitation, and recovery? (2) What social factors contribute to patients' experiences, rehabilitation, and recovery?

METHODS

Semistructured interviews eliciting broad patient experiences of managing knee OA were conducted in an urban, referral-based tertiary hospital in central Singapore. Patients were recruited if they met either of the following criteria: Kellgren-Lawrence grade ≥ 3 (minimum of one knee); Knee Injury and Osteoarthritis Outcome Score ≤ 60; or the Pain average (P), interference with Enjoyment of life (E), and interference with General activity (G) (PEG) ≥ 5. All patients had a clinical diagnosis of knee OA, were ambulatory in the community with or without a walking aid, had not undergone partial arthroplasty or TKA, were prescribed nonsurgical treatment, and were conversant in either English or Mandarin. Forty-six patients (30 women and 16 men, mean age 64 years old) were recruited for this study. A thematic analysis with elements of grounded theory and framework analysis was performed using a deductive approach. Psychologic influences specific to patients' behavioral and emotional responses to pain, as well as social factors known to have an impact on the experience of managing knee OA, were identified in the interview transcripts and coded according to established factors from earlier research. An inductive thematic analysis was then applied to the remaining transcripts to identify new themes that emerged from the data. Thematic saturation was attained when study team members agreed data and thematic sufficiency were met in the 46 transcripts. The study team discussed and deemed the 46 transcripts to contain sufficient insights for a reasonably clear understanding of the codes and development of themes to answer the study's research questions.

RESULTS

Six main themes related to psychosocial influences on pain emerged. Psychologic factors were "loss of face" because of knee OA, anticipation and avoidance of pain and suffering, and a vicious cycle of negative emotional experiences. The social factors we identified were social and family support, workplace environment and employment uncertainty, and built environment (patients' ability to navigate manmade structures and facilities).

CONCLUSION

Psychosocial factors have an important impact on patients' physical, psychologic, and social functioning. Although several of our findings have been addressed previously, the phenomenon of loss of face and the wide spectrum of social and family support dynamics found in our Asian patients with knee OA were new findings. With loss of face, patients were concerned about how others would view the change in them, including movement changes because of knee OA. They appeared to associate the use of walking canes with major disability, loss of respect, and being discriminated against by others, motivating patients to "save face" by dissociating themselves from those stigmas, even at the cost of mobility and independence. An interplay of complex cultural processes (perceived social roles and contributions to family, desire to avoid burdening family, help-seeking behavior, and the preference for unsolicited social support) underpinned by the value of collectivism impacted the behaviors and choices patients exhibited.

CLINICAL RELEVANCE

With knowledge about the impact of culturally relevant psychosocial factors on the experience and outcomes of patients with knee OA, clinicians will be able to screen and actively explore these factors more effectively. Especially important themes include pain perception (paying close attention to signs of pain catastrophizing and negative affect), presence of chronic illness shame associated with a diagnosis of knee OA (including the stigma associated with using a walking aid), and level of social support received and contributions of a patient's built environment to kinesiophobia. For patients who are still working, the presence of workplace stressors and management of these stressors should also be explored. Where possible, screening tools that measure psychosocial factors such as pain catastrophizing and emotional distress can also be used as an added layer of screening in busy clinical settings.

Back Pain without Disease or Substantial Injury in Children and Adolescents: A Twin Family Study Investigating Genetic Influence and Associations

This twin family study first aimed to investigate the evidence for genetic factors predicting the risk of lifetime prevalence of non-specific low back pain of at least three months duration (LBP (life)) and one-month current prevalence of thoracolumbar back pain (TLBP (current)) using a study of children, adolescents, and their first-degree relatives. Secondly, the study aimed to identify associations between pain in the back with pain in other regions and also with other conditions of interest. Randomly selected families (n = 2479) with child or adolescent twin pairs and their biological parents and first siblings were approached by Twins Research Australia. There were 651 complete twin pairs aged 6-20 years (response 26%). Casewise concordance, correlation, and odds ratios were compared for monozygous (MZ) and dizygous (DZ) pairs to enable inference about the potential existence of genetic vulnerability. Multivariable random effects logistic regression was used to estimate associations between LBP (life) or TLBP (current) as an outcome with the potentially relevant condition as predictors. The MZ pairs were more similar than the DZ pairs for each of the back pain conditions (all p values < 0.02). Both back pain conditions were associated with pain in multiple sites and with primary pain and other conditions using the combined twin and sibling sample (n = 1382). Data were consistent with the existence of genetic influences on the pain measures under the equal environments assumption of the classic twin model and associations with both categories of back pain were consistent with primary pain conditions and syndromes of childhood and adolescence which has research and clinical implications.

A healthy settings approach to addressing painogenic environments: New perspectives from health promotion

Structural approaches to promoting health focus on policies and practices affecting health at the community level and concentrate on systems and forces of society, including distribution of power, that foster disadvantage and diminish health and well-being. In this paper we advocate consideration of structural approaches to explore macro level influences on the burden of persistent pain on society. We argue that health promotion is an appropriate discipline to ameliorate painogenic environments and that a "settings approach" offers a crucial vehicle to do this. We encourage consideration of socio-ecological frameworks to explore factors affecting human development at individual, interpersonal, organizational, societal, and environmental levels because persistent pain is multifaceted and complex and unlikely to be understood from a single level of analysis. We acknowledge criticisms that the structural approach may appear unachievable due to its heavy reliance on inter-sectoral collaboration. We argue that a settings approach may offer solutions because it straddles "practical" and cross-sectorial forces impacting on the health of people. A healthy settings approach invests in social systems where health is not the primary remit and utilises synergistic action between settings to promote greater health gains. We offer the example of obesogenic environments being a useful concept to develop strategies to tackle childhood obesity in school-settings, community-settings, shops, and sports clubs; and that this settings approach has been more effective than one organisation tackling the issue in isolation. We argue that a settings approach should prove useful for understanding painogenic environments and tackling the burden of persistent pain.