The Relationship Between Heart Rate Variability, Psychological Flexibility, and Pain in Neurofibromatosis Type 1

Understanding chronic pain in Neurofibromatosis Type 1 using the Neurofibromatosis Pain Module (NFPM)

Neurofibromatosis Type 1 (NF1) is an autosomal dominant genetic disorder that can cause an individual significant chronic pain (CP). CP affects quality of life and daily functioning, yet there are limited effective treatments for CP within NF1. The current study describes the impact of CP using the Neurofibromatosis Pain Module (NFPM). The NFPM is a self-reported clinical assessment that evaluates the impact of CP across multiple domains (e.g., interference, severity, tolerance, and symptomology) and three prioritized pain regions. A cross-sectional study (N = 242) asked adults with NF1 to describe and rate their pain using the NFPM. The results indicated that they reported moderate pain severity (M = 6.6, SD = 2.0) on a 0-10 scale, that 54% (n = 131) had been in pain at least 24 days in the last 30, for 75% (n = 181) sleep was affected, and 16% reported that nothing was effective in reducing their CP for their primary pain region. The current results extend previously published work on CP within adults with NF1 and indicate that more emphasis on understanding and ameliorating CP is required. The NFPM is a sensitive clinical measure that provides qualitative and quantitative responses to inform medical providers about changes in CP.

Prediction of pain using electrocardiographic-derived autonomic measures: A systematic review

BACKGROUND AND OBJECTIVE

Pain is a major clinical challenge, and understanding the pathophysiology is critical for optimal management. The autonomic nervous system reacts to pain stimuli, and autonomic dysfunction may predict pain sensation. The most used assessment of autonomic function is based on electrocardiographic measures, and the ability of such measures to predict pain was investigated.

DATABASES AND DATA TREATMENT

English articles indexed in PubMed and EMBASE were reviewed for eligibility and included when they reported electrocardiographic-derived measures' ability to predict pain response. The quality in prognostic studies (QUIPS) tool was used to assess the quality of the included articles.

RESULTS

The search revealed 15 publications, five on experimental pain, five on postoperative pain, and five on longitudinal clinical pain changes, investigating a total of 1069 patients. All studies used electrocardiographically derived parameters to predict pain assessed with pain thresholds using quantitative sensory testing or different scales. Across all study modalities, electrocardiographic measures were able to predict pain. Higher parasympathetic activity predicted decreased experimental, postoperative, and long-term pain in most cases while changes in sympathetic activity did not consistently predict pain.

CONCLUSIONS

Most studies demonstrated that parasympathetic activity could predict acute and chronic pain intensity. In the clinic, this may be used to identify which patients need more intensive care to prevent, for example postoperative pain and develop personalized chronic pain management.

SIGNIFICANCE

Pain is a debilitating problem, and the ability to predict occurrence and severity would be a useful clinical tool. Basal autonomic tone has been suggested to influence pain perception. This systematic review investigated electrocardiographic-derived autonomic tone and found that increased parasympathetic tone could predict pain reduction in different types of pain.

Work readiness and barriers to employment during COVID-19 for individuals with Neurofibromatosis Type 1 (NF1)

BACKGROUND

The global COVID-19 pandemic has directly impacted individuals with rare diseases who are attempting to maintain or obtain employment. Individuals with Neurofibromatosis Type 1 are especially at risk due to their disease.

OBJECTIVE

The current study compared the impact that generalized anxiety and quality of life had on work readiness and potential barriers that individuals with NF1 had in gaining and maintaining employment during the COVID-19 pandemic to a sample of healthy individuals using a moderating mediation analysis.

METHODS

A total of 213 individuals (105 NF1; 108 Healthy individuals) were recruited to complete a cross-sectional study in which a series of work-related assessments were completed.

RESULTS

Generalized anxiety had an indirect effect on work readiness, fully mediated by barriers, with higher anxiety associated with more barriers, in turn negatively correlating with work readiness; quality of life partially mediated the effect of barriers on work readiness and was negatively associated with the former and positively with the latter.

CONCLUSION

Quality of life was a mediator of the relationship between perceived employment barriers and work readiness for the healthy individuals group only. The results imply that anxiety and quality of life are significant mediators and require consideration in terms of evaluation and facilitation of employment maintenance and acquisition.

Which outcome variables are associated with psychological inflexibility/flexibility for chronic pain patients? A three level meta-analysis

The psychological flexibility model can be seen as a basis for an integrated and progressive psychological approach to chronic pain management. Some researchers suggest that psychological flexibility and inflexibility represent distinct processes and constructs. This meta-analysis is the first to provide a summary estimate of the overall effect size for the relationship between psychological (in)flexibility and common outcomes among chronic pain patients. The research protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO, https://www.crd.york.ac.uk/PROSPERO/), registration number CRD42021285705. Four databases were searched (PsycINFO; PubMed; Web of Science, CINAHL) along with reference lists. Thirty-six cross-sectional studies were included (7,779 participants). Meta-analyses (random effects model) indicated a significant medium negative association between psychological flexibility and pain intensity or functional impairment. The present study also indicated a significant small to medium association between psychological inflexibility and pain intensity, a nearly large association between psychological inflexibility and functional impairment as well as the quality of life, and a large association between psychological inflexibility and anxiety/depression. Due to the limited number of included studies, the relationship between risk behavior and psychological inflexibility may not be significant. Types of countries and instruments measuring psychological inflexibility may explain part of the heterogeneity. These findings may carry significant implications for chronic pain patients regarding the potential relationship between psychological inflexibility or flexibility and these outcomes. It may consequently form the basis for more robust testing of causal and manipulable relationships.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021285705.

Comparison of the autonomic nervous system dysfunction between different chronic spine disorders: neck pain versus low back pain

OBJECTIVE

This study aims to compare heart rate variability (HRV) between patients with chronic neck pain and patients with chronic low back pain and to correlate the chronic pain variables with heart rate variability indices.

METHODS

This is a cross-sectional study. We divided the sample into two groups: neck pain (n=30) and low back pain (n=30). We used the Numeric Pain Rating Scale, Neck Disability Index, Roland-Morris Disability Questionnaire, Pain-Related Catastrophizing Thoughts Scale, Tampa Scale of Kinesiophobia, and Pain Self-Efficacy Questionnaire. For heart rate variability analysis, we used the following indices: mean RR, standard deviation of all RR intervals, mean heart rate, root mean square differences of successive RR intervals, triangular index, triangular interpolation of the interval histogram, low-frequency band in arbitrary units and in absolute values, high-frequency band in arbitrary units and in absolute values, standard deviation of the instantaneous beat-to-beat variability (standard deviation 1), long-term standard deviation of continuous RR intervals (standard deviation 2), and Stress Index. We used Student's t-test for comparisons and Spearman's coefficient for correlations.

RESULTS

We observe insignificant values in the differences between the groups. Disability and self-efficacy were correlated with heart rate variability only in patients with chronic neck pain, whereas catastrophizing and kinesiophobia showed greater correlations with heart rate variability in patients with chronic low back pain.

CONCLUSIONS

Autonomic dysfunction of individuals with chronic neck pain, when compared to patients with chronic low back pain, does present insignificant differences.

Regulatory Emotional Self-Efficacy Buffers the Effect of Heart Rate Variability on Functional Capacity in Older Adults With Chronic Low Back Pain

Introduction

Chronic low back pain is one of the leading causes of disability globally among older adults. Prevailing research suggests that autonomic dysregulation places individuals at increased risk for chronic pain. This study examines the moderating role of emotional self-efficacy (ESE) on the relationship between heart rate variability (HRV) and pain related-outcomes, including movement-evoked pain (MEP) and physical functioning.

Methods

In a secondary analysis of the Adaptability and Resilience in Aging Adults (ARIAA) study, a total of 58 adults (aged 60 and older) with chronic low back pain (cLBP) completed the PROMIS self-efficacy for managing emotions questionnaire and the 6-minute walk test (6 MWT) to assess functional capacity and MEP. Heart rate variability, indexed by the frequency domain, was assessed for 5 min during rest.

Results

For pain-related outcomes, having a lower body mass index (p = 0.03) was associated with better functional capacity on the 6MWT, while higher education level (p = 0.01) and less pain duration (p = 0.00) were correlated with lower MEP. After controlling for sex, age, and body mass index, an increase in low-frequency HRV (LF-HRV) was associated with poorer physical functioning among individuals low in ESE (b = −0.12 p = 0.03). No significant moderation effects were observed for MEP.

Conclusion

Our results bring attention to the degree to which ESE influences the relationship between LF-HRV and physical functioning. Interventions that enhance adaptive psychological processes such as ESE may dampen ANS dysregulation and mitigate risk for adverse pain outcomes among older adults with cLBP.

Do catastrophizing and autonomic-reduced flexibility mediate pain outcomes in chronic headache?

OBJECTIVES

Maladaptive cognitive strategies and reduced autonomic flexibility have been reported in chronic pain conditions. No study to date addressed the effects of maladaptive coping and reduced autonomic flexibility, as indexed by heart rate variability (HRV), in chronic headaches. The present study aimed to assess the mediating role of pain catastrophizing and HRV on pain outcomes in patients with chronic headache.

METHODS

Thirty-two chronic headache patients and 28 healthy controls were recruited. Self-reported pain severity, pain interference on daily activity, and pain catastrophizing were assessed through the Multidimensional Pain Inventory and the Pain-Related Self Statements Scale. HRV was recorded at rest. Correlations and mediation analysis between self-report, HRV, and pain outcomes were run.

RESULTS

Patients with chronic headache reported significantly higher pain severity (p < .001; d =  - 1.98), pain interference on daily activity (p < .001; d =  - 1.81), and pain catastrophizing (p < .001; d =  - 0.96) compared to controls. They also presented significantly lower HRV (p < .05; d = 0.57). Both pain catastrophizing and HRV were associated with pain interference on daily activity. However, from mediation analysis, pain catastrophizing only emerged as the mediator for pain severity (p < .001; b = 0.30) and pain interference (p < .001; b = 0.14).

CONCLUSION

Present results showed that chronic headache patients are characterized by high catastrophizing and lower physiological adaptability. Pain catastrophizing emerged as the only mediator of pain outcomes, suggesting that cognitive factors might have a major influence on the severity of pain and its interference on daily activities. Further studies are needed to evaluate these autonomic-cognitive interactions in chronic pain.

Innovation in the treatment of persistent pain in adults with Neurofibromatosis Type 1 (NF1): Implementation of the iCanCope mobile application

Neurofibromatosis Type 1 (NF1) is a genetic disorder presenting with chronic pain symptoms that has limited treatment options for addressing the pain. The utilization of a mobile application allows for greater reach and scalability when using empirically valid psychosocial self-management treatments for pain. The iCanCope mobile application has been utilized in several different populations dealing with pain symptoms and has demonstrated initial effectiveness. To address the need for this population, we have customized the iCanCope mobile application for the NF1 population and included additional tailored features. We describe the rationale and design of a pilot randomized control study with a sample of 108 adults with NF1, in which two groups will receive access to the mobile application, of which one group will be incentivized to engage in the mobile application and the third group will treatment as usual over the course of 8-week period with a six-week follow-up. Outcomes will focus on the acceptability of the iCanCope-NF mobile application within the NF1 population and the impact of pain related activity on psychometric evaluations to determine if the contingency management will impact the engagement of mobile application, as well as to identify the participants' experiences in relationship to their treatment satisfaction and perceived support.

Heart rate and heart rate variability in patients with chronic inflammatory joint disease: the role of pain duration and the insular cortex

Background

Chronic inflammatory joint diseases (CIJD) have been linked to increased cardiovascular morbidity and mortality. A decisive reason could be a dysregulation of the autonomic nervous system, which is responsible for the control of cardiovascular function. So far, the cause of changes in autonomic nervous system functions remains elusive. In this study, we investigate the role of chronic pain and the insular cortex in autonomic control of cardiac functioning in patients with CIJD.

Methods

We studied the autonomic nervous system through the assessment of heart rate and heart rate variability (HRV) at rest and under cognitive stimulation. Furthermore, we investigated insular cortex volume by performing surface-based brain morphometry with FreeSurfer. For this study, 47 participants were recruited, 22 individual age- and sex-matched pairs for the magnetic resonance imaging analyses and 14 for the HRV analyses. All available patients’ data were used for analysis.

Results

Pain duration was negatively correlated with the resting heart rate in patients with chronic inflammatory joint diseases (n = 20). In a multiple linear regression model including only CIJD patients with heart rate at rest as a dependent variable, we found a significant positive relationship between heart rate at rest and the volume of the left insular cortex and a significant negative relationship between heart rate at rest and the volume of the right insular cortex. However, we found no significant differences in HRV parameters or insular cortex volumes between both groups.

Conclusions

In this study we provide evidence to suggest insular cortex involvement in the process of ANS changes due to chronic pain in CIJD patients.

The study was preregistered with the German Clinical Trials Register (https://www.drks.de; DRKS00012791; date of registration: 28 July 2017).

Depression explains the association between pain intensity and pain interference among adults with neurofibromatosis

INTRODUCTION

Neurofibromatoses (NFs; NF1, NF2 and Schwannomatosis) are incurable genetic syndromes characterized by nerve sheath tumors and often accompanied by substantial emotional distress (e.g., depression and anxiety). Pain is also common but understudied in adults with NF and interferes with daily living. In other medical populations, depression and anxiety have a strong association with pain interference. However, research has not explored the relationship of depression and anxiety to pain interference among adults with NF experiencing pain. The aim of this study was to test the hypothesis that depression and anxiety will mediate the association between pain intensity and pain interference among geographically diverse adults with NF who endorse pain.

METHODS

We used baseline data from an RCT of a mind-body intervention aimed at improving quality of life in adults with NF. Participants (N = 214) who endorsed pain completed measures of demographics, clinical characteristics, baseline pain intensity, pain interference, depression, and anxiety. We constructed a multiple mediation model in R using the lavaan package to test our hypothesis.

RESULTS

Preliminary analyses showed differences in pain interference by NF diagnostic subtype (F(2, 206) = 6.82, p = 001). In a model that controlled for NF diagnostic subtype, we found that depression (β = .07, p = .017), but not anxiety (β = -.003, p = .878), partially mediated the association between pain intensity and pain interference.

CONCLUSION

Improving depression has the potential to decrease pain interference among people with NF who experience pain.

TRIAL REGISTRATION

Clinicaltrials.gov Registration #: NCT03406208.

Chinese Version of the Psychological Inflexibility in Pain Scale for Cancer Patients Reporting Chronic Pain

Background

Cancer-related chronic pain is reported by many patients during treatment. There are very few Chinese tools for measuring psychological inflexibility caused by cancer pain, particularly with regard to psychological processes that might influence pain severity and function disorder during cancer treatment.

Objective

To culturally adapt the Psychological Inflexibility in Pain Scale (PIPS) to Chinese cancer patients experiencing chronic pain, including the determination of psychometric properties of the translated PIPS.

Methods

This cross-sectional study included 2 phases: (1) translation and cultural adaptation and (2) determination of psychometric properties of the translated PIPS. In total, 389 cancer patients with several types of cancer experiencing chronic pain enrolled from May to September 2018 at a tertiary cancer hospital in Yuelu District of Hunan Province, China.

Results

The Chinese PIPS version was semantically equivalent to the original. It had a 2-factor structure with satisfactory content validity (content validity index = 0.78–1.00), convergent and discriminant validity (composite reliability and average variance extracted at 0.41–0.89, P < .001), criterion-related validity (r = 0.54 and 0.41, P < .001), Cronbach’s α coefficients (α = .87), and test-retest reliability (0.9 ≤ r ≤ 0.98).

Conclusions

The Chinese PIPS version has been culturally adapted and has strong psychometric properties. The scale is a psychometrically sound assessment of psychological inflexibility that can be used for future studies of pain and pain management for cancer patients.

Implications for Practice

The study provides a vital tool for the psychological management of cancer patients with chronic pain.

Predicting personal protective equipment use, trauma symptoms, and physical symptoms in the USA during the early weeks of the COVID-19 lockdown (April 9-18, 2020)

The COVID-19 pandemic created a complex psychological environment for Americans. In this study, 450 MTurk workers completed measures of sociodemographic characteristics, perceived risk for COVID-19, general perceived vulnerability to disease, intolerance of uncertainty, and psychological flexibility. These variables were used to predict COVID-19 preventive health behaviors (PPE use), psychological distress, and physical symptoms. The surveys were completed between April 9, 2020 and April 18, 2020 which is a period that corresponded to the first 2-3 weeks of lockdown for most participants. A demographically diverse sample of participants was recruited. A substantial number of participants reported a reduction employment status and 69% were in self-isolation. Participants reported a high degree of perceived vulnerability to COVID-19. PPE mask wearing was variable: 16% "not at all," 20% "some of the time," 42% "a good part of the time," and 26 "most of the time." Using clinical cutoff on the post-trauma scale, 70% of the sample would be considered to have symptoms consistent with PTSD. Physical symptom reporting was also high. Intolerance of uncertainty and psychological inflexibility were significant predictors of psychological distress and physical symptoms. Psychological flexibility moderated the relationship between intolerance of uncertainty and psychological distress/physical symptoms. The relationship between intolerance of uncertainty and psychological distress/physical symptoms was stronger among participants with lower levels of psychological flexibility. These findings indicate psychological flexibility can reduce distress associated with COVID-19. Additionally, these results support the workability of the Unified Flexibility and Mindfulness Model as a framework for studying health behavior.

Physical therapy to address fall risk in an individual with neurofibromatosis

Background: While physical therapy may help improve function and quality of life in patients with neurofibromatosis (NF), a standard of care remains to be established. This case report describes the physical therapy management of an individual with NF who was at high fall risk.Case Description: A 61-year-old male with NF and multiple comorbidities was determined to be at high fall risk by the Dynamic Gait Index, Berg Balance Scale, and Modified Falls Efficacy Scale. Deficits included coordination and strength which limited his ability to ascend and descend stairs or walk on uneven terrain. This reduced his independence at home and in his rural community. Interventions incorporated components of hip and trunk coordination, and addressed balance, strength, and functional mobility.Outcomes: The patient scored above the cutoff for high fall risk on all outcome assessments.Discussion: This case report describes physical therapy management to reduce fall risk for an individual with NF. Due to the limited research on NF, the treatment plan was developed using evidence-based practice for fall-risk reduction in other neurological disorders.

Towards a neurobiological understanding of pain in neurofibromatosis type 1: mechanisms and implications for treatment

Neurofibromatosis type 1 (NF1) is the most common of a group of rare diseases known by the term, "Neurofibromatosis," affecting 1 in 3000 to 4000 people. NF1 patients present with, among other disease complications, café au lait patches, skin fold freckling, Lisch nodules, orthopedic complications, cutaneous neurofibromas, malignant peripheral nerve sheath tumors, cognitive impairment, and chronic pain. Although NF1 patients inevitably express pain as a debilitating symptom of the disease, not much is known about its manifestation in the NF1 disease, with most current information coming from sporadic case reports. Although these reports indicate the existence of pain, the molecular signaling underlying this symptom remains underexplored, and thus, we include a synopsis of the literature surrounding NF1 pain studies in 3 animal models: mouse, rat, and miniswine. We also highlight unexplored areas of NF1 pain research. As therapy for NF1 pain remains in various clinical and preclinical stages, we present current treatments available for patients and highlight the importance of future therapeutic development. Equally important, NF1 pain is accompanied by psychological complications in comorbidities with sleep, gastrointestinal complications, and overall quality of life, lending to the importance of investigation into this understudied phenomenon of NF1. In this review, we dissect the presence of pain in NF1 in terms of psychological implication, anatomical presence, and discuss mechanisms underlying the onset and potentiation of NF1 pain to evaluate current therapies and propose implications for treatment of this severely understudied, but prevalent symptom of this rare disease.