Multimodal digital health treatments for Chronic Migraine associated with Medication Overuse Headache: a literature appraisal and results of a single-arm open trial (the BE-HOME program)

BACKGROUND

Mindfulness-based treatments gained popularity for migraine treatment. In this manuscript we report the results of a single-arm open pilot study that evaluated the impact of a multimodal web-based intervention combining home-based medication withdrawal, patients' education, and online mindfulness-based interventions. We aimed to address whether our program had the ability to show a change in the observed parameters and the study should therefore be intended as an early phase trial.

METHODS

Consecutive patients with chronic migraine associated with medication overuse headache were enrolled, followed-up for 12 months, in a program that included home-based medication withdrawal, education on the correct use of drugs and lifestyle issues, prescription of tailored pharmacological prophylaxis, and attendance to six online mindfulness-based sessions. We tested the effect of the program on improving headache frequency, medication intake, quality of life (QoL), headache impact, depression, self-efficacy, and pain catastrophizing.

RESULTS

A total of 37 patients completed the study (10 dropped out). We observed a large improvement in headache frequency, medication intake, headache impact, and QoL, a moderate improvement in pain catastrophizing and a mild improvement in depression symptoms; 70% to 76% of patients achieved 50% or more reduction in headache frequency from baseline to each follow-up (p < .01).

CONCLUSIONS

The results of our multimodal program showed significant improvements in headache frequency, medication intake, and patient-reported outcomes. Future studies are needed to better identify patients who might benefit most from Digital Health Interventions and to demonstrate at least an equivalence in outcome with in-person programs carried out in hospital settings.

The relationship among emotion regulation and pain catastrophizing in chronic pain patients

OBJECTIVES

Pain catastrophizing (PC) is a cognitive/emotional response to and in anticipation of pain, which may be maladaptive, further exacerbating pain and the difficulty in emotion regulation (ER). There is a lack of research on the interplay between PC and ER and its impact on pain. Our aim was to investigate whether ER exacerbated the pain experience through PC.

MATERIALS AND METHODS

Adults with chronic pain of > 3 months' duration (n = 150) with non-cancer pain and taking opioid medication were recruited from a large medical center in Pennsylvania. A battery of questionaries was conducted to gather data on demographics, substance use, mental health histories, and health and pain outcomes. Measures used included Difficulties in Emotion Regulation Scale 18 Item, Pain Catastrophizing Scale (PCS), Brief Pain Inventory-Short Form (BPI-SF), and Hospital Anxiety and Depression Scale (HADS). A structural equation model with latent variables was conducted to examine our aim.

RESULTS

Both pain interference and severity were significantly positively associated with several psychosocial variables, such as anxiety, depression, ER constructs, PC and distress intolerance. The associations between subscales and pain interference were larger than those with pain severity. PC fully mediated the paths from ER to pain experiences.

DISCUSSION

Our results highlight the importance of several cognitive and emotional constructs: Non-acceptance of negative emotions, lack of emotional awareness, magnification of pain experience, and a sense of helplessness. Further, by showing the indirect effects from PC in affecting ER and pain, we posit that ER, mediated by PC, may serve a critical role in influencing the pain experience in chronic pain patients.

Postoperative Psychological Predictors for Chronic Postsurgical Pain After a Knee Arthroplasty: A Prospective Observational Study

OBJECTIVE

Chronic postsurgical pain (CPSP) is a significant adverse effect shown in around 20% of people who had undergone a knee arthroplasty (KA). Psychological risk factors have emerged as significant and potentially modifiable risk factors for its development. However, there is still little evidence when assessing these factors during the acute postoperative period. This study aimed to assess the predictive value of postoperative pain catastrophizing, pain-related fear of movement, anxiety, depression, and pain attitudes in developing CPSP after KA.

METHODS

A 6-month follow-up prospective observational study design was used. The study sample comprised 115 people who underwent a KA due to painful primary osteoarthritis. Measures of pain catastrophizing, pain-related fear of movement, anxiety, depression, and pain attitudes were obtained 1 week after surgery. CPSP was set at an intensity of ≥30 using a 100-mm visual analog scale at 3 and 6 months after surgery.

RESULTS

Analysis revealed that baseline pain intensity, pain catastrophizing, pain-related fear of movement, anxiety, depression, and maladaptive pain attitudes were significant predictors of chronic pain at 3 and 6 months after surgery in a univariate analysis. However, at 3 months after surgery, only pain intensity and pain catastrophizing were predictors in the final multivariate model forecasting disturbing pain. Moreover, 6 months after surgery, pain intensity and distrust in medical procedures remained independent predictors. Most of the psychological factors can be grouped into a single dimension defined as pain-related psychological distress.

CONCLUSION

The results suggest that postoperative pain intensity, pain catastrophizing, and pain attitudes are independent predictors for CPSP after KA.

IMPACT

Postoperative cognitive and emotional factors should be considered alongside pain intensity during postoperative rehabilitation after KA because they could influence the development of CPSP.

Level of pain catastrophising determines if patients with long-standing subacromial impingement benefit from more resistance exercise: predefined secondary analyses from a pragmatic randomised controlled trial (the SExSI Trial)

OBJECTIVE

The primary aim was to investigate the effectiveness of adding more resistance exercise to usual care on pain mechanisms (including temporal summation, conditioned pain modulation (CPM) and local pain sensitivity) and pain catastrophising in people with subacromial impingement at 16 weeks follow-up. Second, to investigate the modifying effect of pain mechanisms and pain catastrophising on the interventions' effectiveness in improving shoulder strength and disability METHODS: 200 consecutive patients were randomly allocated to usual exercise-based care or the same plus additional elastic band exercise to increase total exercise dose. Completed add-on exercise dose was captured using an elastic band sensor. Outcome measures recorded at baseline, 5 weeks, 10 weeks and 16 (primary end point) weeks included temporal summation of pain (TSP) and CPM assessed at the lower leg, pressure pain threshold at the deltoid muscle (PPT-deltoid), pain catastrophising and the Shoulder Pain and Disability Index.

RESULTS

Additional elastic band exercise was not superior to usual exercise-based care in improving pain mechanisms (TSP, CPM and PPT-deltoid) or pain catastrophising after 16 weeks. Interaction analyses showed that pain catastrophising (median split) modified the effectiveness of additional exercises (effect size 14 points, 95% CI 2 to 25), with superior results in the additional exercise group compared with the usual care group in patients with less pain catastrophising.

CONCLUSION

Additional resistance exercise added to usual care was not superior to usual care alone in improving pain mechanisms or pain catastrophising. Additional exercise was, however, superior in improving self-reported disability in patients with lower levels of pain catastrophising at baseline.

TRIAL REGISTRATION NUMBER

NCT02747251.

Pain Severity and Pain Interference in Late Pregnancy: An Analysis of Biopsychosocial Factors Among Women Scheduled for Cesarean Delivery

OBJECTIVE

Pain is a variably experienced symptom during pregnancy, and women scheduled for cesarean delivery, an increasingly common procedure, are a relatively understudied group who might be at higher pain risk. Although biopsychosocial factors are known to modulate many types of chronic pain, their contribution to late pregnancy pain has not been comprehensively studied. We aimed to identify biopsychosocial factors associated with greater pain severity and interference during the last week of pregnancy.

METHODS

In this prospective, observational study, 662 pregnant women scheduled for cesarean delivery provided demographic and clinical information and completed validated psychological and pain assessments. Multivariable hierarchical linear regressions assessed independent associations of demographic, clinical, and psychological characteristics with pain severity and pain interference during the last week of pregnancy.

RESULTS

Women in the study had a mean age of 34 years, and 73% identified as White, 11% as African American, 10% as Hispanic/Latina, and 6% as Asian. Most women (66%) were scheduled for repeat cesarean delivery. Significant independent predictors of worse pain outcomes included identifying as African American or Hispanic/Latina and having greater depression, sleep disturbance, and pain catastrophizing. Exploratory analyses showed that women scheduled for primary (versus repeat) cesarean delivery reported higher levels of anxiety and pain catastrophizing.

CONCLUSIONS

Independent of demographic or clinical factors, psychological factors, including depression, sleep disturbance, and pain catastrophizing, conferred a greater risk of late pregnancy pain. These findings suggest that women at higher risk of pain during late pregnancy could benefit from earlier nonpharmacological interventions that concurrently focus on psychological and pain symptoms.

Brief Mindfulness-Based Cognitive Behavioral Therapy is Associated with Faster Recovery in Patients Undergoing Total Knee Arthroplasty: A Pilot Clinical Trial

OBJECTIVE

To assess whether brief mindfulness-based cognitive behavioral therapy (MBCBT) could enhance the benefits of total knee arthroplasty (TKA) in improving pain and pain-related disability. Specifically, to determine 1) whether patients who received MBCBT differed from matched controls who received treatment-as-usual with regard to postsurgical pain outcomes and 2) whether changes in pain catastrophizing, depression, or anxiety explained the potential effects of MBCBT on pain outcomes.

DESIGN

Pilot clinical trial.

SETTING

An academic teaching hospital serving a large urban and suburban catchment area surrounding the Boston, Massachusetts metropolitan region.

SUBJECTS

Sample of 44 patients undergoing TKA. Patients who completed a brief MBCBT intervention (n = 22) were compared with age-, race-, and sex-matched controls who received treatment-as-usual (n = 22).

METHODS

The MBCBT intervention included four 60-minute sessions delivered by a pain psychologist in person and via telephone during the perioperative period. Participants were assessed at baseline and at 6 weeks, 3 months, and 6 months after surgery.

RESULTS

Compared with matched controls, patients who received MBCBT had lower pain severity and pain interference at 6 weeks after surgery. Group differences in outcomes were mediated by changes in pain catastrophizing but not by changes in depression or anxiety. The MBCBT group had similar reductions in pain severity and interference as the control group did at 3 and 6 months after surgery.

CONCLUSIONS

This work offers evidence for a safe and flexibly delivered nonpharmacological treatment (MBCBT) to promote faster recovery from TKA and identifies change in pain catastrophizing as a mechanism by which this intervention could lead to enhanced pain-related outcomes.

The psychological burden of disease among patients undergoing cervical spine surgery: Are we underestimating our patients' inherent disability?

BACKGROUND

Studies have utilized psychological questionnaires to identify the psychological distress among certain surgical populations.

RESEARCH QUESTION

Is there an additional psychological burden among patients undergoing surgical treatment for their symptomatic degenerative cervical disease?

MATERIALS AND METHODS

Patients>18 years of age with symptomatic, degenerative cervical spine disease were included and prospectively enrolled. Correlations and multivariable logistic regression analysis assessed the relationship between these mental health components (PCS, FABQ) and the severity of disability described by the NDI, EQ-5D, and mJOA score. Patient distress scores were compared to previously published benchmarks for other diagnoses.

RESULTS

47 patients were enrolled (age: 56.0 years,BMI: 29.7kg/m²). Increasing neck disability and decreasing EQ-5D were correlated with greater PCS and FABQ(all P<0.001). Patients with severe psychological distress at baseline were more likely to report severe neck disability, while physician-reported mJOA had weaker associations. Compared to historical controls of lumbar patients, patients in our study had greater levels of psychological distress, as measured by FABQ (40.0 vs. 17.6; P<0.001) and PCS (27.4 vs. 19.3;P<0.001).

DISCUSSION AND CONCLUSION

Degenerative cervical spine patients seeking surgery were found to have a significant level of psychological distress, with a large portion reporting severe fear avoidance beliefs and catastrophizing pain at baseline. Strong correlation was seen between patient-reported functional metrics, but less so with physician-reported signs and symptoms. Additionally, this population demonstrated higher psychological burden in certain respects than previously identified benchmarks of patients with other disorders. Preoperative treatment to help mitigate this distress, impact postoperative outcomes, and should be further investigated.

LEVEL OF EVIDENCE

Level III.

The Mediating Effect of Perceived Injustice and Pain Catastrophizing in the Relationship of Pain on Fatigue and Sleep in Breast Cancer Survivors: A Cross-Sectional Study

OBJECTIVE

Multidimensional aspects of pain have raised awareness about cognitive appraisals, such as perceived injustice (PI) and pain catastrophizing (PC). It has been demonstrated that they play an important role in patients' pain experience. However, the mediating effect of these appraisals has not been investigated in breast cancer survivors (BCS), nor have they been related to fatigue and sleep.

METHODS

Cross-sectional data from 128 BCS were analysed by structural path analysis with the aim to examine the mediating effect of PI and PC in the relationship of pain on fatigue and sleep.

RESULTS

The indirect mediating effects of PI on fatigue (CSI*PI = 0.21; P < 0.01 and VAS*PI = 1.19; P < 0.01) and sleep (CSI*PI = 0.31; P < 0.01 and VAS*PI = 1.74; P < 0.01) were found significant for both pain measures (Central Sensitization Inventory (CSI) and Visual Analogue Scale (VAS)). PC, on the other hand, only mediated the relationship between pain measured by VAS and fatigue (VAS*PC = 0.80; P = 0.03). Positive associations were found, indicating that higher pain levels are positively correlated with PI and PC, which go hand in hand with higher levels of fatigue and sleep problems.

CONCLUSION

PI is an important mediator in the relationship of pain on fatigue and sleep, while PC is a mediator on fatigue after cancer treatment. These findings highlight that both appraisals are understudied and open new perspectives regarding treatment strategies in BCS.

Prevalence and Impact of Dysmenorrhea Among University Students in Ireland

OBJECTIVE

Primary dysmenorrhea (PD), or painful menstruation, is a common gynecological condition that can cause intense pain and functional disability in women of reproductive age. As a nonmalignant condition, PD is relatively understudied and poorly managed. The purpose of this study was to estimate the prevalence and impact of PD among third-level students in Ireland.

DESIGN

A cross-sectional observational design was used.

METHODS

Students (n = 892; age range = 18-45 years) completed an online survey on menstrual pain characteristics, pain management strategies, pain interference, and pain catastrophizing.

RESULTS

The prevalence of PD was 91.5% (95% confidence interval = 89.67-93.33). Nonpharmacological management strategies were most popular (95.1%); of these, heat application (79%), rest (60.4%), hot shower/bath (40.9%), and exercise (25.7%) were most common. Perceived effectiveness of these methods varied between participants. Analgesic use was also common (79.5%); of these, paracetamol was most used (60.5%) despite limited perceived effectiveness. Pain catastrophizing was a significant predictor of variance in both pain intensity and pain interference scores such that those with higher pain catastrophizing scores reported more intense pain and greater interference with daily activities and academic demands.

CONCLUSIONS

This article presents the first investigation into PD among third-level students in Ireland. Poorly managed menstrual pain may impact functional ability across several domains. Future research should focus on improving menstrual pain management education and support and promoting menstrual health literacy for women affected by PD.

ICD-11 Classification of Pediatric Chronic Pain Referrals in Ireland, with Secondary Analysis of Primary vs Secondary Pain Conditions

Objective

To classify pediatric chronic pain referrals in Ireland according to the classification system of the 11^th version of the International Classification of Diseases (ICD-11). In addition, differences between primary and secondary pain groups were assessed.

Methods

Retrospective review of complex pain assessment forms completed at the time of initial attendance at pediatric chronic pain clinics in Dublin, Ireland. Patients were classified as having a chronic primary (CPP) or chronic secondary (CSP) pain condition as per ICD-11 classification. Secondary analysis of between-group and within-group differences between primary and secondary pain conditions was undertaken.

Results

Of 285 patients coded, 123 patients were designated as having a CPP condition (77% of whom were assigned an adjunct parent code) and 162 patients as having a CSP condition (61% of whom were assigned an adjunct parent code). Between-group comparisons found that the lowest reported pain scores were higher in CPP than in CSP conditions. There were stronger correlations between parental pain catastrophizing and pain intensity, school attendance, and pain interference with social activities in the CSP group than in the CPP group.

Conclusions

The majority of children with both CPP and CSP were assigned multiple parent codes. There appears to be a gradient in the differences in biopsychosocial profile between CPP and CSP conditions. Additional field testing of the ICD-11 classification in pediatric chronic pain will be required.

Early Pain Catastrophizing Exacerbates Impaired Limb Loading and 6-Minute Walk Test Distance 12 Months After Lower Extremity Fracture

OBJECTIVE

Disability is common after lower extremity fracture (LEF). Although psychosocial factors have been associated with patient-reported outcomes after LEF, they have not been associated with objective measures of function. Aberrant gait patterns are important markers of function, but are poorly defined after LEF. The primary purpose of this study was to explore whether pain catastrophizing and fear of movement 6 weeks after surgery were associated with injured limb loading outcomes and 6-minute walk test (6MWT) distance 12 months after femur or tibia fracture. The secondary purpose was to determine if limb loading characteristics differed between injured and uninjured limbs.

METHODS

At 6 weeks after LEF, patients completed validated measures of pain catastrophizing, fear of movement, and depression. At 12 months, patients completed a 6MWT while wearing instrumented insoles that recorded the limb loading outcomes of stance time, impulse, and loading rate. Bivariate correlations assessed how patient and psychosocial characteristics at 6 weeks were associated with injured limb loading outcomes and 6MWT distance. Multivariable regression analyses were performed to determine if psychosocial variables were associated with each outcome after controlling for depression and patient demographic and clinical characteristics. Finally, paired t tests compared limb loading outcomes between limbs.

RESULTS

Forty-seven participants completed the 6MWT at 12 months (65%), and 38 completed the 6MWT with the instrumented insoles. Fear of movement carried a poor relationship (r = 0.11-0.32) and pain catastrophizing a moderate relationship (r = 0.46-0.54) with 12-month outcomes. The regression results indicated that pain catastrophizing continued to be associated with all outcomes. Finally, the injured limb had significantly lower limb loading outcomes than the uninjured limb at 12 months (Cohen d = 0.54-0.69).

CONCLUSION

Pain catastrophizing early after LEF was associated with impaired limb loading and 6MWT distance at 12 months.

IMPACT

Impaired limb loading persists 12 months after LEF. Further research is needed to determine whether rehabilitative efforts focused on pain catastrophizing can restore limb loading after LEF.

Associations of pain catastrophizing with pain-related brain structure in individuals with or at risk for knee osteoarthritis: Sociodemographic considerations

Compelling evidence exists that non-Hispanic blacks (NHB) engage in pain catastrophizing (negatively evaluate one's ability to cope with pain) more often than non-Hispanic whites (NHW). Functional neuroimaging studies revealed that individuals with high levels of trait pain catastrophizing show increased cerebral responses to pain in several pain-related brain regions (e.g., insula, primary somatosensory cortex [S1]), but associations between brain structure and catastrophizing remain largely unexplored. The current investigation was conducted at the University of Florida and the University of Alabama at Birmingham. Participants were 129 community-dwelling adults with or at risk of knee osteoarthritis (OA). Participants completed the pain catastrophizing subscale of the Coping Strategies Questionnaire-Revised and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain intensity subscale. Magnetic Resonance Imaging data were obtained. MANOVA and Chi-Square analyses assessed sociodemographic/clinical differences stratified by ethnicity/race. Multivariate regression analyses with insula and somatosensory cortical thickness entered as dependent variables with catastrophizing and the interaction between catastrophizing and ethnicity/race as the independent variables. Covariates include education, body mass index, study site, and WOMAC pain (ethnicity/race was an additional covariate in non-stratified analyses). There were significant interactions between ethnicity/race, pain catastrophizing, and brain structure. Higher pain catastrophizing was associated with thinner S1 bilaterally (ps < .05) in NHW, but not NHB participants with or at risk for knee OA. These results suggest that pain catastrophizing might have differing effects on pain-related central pathways and may contribute to ethnic/race group differences in individuals with or at risk for knee OA.

The Combination of Preoperative Pain, Conditioned Pain Modulation, and Pain Catastrophizing Predicts Postoperative Pain 12 Months After Total Knee Arthroplasty

OBJECTIVES

Approximately 20% of knee osteoarthritis patients undergoing total knee arthroplasty (TKA) report chronic postoperative pain. Studies suggest that preoperative variables such as impaired descending pain control, catastrophizing, function, and neuropathic pain-like symptoms may predict postoperative pain 12 months after TKA, but the combined prediction value of these factors has not been tested. The current prospective cohort study aimed to combine preoperative risk factors to investigate the predictive value for postoperative pain 12 months after TKA.

DESIGN

Prospective cohort with follow-up 12 months after surgery.

PATIENTS

A consecutive sample of 131 knee osteoarthritis patients undergoing TKA.

METHODS

Pain intensity, Pain Catastrophizing Scale (PCS) scores, PainDETECT Questionnaire scores, conditioned pain modulation (CPM), and Oxford Knee Score (OKS) were obtained before and 12 months after TKA.

RESULTS

TKA improved pain (P < 0.001), PCS scores (P < 0.001), PainDETECT Questionnaire scores (P < 0.001), and OKSs (P < 0.001). Preoperative pain correlated with preoperative PCS scores (r = 0.38, P  <  0.001), PainDETECT scores (r = 0.53, P  <  0.001), and OKSs (r = -0.25, P  =  0.001). Preoperative PainDETECT scores were associated with preoperative PCS scores (r = 0.53, P  <  0.001) and OKSs (r = -0.25, P  =  0.002). Higher postoperative pain was correlated with high preoperative pain (r = 0.424, P  <  0.001), PCS scores (r = 0.33, P  <  0.001), PainDETECT scores (r = 0.298, P  =  0.001), and lower CPM (r = -0.18, P  =  0.04). The combination of preoperative pain, PCS score, and CPM explained 20.5% of variance in follow-up pain. PCS scores had a significant effect on pain trajectory when accounting for patient variance (t  =  14.41, P  <  0.0005).

CONCLUSION

The combination of high preoperative clinical pain intensity, high levels of pain catastrophizing thoughts, and impaired CPM may predict long-term postoperative pain 12 months after surgery.

The Role of Pain-Related Cognitions in the Relationship Between Pain Severity, Depression, and Pain Interference in a Sample of Primary Care Patients with Both Chronic Pain and Depression

OBJECTIVE

The aims of this study were twofold: 1) to better understand the associations between pain-related cognitions and pain severity, and psychological and physical function, and 2) to determine the extent to which these cognitions function as mediators in the association between pain severity and depression in a sample of primary care adult patients with chronic pain and depression.

DESIGN

Cross-sectional design.

METHODS

Three hundred twenty-eight patients with both depression and chronic pain from primary care centers responded to measures of pain severity, pain interference, depression severity, and pain-related cognitions (including measures of catastrophizing and other pain-related beliefs). We performed three hierarchical regression analyses and two multiple regression analyses.

RESULTS

The helplessness domain of pain catastrophizing was positively associated with pain severity, depression severity, and pain interference and mediated the relationship between depression and pain severity and vice versa. Beliefs about disability showed a positive association with pain severity, pain interference, and depression severity, and also mediated the relationship between pain severity and depression. Believing in a medical cure was positively associated with pain interference and negatively associated with depression; emotion beliefs were positively associated with pain severity.

CONCLUSIONS

These findings provide important new information about the associations between several pain-related cognitions and pain severity, depression, and pain interference and the potential mediating roles that these cognitions play in the associations between pain severity and depression in patients with both chronic pain and depression in the primary care setting.

A Prospective Single-Arm Study Evaluating the Effects of a Multimodal Physical Therapy Intervention on Psychosexual Outcomes in Women With Dyspareunia After Gynecologic Cancer

BACKGROUND

Dyspareunia affects most women after treatment for gynecologic malignancies. However, to date, evidence-based interventions remain limited and no study has examined the effects of multimodal physical therapy on psychosexual outcomes in these patients.

AIM

To assess the effects of multimodal physical therapy on psychosexual outcomes including sexual distress, body image concerns, pain anxiety, pain catastrophizing, pain self-efficacy and depressive symptoms in women with dyspareunia after treatment for gynecologic malignancies.

METHODS

Thirty-one gynecologic cancer survivors with dyspareunia enrolled in this prospective single-arm interventional study. The participants undertook 12 weekly sessions of physical therapy incorporating education, pelvic floor muscle exercises with biofeedback, manual therapy and home exercises. Outcome measures were evaluated pre- and post-treatment. Paired t-tests were conducted to investigate the changes from pre-treatment (P-value ˂ 0.05) while effect sizes (Cohen's d) were calculated to measure the magnitude of the change.

MAIN OUTCOME MEASURES

Sexual distress (Female Sexual Distress Scale-Revised), body image concerns (Body Image Scale), pain anxiety (Pain Anxiety Symptoms Scale), pain catastrophizing (Pain Catastrophizing Scale), pain self-efficacy (Painful Intercourse Self-Efficacy Scale) and depressive symptoms (Beck Depression Inventory-II).

RESULTS

Significant changes were found from pre- to post-treatment for all psychosexual outcomes. Women reported reductions in sexual distress (P ˂ 0.001, d = 1.108), body image concerns (P ˂ 0.001, d = 0.829), pain anxiety (P ˂ 0.001, d = 0.980), pain catastrophizing (P ˂ 0.001, d = 0.968) and depression symptoms (P = 0.002, d = 0.636) with an increase in pain self-efficacy (P ˂ 0.001, d ≥ 0.938) following the intervention.

CLINICAL IMPLICATIONS

The results suggest that multimodal physical therapy significantly improves sexual distress, body image concerns, pain anxiety, pain catastrophizing, pain self-efficacy and depressive symptoms in our sample of women with dyspareunia after treatment for gynecologic malignancies. The medium to large effect sizes obtained with the high proportion of women presenting meaningful changes according to the known minimal clinically important difference or clinical cut-off underlines the significance of these effects.

STRENGTHS & LIMITATIONS

The current study used validated questionnaires to assess the psychosexual outcomes of a well-designed physical therapy intervention using multiple modalities to address the multifaceted aspect of dyspareunia in cancer survivors. This study did not include a control group, which may limit drawing definitive conclusions.

CONCLUSION

Findings showed that multimodal physical therapy yielded significant improvements in psychosexual outcomes in gynecologic cancer survivors with dyspareunia. A randomized controlled trial is indicated to confirm these results. Cyr M-P, Dumoulin C, Bessette P, et al. A Prospective Single-Arm Study Evaluating the Effects of a Multimodal Physical Therapy Intervention on Psychosexual Outcomes in Women With Dyspareunia After Gynecologic Cancer. J Sex Med 2021;18:946-954.

Headache Characteristics and Psychological Factors Associated with Functional Impairment in Individuals with Persistent Posttraumatic Headache

OBJECTIVE

Persistent posttraumatic headache (PPTH), one of the most common symptoms following mild traumatic brain injury, is often associated with substantial functional disability. The objective of this study was to assess the contribution of demographics, headache characteristics, and psychological symptoms to disability associated with PPTH.

METHODS

Participants completed the State-Trait Anxiety Inventory (STAI), the Beck Depression Inventory (BDI), the Pain Catastrophizing Scale (PCS), and the Migraine Disability Assessment (MIDAS) questionnaire. Two linear regression models were formulated to interrogate the relationships between 1) demographics and headache characteristics with the MIDAS questionnaire and 2) demographics, headache characteristics, and psychological symptoms with the MIDAS questionnaire. A two-way stepwise regression using the Akaike information criterion was performed to find a parsimonious model describing the relationships between demographics, headache characteristics, and psychological measures with the MIDAS questionnaire.

RESULTS

Participants included 58 patients with PPTH and 39 healthy controls (HCs). The median MIDAS score among those with PPTH was 48.0 (first quartile [1Q] = 20.0, third quartile [3Q] = 92.0), indicative of severe disability. Compared with the HCs, those with PPTH had higher scores on the BDI, STAI, and PCS. Older age predicted lower MIDAS scores (age: B=-0.11, P<0.01), whereas higher headache frequency, greater headache intensity, and higher trait anxiety scores predicted higher MIDAS scores in individuals with PPTH (headache frequency: B=0.07, P<0.001; headache intensity: B=0.51, P=0.04; trait anxiety score: B=1.11, P=0.01).

CONCLUSIONS

Individuals with PPTH had substantial psychological symptoms and headache-related disability. Disability was partially explained by age, headache frequency and intensity, and trait anxiety. Holistic management of patients with PPTH to address headaches and psychological symptoms might reduce headache-associated disability.

Pain Catastrophizing and Arthritis Self-Efficacy as Mediators of Sleep Disturbance and Osteoarthritis Symptom Severity

OBJECTIVE

Sleep and pain-related experiences are consistently associated, but the pathways linking these experiences are not well understood. We evaluated whether pain catastrophizing and arthritis self-efficacy mediate the association between sleep disturbance and osteoarthritis (OA) symptom severity in patients with knee OA.

METHODS

We analyzed cross-sectional baseline data collected from Veterans Affairs (VA) patients enrolled in a clinical trial examining the effectiveness of a positive psychology intervention in managing pain from knee OA. Participants indicated how often in the past two weeks they were bothered by trouble falling asleep, staying asleep, or sleeping too much. We used validated scales to assess the primary outcome (OA symptom severity) and potential mediators (arthritis self-efficacy and pain catastrophizing). To test the proposed mediation model, we used parallel multiple mediation analyses with bootstrapping, controlling for sociodemographic and clinical characteristics with bivariate associations with OA symptom severity.

RESULTS

The sample included 517 patients (Mage = 64 years, 72.9% male, 52.2% African American). On average, participants reported experiencing sleep disturbance at least several days in the past two weeks (M = 1.41, SD = 1.18) and reported moderate OA symptom severity (M = 48.22, SD = 16.36). More frequent sleep disturbance was associated with higher OA symptom severity directly (b = 3.08, P <0.001) and indirectly, through higher pain catastrophizing (b = 0.60, 95% confidence interval [CI] = 0.20 to 1.11) and lower arthritis self-efficacy (b = 0.84, 95% CI = 0.42 to 1.42).

CONCLUSIONS

Pain catastrophizing and arthritis self-efficacy partially mediated the association between sleep disturbance and OA symptom severity. Behavioral interventions that address pain catastrophizing and/or self-efficacy may buffer the association between sleep disturbance and OA symptom severity.

Pain Catastrophizing Is Independently Associated with Quality of Life in Patients with Severe Hip Osteoarthritis

OBJECTIVE

Pain catastrophizing is an important pain-related variable, but its impact on patients with osteoarthritis is uncertain. The aim of the current study was to determine whether pain catastrophizing was independently associated with quality of life (QOL) in patients with osteoarthritis of the hip.

DESIGN

Cross-sectional study conducted between June 2017 and February 2018.

SETTING

Tertiary center.

SUBJECTS

Seventy consecutively enrolled patients with severe hip osteoarthritis who had experienced pain for six or more months that limited daily function, and who were scheduled for primary unilateral total hip arthroplasty.

METHODS

QOL was measured using the EuroQOL-5 Dimensions questionnaire, the Japanese Orthopedic Association Hip Disease Evaluation Questionnaire, and a dissatisfaction visual analog scale. Covariates included pain intensity, pain catastrophizing, range of hip motion, and gait speed. The variables were subjected to multivariate analysis with each QOL scale.

RESULTS

The median age was 68 years, and the median Pain Catastrophizing Scale score was 26. In multiple regression analysis, pain catastrophizing, pain intensity in both hips, pain intensity on the affected side, hip flexion on the affected side, and gait speed were independently correlated with QOL.

CONCLUSIONS

Pain catastrophizing was independently associated with each QOL scale in preoperative patients with severe hip osteoarthritis. Pain catastrophizing had either the strongest or second strongest effect on QOL, followed by pain intensity.

Pain Catastrophizing, Fear of Pain, and Depression and Their Association with Female Sexual Pain

INTRODUCTION

Painful sexual intercourse or dyspareunia is a common complaint among women, affecting 12-21% of premenopausal women. Recent studies have begun to focus on the role of fear avoidance and pain catastrophizing (PC) in genital pain and have consistently highlighted the importance of psych-affective factors in sexual pain.

AIM

To establish the importance of PC, fear of pain, and depression for the development and maintenance of female sexual pain.

METHODS

This longitudinal study was conducted in the United Kingdom to assess sexual pain at 2 different time points, in 2009 and 2013, in a convenience sample of N = 979 British women.

MAIN OUTCOME MEASURE

Well-validated questionnaires including the Pain Catastrophizing Scale, the Pain Anxiety Symptom Scale, and the Female Sexual Function Index (recent and lifelong version) were applied.

RESULTS

Multilevel modeling showed a strong increase of short-lived sexual pain over the 4 years (π₀₁ = -0.33; P < .001). According to the moderation analyses, only depression influenced the change in short-lived pain over the 4 years (π₁₁ = 0.46; P = .016). Similarly, only depression turned out to be independently associated with sexual pain when entered into the multiple regression model, as women reporting higher depression levels also reported more sexual pain (P < 0.05).

CLINICAL IMPLICATIONS

Clinicians should be aware that the mechanisms influencing short-lived sexual pain and changes in sexual pain seem to be different from the more enduring psychological factors that lead to the development and maintenance of "chronic" sexual pain.

STRENGTHS & LIMITATIONS

A very generic and unidimensional definition of sexual pain was used without information on pain frequency or intensity, and no information on the possible underlying (medical or psychological or both) causes was available. However, as far as we know this represents the first study to use repeated measures to assess how pain changes over a 4-year period and to explore the role of potential psychoaffective risk factors.

CONCLUSION

Among the variables studied, symptoms of depression seemed to be the only independent predictor of lifelong sexual pain, overriding potential influences of pain catastrophizing or fear of pain. Burri A, Hilpert P, Williams F. Pain Catastrophizing, Fear of Pain, and Depression and Their Association with Female Sexual Pain. J Sex Med 2020;17:279-288.

Identification of Functioning Domains in the Presurgical Period and Their Relationships with Opioid Use and Pain Catastrophizing

OBJECTIVES

The National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) is a multidimensional screening system evaluating biopsychosocial factors affecting pain and functioning. Using a military sample, the current study 1) examined the structure and domains of the PROMIS, the Defense and Veterans Pain Rating Scale 2.0 (DVPRS), and the Pain Catastrophizing Scale (PCS) within a presurgical setting and 2) examined the relationship of these variables to pre- and postsurgical opioid use.

METHODS

This cross-sectional study included 279 adult patients scheduled for surgery at the Walter Reed National Military Medical Center and a validation sample of 79 additional patients from the Naval Medical Center, San Diego. PROMIS, DVPRS, PCS, and opioid use data were collected before surgery. Exploratory factor analysis and confirmatory factor analysis identified the latent structure for the measures. A structural equation model (SEM) examined their relationship to pre- and postsurgical opioid use.

RESULTS

Two latent factors represented Psychosocial Functioning (PROMIS Depression, PROMIS Anxiety, and PROMIS Social Isolation) and Pain Impact (DVPRS, PROMIS Pain Interference, PROMIS Physical Functioning). The remaining PROMIS scales did not load onto a single factor. In the SEM, the two latent factors and PCS were significantly related to pre- and postsurgical opioid use.

CONCLUSIONS

This study highlights the utility and relative ease of using a convenient multidimensional assessment in presurgical settings. Using such an assessment can help provide targeted interventions for individuals who may be at greatest risk for negative postsurgical outcomes.

Comparison Between Chronic Migraine and Temporomandibular Disorders in Pain-Related Disability and Fear-Avoidance Behaviors

Objective

To compare patients with chronic migraine (CM) and chronic temporomandibular disorders (TMD) on disability, pain, and fear avoidance factors and to associate these variables within groups.

Design

Descriptive, cross-sectional study.

Settings

A neurology department and a temporomandibular disorders consult in a tertiary care center.

Subjects

A total of 50 patients with CM and 51 patients with chronic TMD, classified by international criteria classifications.

Methods

The variables evaluated included pain intensity (visual analog scale [VAS]), neck disability (NDI), craniofacial pain and disability (CF-PDI), headache impact (HIT-6), pain catastrophizing (PCS), and kinesiophobia (TSK-11).

Results

Statistically significant differences were found between the CM group and the chronic TMD group in CF-PDI (P < 0.001), PCS (P = 0.03), and HIT-6 (P < 0.001); however, there were no differences between the CM group and the VAS, NDI, and TSK-11 groups (P > 0.05). For the chronic TMD group, the combination of NDI and TSK-11 was a significant covariate model of CF-PDI (adjusted R2 = 0.34). In the CM group, the regression model showed that NDI was a significant predictive factor for HIT-6 (adjusted R2 = 0.19).

Conclusions

Differences between the CM group and the chronic TMD group were found in craniofacial pain and disability, pain catastrophizing, and headache impact, but they were similar for pain intensity, neck disability, and kinesiophobia. Neck disability and kinesiophobia were covariates of craniofacial pain and disability (34% of variance) for chronic TMD. In the CM group, neck disability was a predictive factor for headache impact (19.3% of variance).

Patients with Concomitant Chronic Neck Pain and Myofascial Pain in Masticatory Muscles Have More Widespread Pain and Distal Hyperalgesia than Patients with Only Chronic Neck Pain

Objective

Insufficient evidence exists to compare widespread pain (WP), pain sensibility, and psychological factors that occur in patients presenting with chronic neck pain (CNP) or a combination of temporomandibular disorder (TMD) and other complaints. The present study compared the pain sensibility and psychological factors of subjects with CNP with those with TMD + CNP.

Design

Cross-sectional study.

Setting

Local community.

Subjects

A nonprobabilistic convenience sample of 86 persons with CNP or TMD was recruited into three groups: CNP, TMD with myofascial pain in masticatory muscles with cocomitant CNP (TMD + CNP), and asymptomatic control groups consisted of 27, 29, and 30 participants, respectively.

Methods

Participants underwent a clinical examination to evaluate WP with computerized assessment based on the pain drawing, pressure pain thresholds (PPT), and psychological factors, which were evaluated using the pain catastrophizing scale (PCS) and the state-trait anxiety inventory (STAI).

Results

Statistically significant differences were observed between participants with CNP and TMD + CNP for WP (t = -2.80, P  < 0.01, d = -1.06). Post hoc analyses only revealed significant differences between TMD + CNP participants and asymptomatic controls for PPT at extratrigeminal areas. Pearson correlation analyses showed a moderate positive association between symptomatic groups within the WP and STAI ( P  < 0.05) and a moderate negative association between PCS and PPT ( P  < 0.05) at the right tibialis muscle.

Conclusion

TMD + CNP participants had more areas of pain and also showed widespread pain hyperalgesia. Both groups of participants had psychological factors positively associated with STAI and WP; further, PCS and the PPT at the extratrigeminal region were negatively associated with each other in both groups, except for the left tibialis in the TMD + CNP group.

Gray matter alteration associated with pain catastrophizing in patients 6 months after lumbar disk surgery: a voxel-based morphometry study

Supplemental Digital Content is Available in the Text.

The link between pain catastrophizing and the differential effect of the components magnification and helplessness on brain morphology in patients with low back pain

Introduction:

Pain catastrophizing (PC), the increased attention to harmful aspects of pain (magnification), and the belief of low controllability (helplessness) has been shown to be important in the maintenance of pain. A growing research on structural alterations in chronic pain revealed an association between PC and brain areas that are involved in affective and cognitive pain processing. However, little is known about a differential effect of the components magnification and helplessness.

Objective:

The aim of this study was to identify brain regions associated with overall PC and with the single components of magnification and helplessness.

Methods:

We investigated 29 patients 6 months after lumbar disk surgery using voxel-based morphometry. Magnification and helplessness were assessed with subscales of the Avoidance-Endurance Questionnaire (AEQ); overall PC was computed using the sum score. The structural brain imaging data were preprocessed and analyzed using SPM8 and VBM8. Multiple regression analyses were performed with PC scales as predictors and depression as covariate.

Results:

Pain catastrophizing was significantly associated with cortical gray matter in brain areas involved in processing attentional, sensory, and affective aspects of pain, including the left posterior cingulate cortex, supplementary motor area, and medial frontal gyrus. In addition, we provide preliminary evidence for brain structure association related to magnification and helplessness.

Conclusion:

This study provides evidence for PC-related structural alterations in patients with low back pain, which are consistent with findings from previous research in different chronic pain disorders. This study is the first to evaluate brain changes related to differential domains of PC.

Effectiveness of a physiotherapist delivered cognitive-behavioral patient education for patients who undergoes operation for total knee arthroplasty: a protocol of a randomized controlled trial

Background

Total Knee Arthroplasty (TKA) is a common and generally effective procedure performed mainly due to advanced osteoarthritis, pain, physical disability and reduced quality of life. However, approximately 20% of the patients respond poorly to the surgery and chronic pain and disability following TKA remains a major health burden for many patients. Among the most well documented and powerful psychological predictors of poor outcome following TKA is pain catastrophizing. Recent research has shown that patients with these thoughts are at higher risk of having persistent pain and lower physical function after the operation than patients with low levels of pain catastrophizing before TKA. There is high need of developing treatments aimed at improving self-management for this group of patients and the aim of this study is to investigate the effectiveness of a patient education in pain coping on physical function and pain among patients with high pain catastrophizing score before a TKA.

Methods

This study is a two-arm parallel group trial design including 56 patients with high levels of pain catastrophizing referred for total knee arthroplasty due to osteoarthritis. Patients eligible for participation will be randomized into the two arms, usual care or usual care and patient education. Usual care consists of operation and standard rehabilitation. The patient education consists of 7 individual sessions focusing on pain behavior and pain coping managed by a physiotherapist. Three before the operation and four after. Measurements will be taken at baseline before the operation and 3 and 12 months after the operation. Primary outcome will be pain after 12 months measured with VAS (Visual Analogue Scale). Secondary outcomes include physical function and activity, quality of life, pain management and psychological factors.

Discussion

Only few studies have evaluated the effectiveness of psychological interventions on patients with high levels of pain catastrophizing before the operation. This trial will provide evidence for the effectiveness of a cognitive-behavioral patient education delivered by physiotherapists and may provide better functional outcome and less pain for a vulnerable group of TKA patients. We expect that the results can provide important new knowledge to the current care recommendations.

Trial registration

Clinical Trials (NCT02587429). Registered 23 October 2015

A 13-Weeks Mindfulness Based Pain Management Program Improves Psychological Distress in Patients with Chronic Pain Compared with Waiting List Controls

BACKGROUND

Eradication of pain is seldom an option in chronic pain management. Hence, mindfulness meditation has become popular in pain management.

OBJECTIVE

This pilot study compared the effect of a 13-weeks cognitive behavioural therapy program with integrated mindfulness meditation (CBTm) in patients with chronic non-malignant pain with a control condition. It was hypothesised that the CBTm program would reduce pain intensity and psychological distress compared to the control condition and that level of mindfulness and acceptance both would be associated with the reduction in pain intensity and psychological distress.

METHODS

A case-control design was used and data were collected from a convenience sample of 70 patients with chronic non-malignant pain. Fifty patients were consecutively recruited to the CBTm intervention and 20 patients matched waiting list controls. Assessments of clinical pain and psychological distress were performed in both groups at baseline and after 13 weeks.

RESULTS

The CBTm program reduced depression, anxiety and pain-catastrophizing compared with the control group. Increased level of mindfulness and acceptance were associated with change in psychological distress with the exception of depression, which was only associated with change in level of mindfulness. Surprisingly, changes in level of mindfulness did not correlate with changes in acceptance.

CONCLUSIONS

The results indicate that different mechanisms are targeted with cognitive behavioural therapy and mindfulness. The finding that changes in level of mindfulness did not correlate with changes in acceptance may indicate that acceptance is not a strict prerequisite for coping with pain related distress.

An Examination of Pain Catastrophizing and Endogenous Pain Modulatory Processes in Adults with Chronic Low Back Pain

OBJECTIVE

Research on chronic low back pain (cLBP) has focused heavily on structural abnormalities with emphasis on diagnostic imaging. However, for many cLBP patients, clinical pain and disability are not clearly associated with identifiable pathology of the spine or associated tissues. Therefore, alternative determinants such as psychological factors and dysfunctional pain modulatory processes have been suggested to be important.

METHODS

This observational study examined differences in pain catastrophizing and endogenous pain modulation between 25 cLBP patients and 25 pain-free controls. Associations among pain catastrophizing, endogenous pain modulatory processes, clinical pain reports, and disability were also examined in cLBP patients. Endogenous pain modulation was examined using temporal summation (TS) of mechanical and heat pain stimuli as well as conditioned pain modulation (CPM) with algometry (test stimulus) and the cold pressor task (conditioning stimulus).

RESULTS

Findings demonstrated significantly greater pain catastrophizing as well as greater TS of mechanical and heat pain for cLBP patients compared with controls. CPM was not present in cLBP patients or controls. Among cLBP patients, pain catastrophizing was significantly associated with disability, while TS of mechanical pain was significantly associated with clinical pain severity and disability.

CONCLUSIONS

This study suggests that endogenous pain modulatory processes are altered for cLBP patients, particularly TS of mechanical and heat stimuli. Pain catastrophizing and TS of mechanical pain may have important clinical relevance for cLBP, given associations with clinical pain and disability; however, future research is needed to replicate these findings.

Patients Presenting to the Emergency Department with Acute Pain: The Significant Role of Pain Catastrophizing and State Anxiety

OBJECTIVE

Pain is one of the most common reasons for emergency department (ED) visits. Given the significant association of psychological variables and pain experience, it is critical to examine the relation of such factors with ED pain reports. This study sought to analyze the association of reported pain intensity in ED with pain catastrophizing and state anxiety.

METHODS

One hundred participants presenting with a primary complaint of acute pain in an urban ED completed the study. The measures included a demographic survey with questions pertaining to pain intensity, type and duration of present pain, the Pain Catastrophizing Scale (PCS), and the State-Trait Anxiety Inventory-State Subscale (STAI-S).

RESULTS

Pain intensity was significantly and positively associated with pain catastrophizing and state anxiety. Follow-up PROCESS mediation analysis revealed a significant indirect effect of pain catastrophizing on the relationship between state anxiety and pain intensity.

CONCLUSIONS

The results suggest that it is important to assess the psychological distress due to anxiety and pain catastrophizing of patients presenting to EDs with acute pain. Setting-appropriate brief behavioral interventions in conjunction with pharmacological interventions could improve outcomes.