[Clinical Picture] Flushing out a plasmacytoma in a patient with POEMS and AESOP syndromes

A 58-year old man presented to our dermatology clinic with a 10-month history of discoloured skin patches on his chest, slowly progressive weakness and altered sensation in both legs. He also complained of chest pain, increased pigmentation of his arms, and episodic flushing of his face.

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N‐Docosahexaenoyl ethanolamine (Synaptamide) has antinociceptive effects in male mice

Abstract

Background

N‐docosahexaenoyl ethanolamine (DHEA; also known as synaptamide) binds to both the CB1 and CB2 cannabinoid receptors and has anti‐inflammatory properties in vitro. However, the in vivo effects of DHEA are unknown. Therefore, this study was designed to understand the effects of DHEA in models of pain and inflammation in mice.

Methods

The intraplantar formaldehyde assay, hot water tail withdrawal assay and hotplate model were used to assess the antinociceptive properties of DHEA in mice. The mechanism of action was studied by antagonising the cannabinoid receptors, transient receptor potential vanilloid 1 (TRPV1) ion channel, peroxisome proliferator‐activated receptors (PPARs) and G‐protein receptor 55 (GPR55).

Results

DHEA (2‐10 mg/kg) reduced the levels of nociceptive and inflammatory pain‐related behaviour over 60 min in the intraplantar formaldehyde assay via both intraperitoneal and local intraplantar administration. The area under the curve analysis showed the overall antinociceptive effects of DHEA (10 mg/kg) were not modulated by pre‐treatment with antagonists for the cannabinoid receptors, TRPV1 ion channel, PPARα, PPARγ, or GPR55. However, the time‐course analysis showed that within the early inflammatory phase, antagonism of the CB2 receptor, PPARα and PPARγ led to a partial reversal of the antinociceptive effects of DHEA. In the hot water tail withdrawal and hotplate models of thermal nociception, DHEA (2‐10 mg/kg) did not have any antinociceptive effects.

Conclusions

DHEA reduced the level of formaldehyde‐induced nociceptive and inflammatory pain‐related behaviour; however, was not active in thermal nociceptive models. This study highlights the potential of DHEA for the treatment of acute inflammatory pain.

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The pathophysiological nature of sarcomeres in trigger points in patients with myofascial pain syndrome: a preliminary study

Abstract

Background

Myofascial pain syndrome (MPS) has a high global prevalence and is associated with myofascial trigger points (MTrPs) in taut bands or nodules. Little is known about the aetiology. The current study assessed the pathophysiological characteristics of MTrPs in MPS patients.

Methods

Biopsies of the trapezius muscle were collected from the MTrPs of MPS patients (MTrP group; n=29) and from healthy controls (control group; n=24), and their morphologies were analysed via haematoxylin‐eosin (H&E) and Masson staining. A protein microarray was used to detect the receptor tyrosine kinase (RTK) family proteins. mRNA and long non‐coding RNA (lncRNA) sequencing and analysis were conducted, and immunohistochemistry and Western blotting were used to examine the expression of EphB and Rho family proteins.

Results

Abnormally contracted sarcomeres showed enlarged, round fibres without inflammation or fibrosis. An lncRNA‐mRNA network analysis revealed activation of muscle contraction signalling pathways in MTrP regions. Among RTK family proteins, 15 exhibited increased phosphorylation, and two exhibited decreased phosphorylation in the MTrP regions relative to control levels. In particular, EphB1/EphB2 phosphorylation was increased on the muscle cell membranes of abnormal sarcomeres. RhoA and Rac1, but not cell division control protein 42 (Cdc42), were activated in the abnormal sarcomeres.

Conclusions

EphB1/EphB2 and RhoA/Rac1 might play roles in the aetiology of abnormally contracted sarcomeres in MTrPs without inflammatory cell infiltration and fibrotic adhesion.

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The burden of pain in rheumatoid arthritis: impact of disease activity and psychological factors

Abstract

Background

Pain remains a prevalent symptom for rheumatoid arthritis (RA) patients despite a wide therapeutic choice. The objective of this study was to provide a multidimensional evaluation of pain.

Methods

295 RA patients from 7 French rheumatology centers were enrolled in a cross‐sectional study. Patients completed a chronic pain assessment questionnaire approved by the French National Authority for Health, the health assessment questionnaire (HAQ), as well as depression and anxiety scales (HAD, Beck Depression Inventory, STAI). Disease activity (DAS28) and ESR were recorded. A multi‐variate descriptive analysis was undertaken using principal component analysis (PCA)

Results

38.4% of patients had a pain score > 40 mm/100 although 83% were on biological treatment and 38.7 % were in remission based on the RA activity score. The PCA analysis found 4 axes representing 70% of total variance. The axes, percent of variance and variables represented were: (1) axis 1, 41% variance, anxiety and depression scores, sensory and affective qualifier score, HAQ and pain impact on daily life; (2) axis 2, 13% variance, disease activity score (DAS28) and pain relief with current treatment; (3) axis 3, 9% of variance, RA duration and radiographic score, (4) axis 4, 6% of variance, DAS28 and ESR. Moderate to severe pain was significantly associated with axes 1 and 2.

Conclusions

Despite a high proportion of patients on biological treatments, 38.4% of patients continue to experience moderate to severe pain. Pain is associated with the RA activity score, but also with the depression and anxiety scores.

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Comment on a manuscript by Paramasivan et al. entitled ‘Intrathecal dexmedetomidine and postoperative pain: A systematic review and meta‐analysis of randomized controlled trials’

Abstract

We read with great interest the manuscript by Paramasivan et al. titled ‘Intrathecal dexmedetomidine and postoperative pain: A systematic review and meta‐analysis of randomized controlled trials’, in a recent issue of European Journal of Pain (Paramasivan et al., 2020). We applaud the authors’ effort to evaluate the effect of intrathecal dexmedetomidine (IT DEX) versus placebo in prolongation of spinal anesthetic, postoperative pain scores, and adverse effects for various surgeries.

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Preventing pain after breast surgery: a systematic review with meta‐analyses and trial‐sequential analyses

Abstract

Background and objective

The aim of this systematic review is to indirectly compare the efficacy of any intervention, administered perioperatively, on acute and persistent pain after breast surgery.

Databases and data treatment

We searched for randomised trials comparing analgesic interventions with placebo or no treatment in patients undergoing breast surgery under general anaesthesia. Primary outcome was intensity of acute pain (up to 6h postoperatively). Secondary outcomes were cumulative 24 hour morphine consumption, incidence of PONV, and chronic pain. We used an original three‐step approach. First, meta‐analyses were performed when data from at least three trials could be combined; secondly, trial sequential analyses were used to separate conclusive from unclear evidence. And thirdly, the quality of evidence was rated with GRADE.

Results

Seventy‐three trials (5512 patients) tested loco‐regional blocks (paravertebral, pectoralis), local anaesthetic infiltrations, oral gabapentinoids or intravenous administration of glucocorticoids, lidocaine, NMDA antagonists or alpha2 agonists. With paravertebral blocks, pectoralis blocks, and glucocorticoids, there was conclusive evidence of a clinically relevant reduction in acute pain (VAS >1.0 cm). With pectoralis blocks, and gabapentinoids, there was conclusive evidence of a reduction in the cumulative 24 hour morphine consumption (≥5 mg). With paravertebral blocks and glucocorticoids, there was conclusive evidence of a relative reduction in the incidence of PONV of 70%. For chronic pain, insufficient data were available.

Conclusions

Mainly with loco‐regional blocks, there is conclusive evidence of a reduction in acute pain intensity, morphine consumption, and PONV incidence after breast surgery. For rational decision‐making, data on chronic pain are needed.

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Initial Evaluation of the Chronic Pain Acceptance Questionnaire – 2

Abstract

Greater acceptance of chronic pain is associated with lesser levels of pain‐related distress and disability and better overall functioning. Pain acceptance is most often assessed using the Chronic Pain Acceptance Questionnaire (CPAQ), which includes both an eight‐item short form (CPAQ‐8) and a twenty item parent measure (CPAQ‐20). This study derived a two‐item CPAQ for use in busy clinical settings and for repeated measurement during treatment, the CPAQ‐2. An Item Response Theory approach was used to identify the strongest items from the CPAQ‐20, one from each of its two subscales. Next, regression analyses were conducted to evaluate the utility of the CPAQ‐2 by examining variance accounted for in the CPAQ‐8, CPAQ‐20, and in measures of depression, pain‐related fear, physical disability, and psychosocial disability. Four clinical databases were combined (N = 1776) for the analyses. Items 9 and 14 were identified as the strongest CPAQ‐20 items in the IRT analyses. The sum score of these two items accounted for over 60% of the variance in the CPAQ‐8 and CPAQ‐20. Furthermore, this score accounted for significant variance in measures of depression, pain‐related fear, physical disability, and psychosocial disability after controlling for data collection method (i.e., in clinic or online), participant age, education, pain duration, and usual pain. Finally, the amount of variance accounted for by the CPAQ‐2 was comparable to that accounted for by both the CPAQ‐8 and CPAQ‐20. These results provide initial support for the CPAQ‐2 and suggest that it is well suited as a brief assessment of chronic pain acceptance.

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The interrelation between interpretation biases, threat expectancies and pain‐related attentional processing

Abstract

Background

Few studies examining the effect of pain‐related threat on eye movements have incorporated a measure of interpretation bias. However, theories suggest that interpretation biases also play an important role in the anticipation of harm in situations where pain could be imminent. The current study investigates the association between interpretation biases and pain‐related threat expectancies and their associations with eye movements to pain‐related imagery.

Methods

Healthy adults’ (N = 91) fear of pain, emotional functioning, and interpretation biases were assessed prior to a threat manipulation where they were given either threatening or reassuring information about an upcoming cold pressor task. Participants were then asked to freely‐view scene images that were either pain‐related or neutral.

Results

We used a data‐driven machine‐learning method to analyse eye movements. We identified an explorative (i.e., greater dispersal of eye fixations) and a focused eye movement pattern subgroup (i.e., mainly focusing on foreground information) for scene‐viewing in the sample. Participants with more negative interpretation biases expected that the cold pressor task would be more harmful, and those with higher levels of anticipated harm used a more explorative strategy when viewing injury scene images. Subsequent analysis confirmed an indirect effect of interpretation biases on eye movements through expected bodily harm. No difference in eye movements was found between participants given threatening and reassuring information.

Conclusions

Interpretation biases may play a prominent role in threat‐related attentional processing. By adopting a novel eye movement analysis approach, our results revealed interesting associations among interpretations, threat expectancies, and eye movements.

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Pain‐autonomic interaction: a surrogate marker of central sensitization

Abstract

Background

Central sensitization represents a key pathophysiological mechanism underlying the development of neuropathic pain, often manifested clinically as mechanical allodynia and hyperalgesia. Adopting a mechanism‐based treatment approach relies highly on the ability to assess the presence of central sensitization. The aim of the study was to investigate potential pain‐autonomic readouts to operationalize experimentally induced central sensitization in the area of secondary hyperalgesia.

Methods

Pinprick evoked potentials (PEPs) and sympathetic skin responses (SSRs) elicited by pinprick stimuli were recorded in 20 healthy individuals. Three blocks of PEP and SSR recordings were performed before and after heat‐induced secondary hyperalgesia. All measurements were also performed before and after a control condition. Multivariate analyses were performed using linear mixed‐effect regression models to examine the effect of experimentally induced central sensitization on PEP and SSR parameters (i.e., amplitudes, latencies, and habituation) and on pinprick pain ratings.

Results

The noxious heat stimulation induced robust mechanical hyperalgesia with a significant increase of PEP and SSR amplitudes (p<0.001) in the area of secondary hyperalgesia. Furthermore, PEP and SSR habituation were reduced (p<0.001) after experimentally induced central sensitization.

Conclusions

The findings demonstrate that combined recordings of PEPs and SSRs are sensitive to objectify experimentally induced central sensitization and may have a great potential to reveal its presence in clinical pain conditions. Corroborating current pain phenotyping with pain‐autonomic markers has the potential to unravel central sensitization along the nociceptive neuraxis and might provide a framework for mechanistically founded therapies.

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[Correspondence] COVID-19 is an opportunity for reform in dentistry

The COVID-19 global pandemic continues to have devastating health, economic, and social effects, and is profoundly affecting the delivery of health services. Because of the infection risks associated with aerosol generated procedures, such as the use of high-speed drills, dental services across much of the world have been essentially closed since late March, 2020. During this period there was limited access to emergency dental care. Consequently, many desperate people with excruciating dental pain and acute oral infections have resorted to do-it-yourself dentistry, including the extraction of molar teeth without any local analgesia1—a scene reminiscent of medieval times.

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[Clinical Picture] Crisis? What crisis? Abdominal pain and darkening skin in Addison's disease

A 19-year-old man presented with a 4-day history of abdominal pain, nausea, vomiting, and fever. He had no medical history. On examination his temperature was 38·8°C, he was dehydrated and tachycardic, and he had postural hypotension: his blood pressure was 110/40 mm Hg supine and 88/36 mm Hg standing. On palpation of his abdomen, the patient reported widespread pain with equivocal rebound tenderness. We also noted diffuse darkening of the mucous membranes and skin, which the patient said had gradually increased over the past 7 years.

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[Seminar] Chronic pancreatitis

Chronic pancreatitis is a multifactorial, fibroinflammatory syndrome in which repetitive episodes of pancreatic inflammation lead to extensive fibrotic tissue replacement, resulting in chronic pain, exocrine and endocrine pancreatic insufficiency, reduced quality of life, and a shorter life expectancy. The incidence and prevalence of chronic pancreatitis is rising and no curative treatment is available. Using novel diagnostic algorithms, definitive chronic pancreatitis can be diagnosed by imaging criteria alone, whereas probable chronic pancreatitis requires clinical features and imaging criteria.

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Headache attributed to craniocervical dystonia: A prospective cohort study

Abstract

Background

Cervical dystonia is the most common form of focal idiopathic dystonia and is frequently associated with pain. Headaches are not considered to be more prevalent among patients presenting with cervical dystonia, and headaches attributed to craniocervical dystonia are considered to be a rare disorder, despite the lack of studies and clinical information regarding the subject.

Objectives

To investigate the prevalence, characteristics and impact of headaches attributed to craniocervical dystonia in cervical dystonia patients receiving treatment with botulinum toxin type‐A (BoT‐A).

Methods

Twenty‐four patients presenting with cervical dystonia were assessed before receiving their scheduled BoNT‐A injections and then again approximately 4 and 16 weeks after, regarding the clinical characteristics of their dystonia and headaches. Headaches were classified in accordance with the current International Classification of Headache Disorders. We used the Short Form‐36 Health Survey, Hospital Anxiety and Depression Scale, Headache Impact Test‐6, Toronto Western Spasmodic Torticollis Rating Scale and McGill Pain Questionnaire.

Results

Nineteen patients (79.1%) presented with cervical dystonia associated with pain and 18 (75.0%) with headaches. The prevalence of headaches attributed to craniocervical dystonia was 29.2%; HIT‐6: 60.1 ± 9.9. Patients with headaches presented significantly poorer TWSTRS pain scores, compared to patients with no headaches. Those with headaches attributed to craniocervical dystonia presented with more disability and demonstrated a significant improvement in the impact of headaches after BoNT‐A injections, together with an improvement in the dystonia.

Conclusions

Headaches are highly prevalent amongst cervical dystonia patients, have an impact on their quality of life and improves after BoNT‐A injections.

Significance

We found that headaches are more frequent among patients with cervical dystonia than previously thought, and that they contribute towards an overall increase in pain in these patients. Headaches attributed to craniocervical dystonia are associated with greater disability among patients with cervical dystonia. These headaches improve after botulinum toxin injections, in parallel with the improvement of cervical dystonia symptoms.

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Generalizability of harm and pain expectations after exposure in chronic low back pain patients

Abstract

Background

Exposure treatments are shown to be effective in reducing pain‐related fear and the perceived harmfulness of physical activities. However, due to the fragility of extinction its stability is questionable. We investigated the generalizability of exposure effects in chronic low back pain (CLBP) patients by integrating a behavioral test in the context of an intervention study.

Methods

The study is an additional analysis of a randomized controlled trial investigating the efficacy of exposure in vivo. A total of 67 CLBP patients were randomly assigned to one of the three groups: Exposure‐short (EXP‐S); exposure‐long (EXP‐L) and cognitive behavioral therapy (CBT). Participants rated the expected harmfulness of daily activities (Photograph Series of Daily Activities) before and after therapy. Post‐treatment participants were confronted with an individually tailored, threatening movement in a new context. Harm and pain expectations before the exposure were compared to the actual experience after exposure.

Results

We found that EXP leads to more strongly reduced harm expectations (F (2,50) = 11.37, p  < .001, η² = 0.31) compared to CBT, regardless of the duration of EXP. After therapy, patients expected less harm (F (2,50) = 3.61, p =  .034, η² = 0.13) but not less pain (F (2,50) = 3.61, p =  .034, η² = 0.13) when confronted with a novel movement.

Conclusions

Exposure successfully reduced harm but not pain expectations in patients with CLBP. Further, preliminary results showed that these specific exposure effects were generalized to a novel activity in a different context outside therapy.

Significance

This study investigats the generalizability and stability of exposure effects in patients with CLBP by combining a behavioral test with an intervention study. We found strong and stable effects on harm expectations but not on pain expectations. Results show promising preliminary evidence that reduced harm expectations can be generalized to a novel threatening activity in a new context. Clinical implications of our findings suggest that exposure treatment would benefit from a clear focus on harm expectations.

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Alterations in SUMOylation of the hyperpolarization‐activated cyclic nucleotide‐gated ion channel 2 during persistent inflammation

Abstract

Background

Unilateral injection of Complete Freund's Adjuvant (CFA) into the intra‐plantar surface of the rodent hindpaw elicits chronic inflammation and hyperalgesia in the ipsilateral hindlimb. Mechanisms contributing to this hyperalgesia may act over multiple time courses and can include changes in ion channel expression and post‐translational SUMOylation. Hyperpolarization‐activated, cyclic nucleotide‐gated (HCN) channels mediate the hyperpolarization‐activated current, I_h. An HCN2‐mediated increase in C‐nociceptor I_h contributes to mechanical hyperalgesia in the CFA model of inflammatory pain. Changes in HCN2 post‐translational SUMOylation and protein expression have not been systematically documented for a given dorsal root ganglia (DRG) throughout the time course of inflammation.

Methods

This study examined HCN2 protein expression and post‐translational SUMOylation in a rat model of CFA‐induced hindpaw inflammation. L5 DRG cryosections were used in immunohistochemistry experiments and proximity ligation assays to investigate HCN2 expression and SUMOylation, respectively, on days 1 and 3 post‐CFA.

Results

Unilateral CFA injection elicited a significant bilateral increase in HCN2 staining intensity in small diameter DRG neurons on day 1 post‐CFA, and a significant bilateral increase in the number of small neurons expressing HCN2 but not staining intensity on day 3 post‐CFA. HCN2 channels were hyper‐SUMOylated in small diameter neurons of ipsilateral relative to contralateral DRG on days 1 and 3 post‐CFA.

Conclusions

Unilateral CFA injection elicits unilateral mechanical hyperalgesia, a bilateral increase in HCN2 expression and a unilateral increase in post‐translational SUMOylation. This suggests that enhanced HCN2 expression in L5 DRG is not sufficient for mechanical hyperalgesia in the early stages of inflammation and that hyper‐SUMOylation of HCN2 channels may also be necessary.

Significance

Nociceptor HCN2 channels mediate an increase in I_h that is necessary for mechanical hyperalgesia in a CFA model of chronic pain, but the mechanisms producing the increase in nociceptor I_h have not been resolved. The data presented here suggest that the increase in I_h during the early stages of inflammation may be mediated by an increase in HCN2 protein expression and post‐translational SUMOylation.

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A multi‐center international study of acupuncture for lateral elbow pain ‐ Results of a randomized controlled trial

Abstract

Background

Lateral elbow pain (LEP) due to tendinosis is one of the most common musculoskeletal pains of the upper limbs, yet there is no satisfactory treatment. This study was an international, prospective, multi‐centre, randomized, controlled, clinical trial to evaluate the efficacy of acupuncture compared to sham laser in the treatment of LEP.

Methods

The study used a parallel and stratified design (1:1 allocation using a computer‐generated sequence) and was participant‐, outcome assessor‐ and statistician‐blinded. Subjects from 18 to 80 years with unilateral chronic LEP (minimum three months) were recruited at four centres in Australia, China, Hong Kong and Italy. The treatment group received manual acupuncture at acupoints LI 10 and LI 11 on the affected side whereas the control group received sham laser acupuncture at the same acupoints. The primary endpoint was disabilities of the arm, shoulder, and hand (DASH) questionnaire score at the three‐week post‐treatment follow‐up visit. Three VAS scales (pain at rest, pain on motion and pain during exertion) were secondary outcomes measures. Ninety‐six subjects were allocated to either the treatment group (n  = 47) or control group (n  = 49) and were all included in the analysis.

Results

At the follow‐up visit, we found significant differences in DASH score between the two groups (p  = .015). The median change to baseline for the treatment group was −11.7 (interval: −50.83 to 23.33), and for the control group −7.50 (interval: −36.67 to 29.10). The estimated effect size was 0.47, indicating a medium effect. Significant differences were also found for secondary outcome measures for VAS of pain. There were no severe adverse events. Our findings suggest that acupuncture has a moderate efficacy in the treatment of LEP.

Conclusions

Acupuncture was shown to be efficacious in improving the function of the arm associated with lateral elbow tendinosis. Both the DASH score and the pain VAS on two occasions (at rest and during motion) showed a significant change over time indicating acupuncture as a potential treatment for LEP due to tendinosis.

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Effects of a person‐centred approach in a school setting for adolescents with chronic pain—The HOPE randomized controlled trial

Abstract

Background

Chronic pain among adolescents is common but effective interventions applicable in a school setting are rare. Person‐centred care (PCC) is a key factor in improving health by engaging persons as partners in their own care.

Methods

In this randomized controlled trial, a total of 98 adolescents in secondary school or upper secondary school (aged 14 − 21 years) with chronic pain were randomly assigned to a PCC intervention or standard school healthcare. In the intervention group a pain management programme, based on a PCC approach, comprising four face‐to‐face sessions with a school nurse over a period of 5 weeks was added to standard school healthcare. The main outcome measure was self‐efficacy in daily activities (SEDA scale) and rating scales for pain intensity and pain impact were used as secondary outcome measures.

Results

At the follow‐up, no significant differences were found between the groups in the SEDA scale (p  = .608) or in the rating scales for pain intensity (p  = .261) and pain impact (p = .836). In the sub‐group analysis, a significant improvement in the SEDA scale was detected at the secondary school in favour of the PCC intervention group (p  = .021).

Conclusion

In this pain management programme based on a PCC approach, we found no effect in the total sample, but the programme showed promising results to improve self‐efficacy in daily activities among adolescents at secondary school.

Significance

This study evaluates the effects of a pain management programme based on a PCC approach in a school setting addressing adolescents at upper secondary and secondary schools with chronic pain. No overall effects were shown, but results illustrate that the intervention improved self‐efficacy in adolescents at secondary school. Implementation of a PCC approach in a school setting may have the potential to improve self‐efficacy in daily activities for adolescents with chronic pain at secondary school.

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Disentangling trait versus state characteristics of the Pain Catastrophizing Scale and the PHQ‐8 Depression Scale

Abstract

Background

Research on the role of trait versus state characteristics of a variety of measures among persons experiencing pain has been a focus for the past few decades. Studying the trait versus state nature of the Pain Catastrophizing Scale (PCS) and the Patient Health Questionnaire (PHQ‐8) depression scale would be highly informative given both are commonly measured in pain populations and neither scale has been studied for trait/state contributions.

Methods

The PHQ‐8 and PCS were obtained on persons undergoing knee arthroplasty at baseline, 2‐, 6‐ and 12‐month post‐surgery (N  = 402). The multi‐trait generalization of the latent trait–state model was used to partition trait and state variability in PCS and PHQ‐8 item responses simultaneously. A set of variables were used to predict trait catastrophizing and trait depression.

Results

For total scores, the latent traits and latent states explain 63.2% (trait = 43.2%; state = 20.0%) and 50.2% (trait = 29.4%; state = 20.8%) of the variability in PCS and PHQ‐8, respectively. Patients with a high number of bodily pain sites, high levels of anxiety, young patients and African‐American patients had high levels of trait catastrophizing and trait depression. The PCS and the PHQ‐8 consist of both enduring trait and dynamic state characteristics, with trait characteristics dominating for both measures.

Conclusion

Clinicians and researchers using these scales should not assume the obtained measurements solely reflect either trait‐ or state‐based characteristics.

Significance

Clinicians and researchers using the PCS or PHQ‐8 scales are measuring both state and trait characteristics and not just trait‐ or state‐based characteristics.

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Comorbidities of self‐reported fibromyalgia in United States adults: A cross‐sectional study from The National Epidemiological Survey on Alcohol and Related Conditions (NESARC‐III)

Abstract

Background

Fibromyalgia has been associated with various physical and mental disorders. However, these comorbidities need to be quantified in a population‐based study.

Method

We compared participants with and without self‐reported fibromyalgia to assess (a) The prevalence of self‐reported fibromyalgia and its sociodemographic characteristics in a US representative sample, (b) The associations between self‐reported fibromyalgia and lifetime and past 12‐month mental and physical disorders and (c) The quality of life associated with self‐reported fibromyalgia. This cross‐sectional study used a large national sample (n  = 36,309) of the US population, the National Epidemiologic Survey on Alcohol and Related Conditions‐III. Face to face interviews were conducted, collecting sociodemographic characteristics, diagnostic and statistical manual of mental disorders‐5 structured diagnosis and self‐reported medical conditions (including fibromyalgia).

Results

The past 12‐month prevalence of self‐reported fibromyalgia was estimated at 2.05%. Participants with self‐reported fibromyalgia were significantly at higher risk to report a lifetime history of mental disorder (adjusted odds ratio [aOR] = 2.32). Self‐reported fibromyalgia was also positively associated with 24 of the 27 physical conditions assessed in this study. Participants with self‐reported fibromyalgia were more likely to report a past 12‐month history of suicide attempts (aOR = 5.81), substance use disorders (aOR = 1.40), mood disorders (aOR = 2.67), anxiety disorders (aOR = 2.75) and eating disorders (aOR = 2.45). Participants with self‐reported fibromyalgia had lower levels of both mental and physical quality of life than those without fibromyalgia.

Conclusions

Participants with self‐reported fibromyalgia have a higher prevalence of comorbid mental and physical disorders, and lower mean levels of mental and physical quality of life than their counterparts without fibromyalgia.

Significance

We showed here a strong association of self‐reported fibromyalgia with both mental and physical comorbidities. We showed that among participants with self‐reported fibromyalgia, more than 8 out of 10 had at least three other physical comorbidities, and almost half had at least three mental comorbidities. This is a cross‐sectional study using a representative sample of the US population with highly reliable psychiatric diagnosis that makes our results generalizable. Practitioners managing fibromyalgia should search and treat these comorbidities.

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The pharmacokinetics, efficacy, and safety of a novel selective‐dose cannabis inhaler in patients with chronic pain: A randomized, double‐blinded, placebo‐controlled trial

Abstract

Background

Precise cannabis treatment dosing remains a major challenge, leading to physicians’ reluctance to prescribe medical cannabis.

Objective

To test the pharmacokinetics, analgesic effect, cognitive performance and safety effects of an innovative medical device that enables the delivery of inhaled therapeutic doses of Δ⁹‐Tetrahydrocannabinol (THC) in patients with chronic pain.

Methods

In a randomized, three‐arms, double‐blinded, placebo‐controlled, cross‐over trial, 27 patients received a single inhalation of Δ⁹‐THC: 0.5mg, 1mg, or a placebo.

Δ⁹‐THC plasma levels were measured at baseline and up to 150‐min post‐inhalation. Pain intensity and safety parameters were recorded on a 10‐cm visual analogue scale (VAS) at pre‐defined time points. The cognitive performance was evaluated using the selective sub‐tests of the Cambridge Neuropsychological Test Automated Battery (CANTAB).

Results

Following inhalation of 0.5 mg or 1mg, Δ⁹‐THC plasma C _max ± SD were 14.3 ± 7.7 and 33.8 ± 25.7 ng/ml. T _max ± SD were 3.7 ± 1.4 and 4.4 ± 2.1 min, and AUC₀ → _infinity±SD were 300 ± 144 and 769 ± 331 ng*min/ml, respectively. Both doses, but not the placebo, demonstrated a significant reduction in pain intensity compared with baseline and remained stable for 150‐min. The 1‐mg dose showed a significant pain decrease compared to the placebo. Adverse events were mostly mild and resolved spontaneously. There was no evidence of consistent impairments in cognitive performance.

Conclusion

This feasibility trial demonstrated that a metered‐dose cannabis inhaler delivered precise and low THC doses, produced a dose‐dependent and safe analgesic effect in patients with neuropathic pain/ complex‐regional pain syndrome (CRPS). Thus, it enables individualization of medical cannabis regimens that can be evaluated pharmacokinetically and pharmacodynamically by accepted pharmaceutical models.

Significance

Evidence suggests that cannabis‐based medicines are an effective treatment for chronic pain in adults. The pharmacokinetics of THC varies as a function of its route of administration. Pulmonary assimilation of inhaled THC causes rapid onset of analgesia. However, currently used routes of cannabinoids delivery provide unknown doses, making it impossible to implement a pharmaceutical standard treatment plan. A novel selective‐dose cannabis inhaler delivers significantly low and precise doses of THC, thus allowing the administration of inhaled cannabis‐based medicines according to high pharmaceutical standards. These low doses of THC can produce safe and effective analgesia in patients with chronic pain.

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Peripheral and central nervous system correlates in fibromyalgia

Abstract

Background

Fibromyalgia (FM) is a syndrome characterized by altered pain processing at central and peripheral level, whose pathophysiologic mechanisms remain obscure. We aimed at exploring the structural changes of peripheral nociceptor measured by skin biopsy, the functional changes of central nociceptive pathway assessed by laser‐evoked potentials (LEP), and their correlation with clinical features and comorbidities.

Methods

In all, 81 patients diagnosed with FM underwent skin biopsies with quantification of intraepidermal nerve fibre density (IENFD) at the thigh and distal leg, and LEP recording by stimulating hand, thigh and foot. Nerve conduction study (NCS), clinical features, comorbidity with migraine and mood disorders, and previous, non‐active immune‐mediated disorders were recorded.

Results

Intraepidermal nerve fibre density was reduced in 85% of patients at the thigh and in 12.3% of patients at the distal leg, whereas it was normal in 14.8% of patients. N2P2 habituation index from laser stimulation at the thigh was altered in 97.5% of patients and correlated with reduced IENFD at the thigh. LEP latencies and amplitudes did not differ among groups. No association was found between IENFD, LEP, clinical features and comorbidities.

Conclusions

Fibromyalgia patients most commonly showed a mild loss of peripheral nociceptors at the thigh rather than distal small fibre neuropathy. This finding was associated with an altered habituation index and strengthened the hypothesis that central sensitization plays a key role in the pathogenesis of the disease.

Significance

Central impairment of pain processing likely underlies FM, which in most patients is associated with mild proximal small fibre pathology.

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What high rates of physical and mental comorbidity remind us about fibromyalgia

European Journal of Pain, Volume 24, Issue 8, Page 1423-1424, September 2020.

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Issue Information

European Journal of Pain, Volume 24, Issue 8, Page 1421-1422, September 2020.

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Orofacial quantitative sensory testing: Current evidence and future perspectives

Abstract

Background and objective

Orofacial quantitative sensory testing (QST) is an increasingly valuable psychophysical tool for evaluating neurosensory disorders of the orofacial region. Here, we aimed to evaluate the current evidence regarding this testing method and to discuss its future clinical potential.

Data treatment

We conducted a literature search in Medline, Embase and Scopus for English‐language articles published between 1990 and 2019. The utilized search terms included QST, quantitative, sensory testing and neurosensory, which were combined using the AND operator with the terms facial, orofacial, trigeminal, intraoral and oral.

Results

Our findings highlighted many methods for conducting QST—including method of levels, method of limits and mapping. Potential stimuli also vary, and can include mechanical or thermal stimulation, vibration or pinprick stimuli. Orofacial QST may be helpful in revealing disease pathways and can be used for patient stratification to validate the use of neurosensory profile‐specific treatment options. QST is reportedly reliable in longitudinal studies and is thus a candidate for measuring changes over time. One disadvantage of QST is the substantial time required; however, further methodological refinements and the combination of partial aspects of the full QST battery with other tests and imaging methods should result in improvement.

Conclusions

Overall, orofacial QST is a reliable testing method for diagnosing pathological neurosensory conditions and assessing normal neurosensory function. Despite the remaining challenges that hinder the use of QST for everyday clinical decisions and clinical trials, we expect that future improvements will allow its implementation in routine practice.

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Effects of neurofeedback in the management of chronic pain: A systematic review and meta‐analysis of clinical trials

Abstract

Background and Objective

Neurofeedback (NFB) provides real‐time feedback about neurophysiological signals to patients, thereby encouraging modulation of pain‐associated brain activity. This review aims to evaluate the effectiveness and safety of NFB in alleviating pain and pain‐associated symptoms in chronic pain patients.

Methods

MEDLINE, PUBMED, Web of Science and PsycINFO databases were searched using the strategy: (“Neurofeedback” OR “EEG Biofeedback” OR “fMRI Biofeedback”) AND (“Pain” or “Chronic Pain”). Clinical trials reporting changes in pain following electroencephalogram (EEG) or functional magnetic resonance imaging (fMRI) NFB in chronic pain patients were included. Only Randomized‐controlled trials (RCT), non‐randomized controlled trials (NRCT) and case series were included. Effect size was pooled for all RCTs in a meta‐analysis.

Results

Twenty‐one studies were included. Reduction in pain following NFB was reported by one high‐quality RCT, five of six low‐quality RCT or NRCT and 13 of 14 case‐series. Pain reduction reported by studies ranged from 6% to 82%, with 10 studies reporting a clinically significant reduction in pain of >30%. The overall effect size was medium (cohen's d −0.76, 95% confidence interval −1.31 to −0.20). Studies were highly heterogeneous (Q [df  = 5] = 18.46, p  = .002, I² = 73%). Improvements in depression, anxiety, fatigue and sleep were also seen in some studies. Common side‐effects included headache, nausea and drowsiness. These generally did not lead to withdrawal of therapy except in one study.

Conclusions

Neurofeedback is a safe and effective therapy with promising but largely low‐quality evidence supporting its use in chronic pain. Further high‐quality trials comparing different protocols is warranted to determine the most efficacious way to deliver NFB.

Significance

Neurofeedback is a novel neuromodulatory approach which can be used to reduce the severity of pain and pain‐associated symptoms such as sleep disturbances, mood disturbances, fatigue and anxiety in a number of chronic pain conditions. It has a potential to provide integrative non‐pharmacological management for chronic pain patients with pain refractory to pharmacological agents with high side‐effect profiles. Further high‐quality double‐blinded randomized sham‐controlled trials are needed in order to fully explore the potential of this therapy.

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Chronic Pain and Premature Aging – The Moderating Role of Physical Exercise

Chronic pain induces a multitude of harmful effects; recently it has been suggested that chronic pain is also associated with premature aging, manifested in shortened telomere length (TL). However, evidence for this hypothesis is scarce and inconsistent. The aim was twofold: 1) Investigate whether chronic pain is associated with premature aging, and 2) Determine whether physical exercise (PE) moderates this association if it exists. Participants were 116 male subjects, with (n=67) and without chronic pain (n=49).

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Smell and taste dissociations in the modulation of tonic pain perception induced by a capsaicin cream application

Abstract

Background

Pain is a subjective experience characterized by sensory (intensity) and emotional (unpleasantness) aspects. Although literature reports behavioral effects on pain due to smell and taste influence, to our knowledge the relationship between tonic pain induced by a capsaicin cream and these chemosensory systems has never been explored before. The aim of this study was to investigate the modulation of olfactory and gustatory substances having different valence on tonic pain perception mediated by a capsaicin cream application.

Methods

Sixty healthy volunteers were included in two separated experiments (N=30 smell; N=30 taste) and underwent different valence smell and taste stimulations, while receiving painful stimuli. Perception of pain intensity (the sensory component) and unpleasantness (the affective component) was measured with a numerical rating scale, both during the two aforementioned experiments.

Results

Pain unpleasantness rating showed differences only in the smell experiment between the two odorous conditions. In particular, pleasant odor induced lower ratings of pain unpleasantness, while no significant results were found for intensity. Regarding taste, we couldn’t observe significant effects nor for pain unpleasantness or intensity.

Conclusions

These findings highlight the potential role of pleasant odors in influencing the affective aspects of pain perception induced by this kind of tonic pain. Such evidence might provide new insight for using chemosensory substances as analgesics for modulating the cognitive aspects of neuropathic pain.

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Prefrontal white matter abnormalities associated with pain catastrophizing in patients with complex regional pain syndrome

Publication date: Available online 10 August 2020

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Jooyeon Jamie Im, Jungyoon Kim, Hyeonseok Jeong, Jin Kyoung Oh, Suji Lee, In Kyoon Lyoo, Yong-An Chung, Sujung Yoon

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Fear of movement in children and adolescents undergoing major surgery: A psychometric evaluation of the Tampa Scale for Kinesiophobia

Abstract

Background

The objective of this study was to evaluate the psychometric properties of the 17‐item Tampa Scale for Kinesiophobia (TSK) in youth.

Methods

Participants were 264 children and adolescents (58.7% female, M _age=14.1 years, SD _age=2.51) scheduled for major surgery who were assessed before surgery, while in hospital postoperatively, and at 6 and 12 months after surgery. Exploratory factor analyses (EFA) were conducted to determine the factor structure of pre‐operative TSK scores. Reliability, and convergent, discriminant, and predictive validity were examined.

Results

EFA on the 17‐item TSK revealed a two‐factor model distinguishing the 13 positively scored items from the 4 reverse scored items, but the fit was poor. A second EFA was conducted on the 13 positively scored items (TSK‐13) revealing a three‐factor model: Fear of injury, bodily vulnerability, and activity avoidance. The TSK‐13 showed adequate internal consistency (Ω =0.82) and weak convergent validity. The TSK‐13 was not correlated with postoperative, in‐hospital physical activity (actigraphy; r (179) =‐0.10, p =0.18) and showed adequate discriminant validity, that is correlations less than .70, with measures of depression (r (225)=0.41, p <0.001) and general anxiety (r (224)=0.35, p <0.001). Predictive validity for pain‐related disability at 12 months (r (70)=0.34, p <0.001) was adequate.

Conclusions

The original TSK‐17 does not appear to be a meaningful measure of kinesiophobia in youth after surgery possibly because of the syntactic structure of the reverse scored items. In contrast, a modified TSK‐13, comprised of only the positively scored items, revealed a 3‐factor structure that is reliable and demonstrates adequate convergent, discriminant, and predictive validity.

Significance

Kinesiophobia is an important construct to evaluate in the transition from acute to chronic pain among children and adolescents. The 17 item Tampa Scale for Kinesiophobia (TSK) does not show adequate validity or reliability in youth undergoing major surgery, however, the psychometric properties of a 13‐item modified scale (TSK‐13) are promising.

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[Correspondence] Recurrence of breast cancer after anaesthesia

Daniel Sessler and colleagues1 presented the findings from their multicentre, randomised trial that compared the effect of regional anaesthesia (paravertebral block and propofol) with general anaesthesia (sevoflurane) and opioids on breast cancer recurrence and postoperative pain after potentially curative surgery. Regional anaesthesia was reported to be equivalent to general anaesthesia regarding disease recurrence and postoperative pain.1

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The Time Course of Facial Expression Recognition Using Spatial Frequency Information: Comparing Pain and Core Emotions

Accurately detecting and interpreting nonverbal expressions of pain is important for caregiving. Although not conceptualised as an emotion, pain can also be communicated through facial expressions 19,32,38. The main method used to explore this takes a component approach, measuring movements of facial muscles during pain 12. However, this may be different to how we process facial expressions in naturalistic environments, where challenging visual conditions mean that specific details are difficult to see, e.g., brief exposure, limited visibility 10,34,43,44.

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Visual trajectory pattern as prognostic factors for neck pain

Abstract

Background

A novel approach capturing both temporal variation and pain intensity of neck pain is by visual trajectory patterns. Recently, both previous and expected visual trajectory patterns were identified as stronger predictors of outcome than traditional measures of pain history and psychological distress. Our aim was to examine patient characteristics within the various previous and expected patterns, relationship between the two patterns and predictive value of a variable combining the previous and expected patterns.

Methods

Patients with neck pain (n  = 932) consulting chiropractors were included. Baseline measures included pain intensity, disability, psychological variables and symptom history and expectations. Participants reported global perceived effect after 12 weeks. Analyses included descriptive statistics and logistic regression.

Results

Pain intensity, disability, psychological and worse outcome expectations increased from a single pain episode to severe ongoing pain of previous and expected patterns. Having a severe pain history was associated with poor prognosis, particularly if combined with negative expectations. The variable combining previous and expected patterns had a discriminative ability similar to that of other predictors AUC = 0.64 (95% CI = 0.60–0–67) versus AUC = 0.66 (95% CI = 0.62–0.70). The model with highest discriminative ability was achieved when adding the combined patterns to other predictors AUC = 0.70 (95% CI = 0.66–0.73).

Conclusion

The study indicates that pain expectations are formed by pain history. The patients’ expectations were similar to or more optimistic compared with their pain history. The prognostic ability of the model including a simplified combination of previous and expected patterns, together with a few other predictors, suggests that the trajectory patterns might have potential for clinical use.

Significance

The dynamic nature of neck pain can be captured by visual illustrations of trajectory patterns. We report, that trajectory patterns of pain history and future expectations to some extent are related. The patterns also reflect a difference in severity assessed by higher degree of symptoms and distress. Moreover, the visual trajectory patterns predict outcome at 12‐weeks. Since the patterns are easily applicable, they might have potential as a clinical tool.

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Mothers’ appraisals of injustice in the context of their child’s chronic pain: An Interpretative Phenomenological Analysis

Abstract

Background

In line with research highlighting the role of observer appraisals in understanding individuals’ pain experience, recent work has demonstrated the effects of parental child‐ and self‐oriented injustice appraisals on child pain‐related outcomes. However, research on parental injustice appraisals is in its infancy and lacks a valid and context‐specific operationalization of what parental injustice appraisals of child pain precisely entail. The current study presents an in‐depth qualitative analysis of parental child‐ and self‐oriented appraisals of injustice in the context of their child’s chronic pain.

Methods

Twenty‐one mothers of children living with chronic pain participated in one of five focus group interviews conducted in Ghent (Belgium), Glasgow (Scotland) and Indianapolis (USA).

Results

The interviews were subjected to interpretative phenomenological analysis, which revealed three key justice‐related themes, labelled ‘You shouldn’t be in this much pain’, ‘The problem’s probably with the mother’ and ‘At least it’s not cancer’. Maternal injustice appraisals focused mainly on the child rather than the self and reflected various perceived barriers to their efforts to provide quality of life for their child. A fourth theme labelled ‘Not everybody gets a healthy child’ reflected maternal strategies to effectively cope with the child’s condition and the associated appraisals of injustice.

Conclusions

The current findings attest to the relevance of (child‐ and self‐oriented) injustice in the parental experience of caring for a child with chronic pain and provides insight into the specific content and scope of these appraisals. As such, this study provides valuable insights to further research in this area.

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Conduction velocity of the cold spinal pathway in healthy humans

Abstract

Objectives

We aimed to investigate the conduction velocity of the cold spinal pathway in healthy humans.

Methods

Using a cold stimulator consisting of micro‐Peltier elements that was able to produce steep cooling ramps up to ‐300°C/s we recorded cold‐evoked potentials after stimulation of the dorsal midline at C5, T2, T6, and T10 vertebral levels and calculated the conduction velocity of the cold spinal pathway. In all participants, we used laser stimulation to deliver painful heat (Aδ‐fibres mediated) and warm (C‐fibres mediated) stimuli to the same sites in order to compare the conduction velocity of the cold spinal pathway with that of the nociceptive and warm spinal pathways.

Results

Cold stimulation evoked large‐amplitude vertex potentials from all stimulation sites. The mean conduction velocity of the cold spinal pathway was 12.0 m/s, which did not differ from that of the nociceptive spinal pathway (10.5 m/s). The mean conduction velocity of the warm spinal pathway was 2.0 m/s.

Discussion

This study provides previously unreported findings regarding cold spinal pathway conduction velocity in humans, that may be useful in the assessment of spinal cord lesions, as well as in intraoperative monitoring during spinal surgery.

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Individuals with Back and Neck Pain on Medical Forums: What do They Mention? What Do They Fear?

Abstract

Background

The use of online medical forums is on the rise globally. Data scraping is a method of extracting website content using an automated computer program. We scraped users’ questions regarding back and neck pain (BNP) from popular Israeli online medical forums. We aimed to identify the sort of questions being asked about BNP, and to analyze explicit themes that characterize their questions.

Methods

Six leading Israeli BNP forums were identified. In phase 1, Python scripts scraped 12,418 questions into a data set. In phase 2 ‐ five themes were identified: Surgery (n=2957); health care professions (n=2361); Sports (n=2304); drugs (n=1419); Interpretation of imaging (n=845). Phase 3 ‐ included the categorization of explicit fear‐related words by the authors. Phase 4 ‐ analysis of explicit fear‐related themes yielded 402 questions.

Results

Gender was identified for 394 users, and age was identified for 181 users. A total of 248 users (61.6%) were females and 146 males (36.3%). Mean age 36.3±16.15 for females and 35.5±16.1 for males. The most commonly expressed fears were related to: invasive procedures, 30.9% (131 questions); fear of serious condition or misdiagnosis, 17.0% (72 questions); General concerns, 13.7% (8 questions); fear of worsening or relapse, 12.3% (52 questions); adverse effects of oral drugs or radiation, 10.8% (46 questions); and concerns related to lifestyle, 9.7% (41 questions).

Conclusions

Web scraping is a feasible strategy with which to explore medical forums and the above‐mentioned themes, all of which are of potential clinical significance.

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Pelvic floor muscle training for women with lumbopelvic pain: a systematic review and meta‐analysis

ABSTRACT

Background and Objective

It has been suggested that pelvic floor dysfunction may contribute to the development of lumbopelvic pain as a result of changes in trunk muscle control. However, there is limited evidence that pelvic floor muscle training (PFMT) can improve clinical outcomes in women with lumbopelvic pain.

Databases and Data Treatment

Six databases were searched for randomised controlled trials (RCTs) comparing the effectiveness of PFMT to other conservative interventions (usual physiotherapy care or minimal intervention), no treatment, or placebo interventions on pain and disability in women with lumbopelvic pain.

Results

We included eight RCTs totalling 469 participants. PFMT were more effective than minimal intervention for lumbopelvic pain [Mean Difference (MD) 15.9/100 (95% Confidential Interval (CI), 8.2 to 23.6; p=0.00; I²=3.92%)] and disability [Standardized Mean Difference (SMD) 0.5 (95% CI, 0.1 to 0.9; p=0.00; I²=0%)] during pregnancy. PFMT were more effective than usual physiotherapy care for pain [MD 11.7/100 (95% CI, 7.5 to 15.9; p=0.00; I²=94.14%)] and disability [SMD 0.3 (95% CI, 0.0 to 0.6; p=0.01; I²=82.54%)] in non‐pregnant women. Effect sizes were in general of arguable clinical relevance.

Conclusions

Overall, the certainty of the evidence was very low‐to low. There is no conclusive evidence that the addition of PFMT to usual physiotherapy care or minimal intervention is superior to minimal intervention and usual care alone given the small number of studies and high levels of heterogeneity of included studies. Further well‐design trials are needed to establish the effectiveness of PFMT for lumbopelvic pain in women.

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Self‐compassion predicting pain, depression and anger in people suffering from chronic pain: a prospective study

Abstract

Self‐compassion is associated with disability, pain‐related anxiety as well as depression and anger in patients with chronic pain. However, the unique value of self‐compassion versus other concepts such as psychological flexibility and self‐esteem is unknown. The present study therefore aimed to clarify these relationships.

Individuals with chronic pain (N_CP =872) and without chronic pain (N_NP = 356) took part in a longitudinal study. Participants completed self‐report instruments: Pain Disability Index (PDI), Pain Catastrophizing Scale (PCS), Pain Anxiety Symptom Scale (PASS‐20), Patient‐Health‐Questionnaire (PHQ‐9), State‐Trait‐Anger‐Expression Inventory (STAXI), Self‐Compassion Scale (SCS), Psychological Inflexibility in Pain Scale (PIPS) and Rosenberg Self‐Esteem Scale (RSES). Assessments were repeated after eight weeks.

We found differences in baseline‐levels of all relevant variables except for anger‐out and anger‐control between people with and without chronic pain. Subsequently, we computed a path model analysis regarding individuals suffering from chronic pain (N _CP), addressing the predictive value of reduced uncompassionate self‐responding (RUS), compassionate self‐responding (CS), avoidance (PIPS), cognitive fusion (PIPS) and self‐esteem (RSES) regarding pain‐related (PDI, PCS, PASS) and emotional variables (PHQ‐9, STAXI). Avoidance predicted disability, catastrophizing, anxiety and depression. RUS predicted catastrophizing and pain‐related anxiety. Self‐esteem predicted depression. CS and cognitive fusion had no unique predictive value. The model explained 65.4%‐72.1% of the variance in pain‐related variables, 68.7% of the variance in depression and 38.7%‐60.7% in the variance of anger‐related variables.

In conclusion, psychological flexibility, in terms of avoidance, seems to be more relevant for chronic pain than self‐compassion. Future research should focus on subgroups and tailored‐treatment approaches.

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