Pain catastrophizing as a treatment process variable in cognitive behavioural therapy for adults with chronic pain

Abstract

Background

Interdisciplinary cognitive behavioural therapy (CBT) for chronic pain is effective at improving function, mood and pain interference among individuals with disabling chronic pain. Traditionally, CBT assumes that cognitive change is an active therapeutic ingredient in the determination of treatment outcome. Pain catastrophizing, a cognitive response style that views the experience of pain as uncontrollable, permanent and destructive, has been identified as an important maladaptive cognition which contributes to difficulties with the management of chronic pain. Consequently, pain catastrophizing is commonly targeted in CBT for chronic pain.

Objectives

To examine change trajectories in pain catastrophizing during treatment and assess the relevance of these trajectories to outcomes at posttreatment.

Methods

Participants included individuals with chronic pain (N = 463) who completed a 3‐week program of interdisciplinary CBT. Pain catastrophizing was assessed weekly over the 3 weeks of treatment and latent growth curve modelling was used to identify trajectories of change.

Results

Findings indicated the presence of two classes of linear change, one with a significant negative slope in pain catastrophizing (i.e. improved class) and the other with a non‐significant slope (i.e. unchanged class). Next, latent growth mixture modelling examined treatment outcome in relation to class membership. These results indicated that individuals in the ‘improved’ PCS class had significantly greater improvement in pain interference and mood, as well as physical and mental quality of life compared to the ‘unchanged’ class.

Conclusions

Implications for our findings, in relation to the CBT model, are discussed.

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Transcranial direct current stimulation of the dorsolateral prefrontal cortex alters emotional modulation of spinal nociception

Emotion has a strong modulatory effect on pain perception and the nociceptive system 8,42,43. In healthy individuals, experience of unpleasant emotions facilitates pain, whereas experience of pleasant emotions inhibits pain 43. Dysregulation of this system has been identified in clinical populations and has been theorized as a mechanism underlying development and maintenance of chronic pain 8,12,17,38,49. However, experimental evidence for the neural mechanisms involved in these processes is limited 46.

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[Clinical Picture] A disease disregards anatomical planes: actinomycosis and an intrauterine device

A 24-year-old woman was referred to our specialist unit with a 3-month history of 15·8 kg weight loss, increasing abdominal pain and bloating, fatigue, night sweats, difficulty passing urine, amenorrhoea, and trouble walking. She was nulligravida and had a copper intrauterine device (IUD) in situ for the past 4 years. She was a non-smoker, drank alcohol socially, and had no history of recent travel. She stated she was allergic to penicillin.

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Involvement of TACAN, a mechanotransducing ion channel, in inflammatory but not neuropathic hyperalgesia in the rat

Most clinical pain syndromes are associated with sensitization of nociceptors to mechanical stimuli, especially those pain syndromes associated with inflammation 33,42,44,46,54 and peripheral neuropathy 12,22,31,53. Mechanotransduction in sensory neurons is a vital process underlying several physiological functions, including hearing, touch, pain, and proprioception 14,18,41,61. The mechanisms underlying mechanotransduction in somatosensory neurons have only recently begun to be elucidated. Piezo2, a mechanotransducing ion channel is now well-established to contribute to the sensation of light touch 34,62, and may also contribute to some forms of nociception 37.

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Use of Real-Time Visual Feedback To Facilitate Core Muscle Activation In Individuals With Low Back Pain

Publication date: December 2020

Source: Archives of Physical Medicine and Rehabilitation, Volume 101, Issue 12

Author(s): Linda Lancere, Jason Wilken

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A cost-effectiveness analysis of an internet-delivered pain management program delivered with different levels of clinician support: Results from a randomised controlled trial.

Chronic pain significantly affects the lives of approximately 1 in 20 adults37 and is associated with increased risk of mental health difficulties, such as anxiety and depression30,32. The economic costs of chronic pain are also significant in terms of both lost workforce participation and ongoing health care use2,39. Reflecting this, in 2012, chronic pain was estimated to cost up to $635 billion every year in the United States18.

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Longitudinal transcriptomic profiling in carrageenan-induced rat hind paw peripheral inflammation and hyperalgesia reveals progressive recruitment of innate immune system components.

Pain is a common yet complex and potentially debilitating symptom that can negatively influence the quality of life for patients with acute and chronic medical conditions.56 In the United States, approximately 100 million adults are affected by chronic pain at a total medical cost of approximately $600 billion in 2010.13 Providing appropriate pain management with accurate pain assessment in the early phases of tissue injury is essential. However, difficulties in accurately assessing pain can be encountered due to complexities associated with the etiology of the original insult and the neural mechanisms of nociception that are activated.

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Analgesic Effects of Topical Amitriptyline in Patients with Chemotherapy-Induced Peripheral Neuropathy: Mechanistic Insights from Studies in Mice

Antidepressants are an essential component of the therapeutic strategy for treatment of many causes of persistent pain 15, 49. Tricyclic antidepressants (TCAs) are the recommended first-line treatment for many forms of persistent neuropathic pain 11, 15, 22. Amitriptyline hydrochloride (amitriptyline), a TCA approved for the treatment of major depression, has been shown to be effective for the treatment of pain associated with a range of neuropathic pain conditions, including diabetic neuropathy, fibromyalgia and postherpetic neuralgia 19, 25, 27.

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[Clinical Picture] A painful lump on a teenager's toe is a benign enchondroma

A 16-year-old girl attended our outpatient clinic complaining about a hard lump on the second toe of her left foot. She said it had been present for 6 years, but that in the past 3 months it had become moderately painful and that the pain was aggravated by walking. She said that the lump had not increased in size. She reported no history of trauma and no relevant medical history.

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Acute otitis media in children

What you need to knowSuspect acute otitis media in children with ear pain (ear symptoms can be subtle especially in young pre-verbal children), with or without feverThe presence of middle ear...

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Treating Heel Pain in Adults: A Randomized Clinical Trial of Hard Versus Modified Soft Custom Orthotics and Heel Pads

Publication date: Available online 18 November 2020

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Deborah A.R. Seligman, Deirdre Dawson, David L. Streiner, David Seligman, Aileen Davis

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Assessment of Chronic Pain Management in the Treatment of Opioid Use Disorder: Gaps in Care and Implications for Treatment Outcomes

Chronic pain (i.e., pain experienced for 3 months or longer) is a significant comorbid condition among individuals with opioid use disorder (OUD).3,17 Despite this well-documented complexity, there are conflicting perceptions of who is responsible for addressing chronic pain within OUD, with prior literature referencing the assessment and management of chronic pain within a general term of “physicians” or across multiple physician specialties such as addiction medicine, pain specialists, or primary care physicians.

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[Correspondence] Lessons from The Lancet Low Back Pain Series media strategy

Mass media campaigns improve population health by promoting positive health behaviours and discouraging negative ones.1 Campaigns have helped to successfully reduce smoking and promote physical exercise. For some health conditions, campaigns sometimes have to compete with the marketing of unproven tests and treatments by industry and professional associations. An example of success in this context was an Australian campaign that improved population and general practitioner beliefs about back pain, improved medical management, and reduced workers' compensation costs for back pain.

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Acceptance is not acceptance, but acceptance!

European Journal of Pain, EarlyView.

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Predicting long‐term postsurgical pain by examining the evolution of acute pain

Abstract

Background

Increased acute postoperative pain intensity has been associated with the development of persistent postsurgical pain (PPP) in mechanistic and clinical investigations, but it remains unclear which aspects of acute pain explain this linkage.

Methods

We analyzed clinical postoperative pain intensity assessments using symbolic aggregate approximations (SAX), a graphical way of representing changes between pain states from one patient evaluation to the next, to visualize and understand how pain intensity changes across sequential assessments are associated with the intensity of postoperative pain at 1 (M1) and 6 (M6) months after surgery. SAX‐based acute pain transition patterns were compared using cosine similarity, which indicates the degree to which patterns mirror each other.

Results

This single‐center prospective cohort study included 364 subjects. Patterns of acute postoperative pain sequential transitions differed between the “None” and “Severe” outcomes at M1 (cosine similarity 0.44) and M6 (cosine similarity 0.49). Stratifications of M6 outcomes by preoperative pain intensity, sex, age group, surgery type, and catastrophizing showed significant heterogeneity of pain transition patterns within and across strata. Severe‐to‐severe acute pain transitions were common, but not exclusive, in patients with moderate or severe pain intensity at M6.

Conclusions

Clinically, these results suggest that individual pain‐state transitions, even within patient or procedural strata associated with PPP, may not alone offer good predictive information regarding PPP. Longitudinal observation in the immediate postoperative period and consideration of patient‐ and surgery‐specific factors may help indicate which patients are at increased risk of PPP.

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Sensory and pain modulation profiles of ongoing central neuropathic extremity pain in multiple sclerosis

Abstract

Central neuropathic extremity pain (CNEP) is the most frequent type of pain in multiple sclerosis (MS). The aim of the present study was to evaluate sensory and pain modulation profiles in MS patients with CNEP. In a single‐centre observational study, a group of 56 CNEP MS patients was compared with 63 pain‐free MS patients and with a sex‐ and age‐adjusted control group. Standardized quantitative sensory testing (QST) and dynamic QST (dQST) protocols comprising temporal summation and conditioned pain modulation tests were used to compare sensory profiles. Loss‐type QST abnormalities in both thermal and mechanical QST modalities prevailed in both MS subgroups and correlated significantly with higher degree of disability expressed as Expanded Disability Status Scale (EDSS). Comparison of sensory phenotypes disclosed a higher frequency of the “sensory loss” prototypic sensory phenotype in the CNEP subgroup (30%) compared with pain‐free MS patients (6%; p = 0.003). The role of aging process and higher lesion load in the spinothalamocortical pathway might be possible explanation for pain development in this particular “deafferentation” subtype of central neuropathic pain in MS. We were unable to support the role of central sensitization or endogenous facilitatory and inhibitory mechanisms in the development of CNEP in MS.

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The serotonin receptor 2A (HTR2A) rs6313 variant is associated with higher ongoing pain and signs of central sensitization in neuropathic pain patients

Abstract

Background

The serotonin receptor 2A (HTR2A) has been described as an important facilitation mediator of spinal nociceptive processing leading to central sensitization (CS) in animal models of chronic pain. However, whether HTR2A single nucleotide variants (SNVs) modulate neuropathic pain states in patients has not been investigated so far. The aim of this study was to elucidate the potential association of HTR2A variants with sensory abnormalities or ongoing pain in neuropathic pain patients.

Methods

At total of 240 neuropathic pain patients and 253 healthy volunteers were included. Patients were phenotypically characterized using standardized quantitative sensory testing (QST). Patients and controls were genotyped for HTR2A g.‐1438G>A (rs6311) and c.102C>T (rs6313). Genotype‐related differences in QST parameters were assessed considering QST profile clusters, principal somatosensory components and sex.

Results

There was an equal distribution of rs6313 and linked rs6311 between patients and controls. However, the rs6313 variant was significantly associated with a principal component of pinprick hyperalgesia and dynamic mechanical allodynia indicating enhanced CS in patients with sensory loss (‐0.34 ± 0.15 vs. +0.31 ± 0.11 vs, p<0.001). In this cluster, the variant allele was also associated to single QST parameters of pinprick hyperalgesia (MPT, +0.64 ± 0.18 vs. ‐0.34 ± 0.23 p=0.002; MPS, +0.66 ± 0.17 vs. ‐0.09 ± 0.23, p=0.009) and ongoing pain was increased by 30%.

Conclusions

The specific association of the rs6313 variant with pinprick hyperalgesia and increased levels of ongoing pain suggests that the HTR2A receptor might be an important modulator in the development of CS in neuropathic pain.

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Conditioned Pain Modulation affects the N2/P2 complex but not the N1 wave: a pilot study with Laser‐Evoked Potentials

Abstract

Background

The “pain‐inhibits‐pain”’ effect stems from neurophysiological mechanisms involving endogenous modulatory systems termed diffuse noxious inhibitory controls (DNIC) or conditioned pain modulation (CPM). Laser‐evoked potentials (LEPs) components, the N2/P2 complex, and the N1 wave, reflect the medial and lateral pain pathway, respectively: anatomically, the lateral thalamic nuclei (LT) project mainly to the somatosensory cortex (N1 generator), while the medial thalamic nuclei (MT) are bound to the limbic cortices (N2/P2 generators).

Methods

We applied a CPM protocol in which the test stimulus was laser stimulation and the conditioning stimulus was a cold pressor test. LEPs recordings were obtained from 15 healthy subjects in three different conditions: baseline, during heterotopic noxious conditioning stimulation (HNCS), and post‐HNCS.

Results

We observed a significant reduction in N2/P2 amplitude during HNCS and a return to pre‐test amplitude post‐HNCS, whereas the N1 wave remained unchanged during and post‐HNCS.

Conclusions

Our results indicate that CPM affects only the medial pain system. The spinothalamic tract (STT) transmits to both the LT and the MT, while the spinoreticulothalamic (SRT) projects only to the MT. The reduction in the amplitude of the N2/P2 complex and the absence of change in the N1 wave suggest that DNIC inhibition on the dorsal horn neurons affects only pain transmission via the SRT, while the neurons that give rise to the STT are not involved. The N1 wave can be a reliable neurophysiological parameter for assessment of STT function in clinical practice, as it does not seem to be influenced by CPM.

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Clinical, psychological and quality of life differences in fibromyalgia patients from secondary and tertiary healthcare

Abstract

Background

The “funnel effect” of Fibromyalgia (FM) assumes that as patients access healthcare services, they present greater severity and a more complex clinical situation than individuals with FM from the general population, but the studies comparing patients treated in different levels of healthcare are scarce. The aim of this study is to analyse the “funnel effect” hypothesis by comparing patients from secondary and tertiary healthcare services.

Methods

A cross‐sectional sample of female patients was selected in secondary (rheumatology practices ‐ RP) and in tertiary healthcare (chronic pain clinics ‐ CPC). Information about sociodemographic, clinical and psychological characteristics was collected and health related quality of life (HRQL) was assessed.

Results

55 patients from RP and 60 patients from CPC were included in the comparison. Patients from CPC revealed a worst clinical status (higher number of tender points, medical visits and comorbidity), more somatic symptoms (pain and daytime dysfunction levels) and worst emotional status (more anxiety) than patients from RP. Patients attending CPC also revealed a worst HRQL than RP patients although this difference was mediated by the differences in clinical and psychological variables.

Conclusions

Our study supports the “funnel effect” hypothesis among patients of different healthcare levels, with patients from tertiary healthcare services revealing worst clinical status, more somatic and psychological symptoms, and worst HRQL than patients from secondary healthcare services.

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Physical activity and cold pain tolerance in the general population

Abstract

Background

The relationship between habitual physical activity (PA) and experimental pain tolerance has been investigated in small samples of young, healthy, and/or single‐sex volunteers. We used a large, population‐based sample to assess this relationship in men and women with and without chronic pain.

Methods

We used data from the sixth and seventh Tromsø Study surveys (2007‐08; 2015‐16), with assessed pain tolerance of participants with the cold‐pressor test (CPT: dominant hand in circulating cold water at 3°C, maximum test‐time 106 seconds), and self‐reported total amount of habitual PA in leisure time (n=19,087), exercise frequency (n=19,388), exercise intensity (n=18,393), and exercise duration (n=18,343). A sub‐sample had PA measured by accelerometers (n=4,922). We used Cox regression to compare CPT tolerance times between self‐reported PA levels. For accelerometer‐measured PA, we estimated hazard ratios for average daily activity counts, and for average daily minutes of moderate‐to‐vigorous PA done in bouts lasting 10 minutes or more. Models were tested for PA‐sex, and PA‐chronic pain and PA‐moderate‐to‐severe chronic pain interactions.

Results

Leisure‐time PA, exercise intensity, and exercise duration were positively associated with CPT tolerance (p<0.001; p=0.011; p<0.001). More PA was associated with higher CPT tolerance. At high levels of leisure‐time PA and exercise intensity, men had a significantly higher CPT tolerance than women. Accelerometer‐measured PA was not associated with CPT tolerance.

Conclusions

This study is one of the first to show that higher self‐reported habitual PA was connected to higher experimental pain tolerance in a population‐based sample, especially for men. This was not found for accelerometer‐measured PA.

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Modulation of SI and ACC response to noxious and non‐noxious electrical stimuli after the spared nerve injury model of neuropathic pain

Abstract

Background

The current knowledge on the role of SI and ACC in acute pain processing and how these contribute to the development of chronic pain is limited. Our objective was to investigate differences in and modulation of intracortical responses from SI and ACC in response to different intensities of peripheral presumed noxious and non‐noxious stimuli in the acute time frame of a peripheral nerve injury in rats.

Methods

We applied non‐noxious and noxious electrical stimulation pulses through a cuff electrode placed around the sciatic nerve and measured the cortical responses (6 electrodes in each cortical area) before and after the spared nerve injury model.

Results

We found that the peak response correlated with the stimulation intensity and that SI and ACC differed in both amplitude and latency of cortical response. The cortical response to both noxious and non‐noxious stimulation showed a trend towards faster processing of non‐noxious stimuli in ACC and increased cortical processing of non‐noxious stimuli in SI after SNI.

Conclusions

We found different response in SI and ACC to different intensity electrical stimulation based on two features and changes in these features following peripheral nerve injury. We believe that these features may be able to assist to track cortical changes during the chronification of pain in future animal studies.

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Does Threat Enlarge Nociceptive Reflex Receptive Fields?

Pain modulation can increase survival. For example, during situations of possible threat, increased pain perception allows for early detection, and stronger reaction to, somatic danger 45, 52. Consistent with this, several studies have noted an increase in pain perception when anticipating an unpredictable threat 30, 76, 79.

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Shoulder pain is associated with rate of rise and jerk of the applied forces during wheelchair propulsion in persons with paraplegic spinal cord injury

Publication date: Available online 5 November 2020

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Benjamin J.H. Beirens, Fransiska M. Bossuyt, Ursina Arnet, Lucas H.V. van der Woude, Wiebe H.K. de Vries

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Chest pain with a cold

A man in his 60s presented to the emergency department with two hours of gradually worsening right-sided chest pain that occurred at rest.During the week before presentation he had also experienced a...

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Acute gastric pain after eating sashimi

This gastroscopy photograph (fig 1) shows a parasitic nematode belonging to the genus Anisakis (2-3 cm long roundworm) that is half embedded within the gastric mucosa of a man in his 60s. He...

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Faces of clinical pain: inter‐individual facial activity patterns in shoulder pain patients

Abstract

Background

Facial activity during pain is composed of varying combinations of a few elementary facial responses (so called Action Units). A previous study of experimental pain showed that these varying combinations can be clustered into distinct facial activity patterns of pain. In the present study, we examined whether comparable facial activity patterns can also be identified among people suffering from clinical pain; namely shoulder pain.

Methods

Facial expressions of patients suffering from shoulder pain (N=126) were recorded while twice undergoing a battery of passive range‐of‐motion‐tests to their affected limbs (UNBC‐McMaster Shoulder Pain Expression Archive Database), which elicited peaks of acute pain. Facial expressions were analysed using the Facial Action Coding System to extract facial Action Units (AUs). Hierarchical cluster analyses were used to look for characteristic combinations of these AUs.

Results

Cluster analyses revealed four distinct activity patterns during painful movements. Each cluster was composed of different combinations of pain‐indicative AUs, with one AU common to all clusters, namely “narrowed eyes”. Besides these four clusters, there was a “stoic” pattern, characterized by no discernible facial action. The identified clusters were relatively stable across time and comparable to the facial activity patterns found previously for experimental heat pain.

Conclusions

These findings corroborate the hypothesis that facial expressions of acute pain are not uniform. Instead, they are composed of different combinations of pain‐indicative facial responses, with one omnipresent response, namely “narrowed eyes”. Raising awareness about these inter‐individually different “faces of pain” could improve the recognition and, thereby, its diagnostic training for professionals, like nurses and physicians.

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Analgesic effect of music during wound care among patients with diaphyseal tibial fractures: Randomized controlled trial

Abstract

Background

Evidence is scarce regarding the analgesic effect of music for the relief of acute pain during the care of surgical tibial fracture wounds.

Objective

To evaluate the analgesic effect of music on acute procedural pain during the care of surgical tibial fracture wounds.

Method

This was a randomized, controlled, blinded clinical trial with 70 patients in the immediate postoperative period for diaphyseal tibial fracture surgery. Participants were randomly allocated to two groups: a control group (CG), in which patients received only the institution's standard analgesia, and an intervention group (IG) composed of patients receiving a 30 minute session of music of their own choice, as a complementary method to the institution's standard analgesia. Pain was evaluated during the first postoperative dressing change, using the Numerical Rating Scale (NRS).

Results

The sample was homogeneously composed of men (91.4%), young adults (61.4%), without previous diseases (88.6%) and whose traumas were related to a motorcycle crash (84.3%). The main musical genres chosen by participants were the most popular in their region (61.4%). Those who listened to music presented lower pain scores when compared to those in the CG (IG:2.4±2.4 vs. CG:5.8±2.7; p<0.001; ƞ ²=0.171; p<0.001).

Conclusion

Listening to music is effective for relieving acute procedural pain during the first post‐operative tibial fracture dressing change. Music should be incorporated into the multimodal analgesia protocols for management of orthopedic postoperative wound care related pain.

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Validation of the Questionnaire for Symptom Assessment in Pain disorders for Back pain patients (Q‐SAP)

Abstract

Background

Previous studies have shown that not only pain intensity, but also impairment of quality of life and functionality are important parameters for the evaluation of treatment of chronic low back pain patients. The aim of the study was to validate a specific self‐questionnaire for symptom assessment and their influence on quality of life and functionality of chronic low back pain patients (Questionnaire for Symptom Assessment in Pain disorders for back pain patients, Q‐SAP).

Methods

The self‐questionnaire consists of two parts (for back and if applicable leg symptoms) and was tested in 152 chronic low back pain patients with and without radiculopathy. Test‐retest reliability, exploratory factor analysis, convergent validity, criterion‐related validity, and the sensitivity to detect patient reported changes were investigated.

Results

The questionnaire showed a good to excellent test‐retest reliability. In the factor analysis nociceptive and neuropathic pain components could be separated and the highest convergent validities were shown for the painDETECT, EQ‐5D‐3L, and the FFbH‐R. The criterion‐related validity showed concordance of QST and the Q‐SAP Back for warmth induced pain and numbness. Regarding the sensitivity to patient reported changes a moderate correlation was found for both parts of the questionnaire.

Conclusions

The Q‐SAP was tested as a useful, valid, and reliable tool. This new questionnaire records classical nociceptive and neuropathic pain symptoms of chronic low back pain patients depending on their local distribution. Furthermore, the questionnaire records the intensity of these symptoms and their influence on quality of life and functionality and can be used for the evaluation of treatment.

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