Pain site and the effects of amputation pain: further clarification of the meaning of mild, moderate, and severe pain

Research among persons with cancer pain suggests that the association between pain intensity and pain interference is non-linear. That is, pain begins to have a serious impact on functioning when it reaches a certain threshold level (about 5 on 0--10 scales). Often, a second pain threshold can be identified which, once reached, shows an even greater proportional negative impact on functioning. This finding supports the potential clinical utility of classifying pain as mild, moderate, and severe based on the impact of pain on quality of life, and research among persons with cancer pain supports specific cutoffs (mild: 1--4, moderate: 5--6, severe: 7--10, see Pain 61 (1995) 277) for this classification. The current study sought to replicate the non-linear association between pain and pain interference in a non-cancer pain sample, determine whether the cutoffs that have been identified as optimal for cancer patients are also optimal for persons with pain associated with amputation, and determine whether the optimal cutoffs replicate across pain types (in this case, phantom limb, back, and general pain) within a single sample. Two-hundred and five persons with acquired amputation and phantom limb pain, back pain, or both, rated their average pain intensity and degree of pain interference for each type of pain. The results support a non-linear association between pain intensity and pain interference. However, the optimal cutoffs for classifying mild, moderate and severe pain in the present sample replicated the findings for persons with cancer pain only for back pain -- different optimal cutoffs were found for phantom limb and general pain. Moreover, the degree of pain interference appeared to vary as a function of pain type. The same level of back pain interfered more significantly with daily function than phantom limb pain did after pain levels reached five or more (on a 0--10 scale). These findings have implications for understanding the meaning of pain intensity levels, as well as for the assessment of pain intensity in persons with amputation-related pain.     

Analysis and treatment of different types of neuropathic cancer pain

Neuropathic pain is a major problem in the treatment of cancer pain. We performed a retrospective analysis of 213 cancer patients with neuropathic pain treated by a pain service following the World Health Organization guidelines for relief of cancer pain. Of these, 79% presented with nerve compression pain, 16% with nerve injury pain, and 5% with sympathetically-maintained pain. Whereas nerve compression and nerve injury pain were caused most frequently by cancer growth, sympathetically-maintained pain was caused most frequently by cancer treatment. There were no significant differences in the use of analgesics, the mean pain intensity, or the efficacy of analgesic treatment among the three groups. Nerve injury pain and sympathetically-maintained pain were treated more frequently with adjuvant analgesics, especially antidepressants and anticonvulsants. The variety of different neuropathic pain syndromes should be separated in future studies of the efficacy of different treatment approaches.     

Psychiatric Assessment and Treatment of Pediatric Pain

TOPIC: The clinical nurse specialist's role as part of a multidisciplinary pain team in assessing and treating children with pain, and children with co-morbid pain and a psychiatric diagnosis. PURPOSE: To help nurse clinicians use relatively new assessment and treatment strategies in the arena of children's pain, gain a better understanding of pain's co-morbidity with psychiatric problems, and understand the nurse's important role in working with children with pain. SOURCES: Published literature: Pain assessment, theories of pain, psychiatric assessment, pain and psychiatric co-morbidity, treatment modalities for pain. A case study of a teenage girl with chronic pain and a psychiatric disorder. CONCLUSIONS: Nursing interventions in pediatric pain assessment and treatment play a vital role in the child's and adolescent's physical and emotional rehabilitation from pain and psychiatric symptoms.     

Hypervigilance to pain in fibromyalgia: the mediating role of pain intensity and catastrophic thinking about pain

OBJECTIVE: To investigate the mediating role of pain intensity, catastrophic thinking about pain, and negative affectivity in explaining enhanced attention for pain in patients with fibromyalgia. METHODS: Sixty-four patients with fibromyalgia and 46 patients with chronic low back pain completed self-report instruments of vigilance to pain, negative affectivity, and catastrophic thinking about pain. These measures, along with diagnostic group and pain intensity, were entered into a partial correlational analysis to investigate which variables mediate the relationship between diagnostic group (fibromyalgia vs. chronic low back pain) and vigilance to pain. RESULTS: Fibromyalgia patients reported significantly greater vigilance to pain than patients with chronic low back pain. They also reported higher pain intensity, more negative affectivity, and more catastrophic thinking about pain than patients with chronic low back pain. Vigilance to pain was correlated significantly with pain intensity, negative affectivity, and catastrophic thinking about pain. Further analyses revealed that pain intensity and catastrophic thinking about pain, but not negative affectivity, mediated the relationship between diagnostic group and vigilance to pain. CONCLUSION: Fibromyalgia patients report a heightened vigilance to pain. This vigilance is not a unique characteristic of fibromyalgia but is related to the intensity of pain and catastrophic thinking about pain.     

Validity of pain intensity assessment in persons with cerebral palsy: a comparison of six scales.

Chronic pain is a common condition in persons with cerebral palsy (CP), although there is a paucity of research studying CP-related pain. One of the barriers to a better understanding of pain in persons with CP is the lack of information concerning the validity of pain measures that may be used with this population. The purpose of this study was to determine the relative validity of several pain measures in a sample of persons with CP-related pain. Six pain rating scales and measures of depression and pain interference were administered to a sample of 45 adults participating in a longitudinal study of pain in persons with CP. An additional 24 persons with CP were administered 5 of the 6 pain intensity scales. The results of factor analyses support the validity of each measure of pain in this sample of persons with CP. However, an examination of the pattern of associations between each of the pain ratings with measures of pain interference and depression suggest that the 7-point Faces Scale may be somewhat less valid than the other measures.     

Stability of pain parameters and pain-related quality of life in adolescents with persistent pain: a three-year follow-up

OBJECTIVE: Many juveniles with chronic pain of no known organic cause recover. Because adolescents whose pain persists may have chronic pain as adults, a subsample of 42 adolescents from a prevalence study in which continuation of their pain was observed throughout the study period was investigated quantitatively and qualitatively. All mothers (n = 42) completed a questionnaire on the impact of the adolescent's pain on the family. The authors tested the hypothesis that pain parameters, pain-related quality of life, and impact of pain on the family would deteriorate over time. DESIGN: Three-year follow-up questionnaires, diaries, and interviews were used. SETTING: The study was conducted in the general population in the Rotterdam area. PARTICIPANTS: Adolescents (aged 12-18 years) who indicated chronic pain in our previous prevalence study and in a diary and questionnaire each year of the 3-year follow-up were included in the study. RESULTS: The most prevalent pains were limb pain and headache. The pain intensity was mild (33 mm on a visual analog scale), very frequent (72% of all diary entries), and associated with relatively poor functional status and poor psychological and somatic functioning. The pain parameters, pain-related quality of life, and impact of pain on the family (i.e., restrictions in social life and problems in dealing with the stress of the adolescent's pain) remained surprisingly stable across the assessments. The interviews showed that pain had become part of the daily life of several adolescents, who structured their activities and sleeping hours to prevent aggravation of pain. In particular, adolescents with headache reported problems with cognitive activities, whereas those with limb pain and back pain reported problems with physical activities. CONCLUSIONS: For adolescents with persistent pain with no known organic cause, intensity and frequency of pain, quality of life, and impact of pain on the family did not change. Generally, they seemed to cope quite well with their pain. In view of these results, further studies should involve follow-up of adolescents with persistent pain into adulthood to establish the determinants of their pain and to find out whether they maintain their adaptive ways of living with their pain.     

Multidisciplinary treatment of chronic pain in the German federal state of Northrhine-Westphalia

BACKGROUND: Multidisciplinary treatment of patients with chronic pain in pain centers was studied. The conditions of all multidisciplinary pain centers in the German federal state of Northrhine-Westphalia (NRW), an area of about 17 million inhabitants, were investigated. METHODS: The study included data from the index of all registered multidisciplinary pain centers in the years 1992, 1994, 1996, and empirical data of a written (questionnaire) in 1993 from physicians and psychologists working as specialists in the pain centers studied. RESULTS: Several new pain centers (inpatient wards, outpatient pain clinics) had been built up in the last years in Northrhine-Westphalia. The pain centers are organized mostly as outpatients' departments. Departments of psychological treatment of chronic pain are usually integrated into pain clinics. In recent years, the use of qualified psychological pain treatment by psychologists has been under-represented. Pain treatment evaluation is carried out by considering the structure of supply in pain management, the qualification and specialization of physicians and psychologists and the amount of treated patients with chronic pain. The 57 pain centers in the investigated area reported on about 120,000 patients with chronic pain a year, who were treated in multidisciplinary pain centers. The estimated number of patients with chronic pain in Northrhine-Westphalia was approximately 850,000 patients (4 million in Germany). CONCLUSIONS: There is an existing network of multidisciplinary pain centers in Northrhine-Westphalia. If we consider the estimated number of 850,000 patients with chronic pain in this area, the low number of yearly treated patients (120,000) indicates, that the capacity of multidisciplinary pain centers is inadequate for the demand of multidisciplinary treatment of patients with chronic pain in Northrhine-Westphalia.     

Pain tolerance as a predictor of outcome following multidisciplinary treatment for chronic pain: differential effects as a function of sex

Sex-related differences in the experience of clinical and experimental pain have been widely reported. Females are at elevated risk for developing several chronic pain conditions and women demonstrate greater sensitivity to noxious stimulation in the laboratory. However, relationships between responses to experimental noxious stimuli and the experience of clinical pain have not been well characterized. One previous study of healthy adults indicated that pain threshold and tolerance were associated with clinical pain among women but not men (i.e. females with lower pain threshold and tolerance reported more clinical pain). In the present investigation, relationships between pain tolerance and outcomes of treatment for chronic pain were evaluated in a sex-dependent manner. Ischemic pain tolerance was assessed prior to treatment in 171 chronic pain patients completing a pain management program. Outcomes were measured as changes in pain severity, affect, and pain-related disability. Over the course of treatment, women demonstrated greater improvement in pain-related disability while men showed more reduction in pain. Ischemic pain tolerance was related to outcome in a sex-specific fashion. Women with higher pain tolerances showed greater improvement in pain, more reduction in pain-related interference, and more increases in activity level than women with lower pain tolerances. In contrast, pain tolerance was not associated with positive treatment outcomes among men. These results indicate that experimental pain responses may be most clinically relevant for women, and that sex differences may exist in the determinants of pain-treatment outcomes.     

Categorizing the severity of cancer pain: further exploration of the establishment of cutpoints

Previous work by Serlin and colleagues [Serlin R C, Mendoza T R, Nakamura Y, Edwards K R, Cleeland C S. When is cancer pain mild, moderate, or severe? Grading pain severity by its interference with function. Pain 1995;61:277-84] established cutpoints for mild, moderate, and severe cancer pain based on the pain's level of interference with function. Recent work [Jensen M P, Smith D G, Ehde D M, Robinson L R. Pain site and the effects of amputation pain: further clarification of the meaning of mild, moderate, and severe pain. Pain 2001;91:317-22; Zelman D C, Hoffman D L, Seifeldin R, Dukes, E. Development of a metric for a day of manageable pain control: derivation of pain severity cutpoints for low back pain and osteoarthritis. Pain 2003;106(1/2):35-42]found differences in cutpoints for pain severity for different pain-related conditions. Reasons for these discrepancies may relate to the methods used to determine the cutpoints or to differences based on the type or the cause of the pain. The purposes of this study were to determine the optimal cutpoints for mild, moderate, and severe pain based on patients' ratings of average and worst pain severity, using a larger range of potential cutpoints, and to determine if those cutpoints distinguished among the three pain severity groups on several outcome measures. Results from a homogenous sample of oncology outpatients with pain from bone metastasis confirm a non-linear relationship between cancer pain severity and interference with function and also confirm that the boundary between a mild and a moderate level of cancer pain is at 4 on a 0-10 numeric rating scale. However, this analysis did not confirm the boundary between moderate and severe cancer pain previously described by Serlin and colleagues [Serlin R C, Mendoza T R, Nakamura Y, Edwards K R, Cleeland C S. When is cancer pain mild, moderate, or severe? Grading pain severity by its interference with function. Pain 1995;61:277-84]. In addition, these results were not consistent with the cutpoints that were found for back pain, phantom limb pain, pain 'in general', or osteoarthritis pain reported by Jensen and colleagues and Zelman and colleagues [Jensen M P, Smith D G, Ehde D M, Robinson L R. Pain site and the effects of amputation pain: further clarification of the meaning of mild, moderate, and severe pain. Pain 2001;91:317-22; Zelman D C, Hoffman D L, Seifeldin R, Dukes, E. Development of a metric for a day of manageable pain control: derivation of pain severity cutpoints for low back pain and osteoarthritis. Pain 2003;106(1/2):35-42]. Possible explanations for these differences are discussed, as well as implications for future research.     

Comparison of patient satisfaction and self-reports of pain in adult burn-injured patients

Procedural and background pain scores were assessed prospectively and compared with treatment goals and satisfaction scores in 84 adult (67 men and 17 women) burn-injured patients treated at a single, tertiary care medical center. We hypothesized that patient satisfaction with pain management plans would be highest among those patients who were experiencing the least pain and also among patients whose experiences most closely matched their treatment analgesic goals. Twice-weekly patient self-reports of worst and average procedural pain, background pain, treatment goals (the level of procedural pain and background pain patients reported that they would be satisfied as experiencing), and overall satisfaction with pain management plans were assessed using 10-point Graphic Rating Scales. Data concerning adjunctive treatments were also obtained. Opioid equivalents, representing pain medications administered, were compared. The majority of patients perceived that "no pain" during burn wound care was an unrealistic goal, a perception that was consistent throughout hospitalization. As hypothesized, average procedural pain levels demonstrated a negative association with patient satisfaction, indicating that patients with the highest levels of procedural pain also reported the lowest level of satisfaction. Opioid analgesic dosing was not significantly associated with ratings of procedural pain or treatment goals. Our findings support the hypothesis that patient satisfaction with pain management is highest in those who experience the least amount of burn care pain and do not support the hypothesis that satisfaction is highest in those whose pain experiences most closely match treatment analgesic goals.     

The Role of Trait Mindfulness in the Pain Experience of Adolescents

Trait mindfulness appears to mitigate pain among adult clinical populations and has a unique relationship with pain catastrophizing. However, little is understood about this phenomenon among adolescents. The association between trait mindfulness and pain in both real-world and experimental contexts was examined in a community sample of adolescents. Participants were 198 adolescents who completed measures of trait mindfulness, pain catastrophizing, and pain interference, as well as an interview on day-to-day pain before undergoing an acute experimental pain task. Following the task, they provided ratings of pain intensity and state catastrophizing. Results showed that with regard to day-to-day pains, mindfulness was a significant and unique predictor of pain interference, and this relationship was partially mediated by pain catastrophizing. Mindfulness also had an indirect relationship with experimental pain intensity and tolerance. These associations were mediated by catastrophizing during the pain task. These findings highlight the association between trait mindfulness and both real-world and experimental pain and offer insight into how mindfulness may affect pain among youth. Findings are discussed in the context of current psychological models of pediatric pain and future avenues for research.     

Validation of the Pain Sensitivity Questionnaire in chronic pain patients

Recently, a self-rating measure for pain perception based on imagined painful daily life situations, the Pain Sensitivity Questionnaire (PSQ), has been developed and shown to correlate with experimentally obtained pain intensity ratings in healthy subjects. Here, we assessed the validity of the PSQ for investigation of general pain perception (ie, pain perception outside the site of clinical pain) in chronic pain patients. PSQ scores were obtained in 134 chronic pain patients and compared to those of 185 healthy control subjects. In a subgroup of 46 chronic pain patients, we performed experimental pain testing outside the clinical pain site, including different modalities (heat, cold, pressure, and pinprick) and different measures (pain thresholds, pain intensity ratings). Results show that PSQ scores were significantly correlated with both experimental pain intensity ratings (Pearson's r=0.71, P<.001) and experimental pain thresholds (r=-0.52, P<.001). In addition, chronic pain patients exhibited significantly elevated PSQ scores as compared to healthy controls, consistent with the generalized increase of experimentally determined pain perception that has repeatedly been reported in chronic pain patients. These results demonstrate that the PSQ constitutes a valid self-rating measure of pain perception outside the clinical pain site in chronic pain patients and might serve as an alternative to experimental assessment of pain perception outside the clinical pain site in situations where experimental pain testing is not feasible.     

Examining the Adjustment Patterns of Adults With Multiple Chronic Pain Conditions and Multiple Pain Sites: More Pain,No Gain

The present study examined how multiple chronic pain conditions and pain sites are associated with sociodemographics, chronic pain adjustment profiles, and emotional distress. A total of 2,407 individuals who reported at least 6 months of having consistent pain severity, pain interference, and/or emotional burden due to pain were recruited through random digit dialing across the United States. Participants’ chronic pain adjustment profiles (ie, pain intensity, pain interference, emotional burden, pain catastrophizing, pain coping, pain attitudes, and social resources) were assessed. Anxiety and depressive symptoms were also measured using a subsample of 181 participants who provided 3-month follow-up data. More than 60% of individuals with chronic pain reported having multiple pain conditions. Middle-aged single women with fibromyalgia, disability and of low socioeconomic status reported a greater number of pain conditions and pain sites. Structural equation modeling revealed that a higher number of pain conditions and sites were associated with more dysfunctional chronic pain adjustment profiles. The subsample analyses showed that reporting a greater number of pain conditions predicted a higher level of depression and anxiety 3 months later, controlling for pain-related anxiety and depressive symptoms, pain severity and interference at baseline. Having multiple pain conditions and sites may represent a psychosocial barrier to successful adjustment to chronic pain.PerspectiveThis article argues for the importance of assessing the number of co-occurring chronic pain conditions and bodily areas that are affected by pain in both pain research and clinical settings. Measuring and incorporating such information could potentially enhance our nascent understanding of the adjustment processes of chronic pain.     

Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression

Cesarean delivery rates continue to increase, and surgery is associated with chronic pain, often co-existing with depression. Also, acute pain in the days after surgery is a strong predictor of chronic pain. Here we tested if mode of delivery or acute pain played a role in persistent pain and depression after childbirth. In this multicenter, prospective, longitudinal cohort study, 1288 women hospitalized for cesarean or vaginal delivery were enrolled. Data were obtained from patient interviews and medical record review within 36 h postpartum, then via telephone interviews 8 weeks later to assess persistent pain and postpartum depressive symptoms. The impact of delivery mode on acute postpartum pain, persistent pain and depressive symptoms and their interrelationships was assessed using regression analysis with propensity adjustment. The prevalence of severe acute pain within 36 h postpartum was 10.9%, while persistent pain and depression at 8 weeks postpartum were 9.8% and 11.2%, respectively. Severity of acute postpartum pain, but not mode of delivery, was independently related to the risk of persistent postpartum pain and depression. Women with severe acute postpartum pain had a 2.5-fold increased risk of persistent pain and a 3.0-fold increased risk of postpartum depression compared to those with mild postpartum pain. In summary, cesarean delivery does not increase the risk of persistent pain and postpartum depression. In contrast, the severity of the acute pain response to childbirth predicts persistent morbidity, suggesting the need to more carefully address pain treatment in the days following childbirth.     

Electronic diary assessment of pain, disability and psychological adaptation in patients differing in duration of pain

Computerized diary measurement of pain, disability and psychological adaptation was performed four times a day for 4 weeks in 80 patients with various duration of unexplained pain. Reported are (1) the temporal characteristics and stability of pain report during the 4-week measurement period, (2) the association between pain duration and pain report, disability and general psychopathology, and (3) the accordance between diary assessment versus questionnaire assessment of pain, disability and psychological adaptation. No evidence of instrument reactivity was found: pain report was stable across the 4-week period. However, pain report appeared to be highly variable both between and within days. About half the patients showed a clear increasing trend in pain during the day. Several differences were found between subgroups of patients varying in pain duration. Patients with less than 6 months of pain reported significantly less pain intensity, disability and fatigue than patients whose pain persisted for more than 6 months. Pain coping and responses to pain behaviors by the spouse also differed for the subgroups: longer pain duration was associated with increased catastrophizing and solicitous responses from the spouse. Comparison of scores obtained with diary versus questionnaire assessment indicated moderate correlations for most variables. Retrospective (questionnaire) assessment of pain intensity yielded significantly higher pain scores than diary assessment.