Educational achievement and chronic pain disability: mediating role of pain-related cognitions

OBJECTIVE: This study examined the relation between level of educational achievement (LOE) and the clinical morbidity associated with chronic pain. SETTING: a multidisciplinary pain rehabilitation program located within a university hospital. PATIENTS: Two hundred ninety-nine consecutive patients with chronic spinal pain, average age 39.6 years (SD = 10.7) and with an average duration of pain of 41.9 months (SD = 51.6). OUTCOME MEASURES: Age, duration of pain, sex, and compensation and litigation status were controlled for in the statistical analysis because each was found to be significantly associated with LOE. Pain intensity was assessed by the McGill Pain Questionnaire. Affective distress was assessed by the Global Severity Index from the Brief Symptom Inventory. Severity of depressive symptoms was derived from scores from the Center for Epidemiological Studies-Depression Scale. Pain beliefs and pain coping strategies were assessed by the Survey of Pain Attitudes and the Coping Strategies Questionnaire, respectively. Finally, self-report of pain-related disability was assessed by the Pain Disability Index. RESULTS AND CONCLUSIONS: After controlling for relevant covariates, LOE was unrelated to pain intensity, severity of depressive symptoms, or affective distress, but was inversely related to self-reported disability. Persons with lower LOEs possessed a greater belief that pain is a "signal of harm," unrelated to emotional experience, disabling and uncontrollable. They also endorsed more passive and maladaptive coping strategies, including a tendency to catastrophize about their pain. Path analysis indicated that, after controlling for the influence of both the belief that pain is a "signal of harm" and catastrophizing on the association between LOE and disability, this relation loses statistical significance. These results suggest that pain-related cognitions mediate the relation between LOE and pain disability and that persons with lower LOEs are more likely to develop maladaptive pain beliefs and coping strategies.     

Sex differences in adolescent chronic pain and pain-related coping

Sex differences exist in pain and the strategies used to cope with pain. Although it is has been proposed that such differences become apparent around puberty, somewhat surprisingly very little research has specifically investigated sex as a moderator of pain within adolescents. The primary aim of the current study was to investigate sex differences in pain and coping within a group of 46 male and 115 female adolescent chronic pain sufferers. All were aged between 11 and 19 years and had been referred to the Pain Management Unit at the Royal National Hospital for Rheumatic Diseases, United Kingdom. Patients completed a battery of measures including pain experiences and a pain coping questionnaire. No sex differences were found in pain chronicity, although males and females did differ in self-reported pain experiences (females reported higher pain). Sex differences were also found in coping behaviours. Females used more social support, positive statements and internalizing/catastrophizing, whereas males reported engaging in more behavioural distraction. Of these strategies internalizing/catastrophizing was found to mediate the relationship between sex and pain. This suggests that not only do sex differences exist in the pain experiences and pain-coping strategies of adolescents with chronic pain, but that internalizing/catastrophizing may be an important mechanism in understanding such differences. More research examining potential sex differences in children and adolescents is recommended.     

The perception of pain and pain-related cognitions in subacute whiplash-associated disorders: Its influence on prolonged disability

Purpose.?To clarify the relations between the sensory, affective and cognitive dimensions of pain and to analyse what influence these components have on persistent disability in patients with subacute whiplash-associated disorders (WAD).

Method.?The data was obtained from an on-going randomised controlled trial (RCT) on 47 patients. The sensory dimension of pain was evaluated with a visual analogue scale (VAS) diary and a Painometer®. The affective dimension was assessed using the Painometer®. The Tampa Scale for Kinesiophobia (TSK) and the Self-Efficacy Scale (SES) were used as measures of pain-related cognitions. The Pain Disability Index (PDI) was used as the outcome measure.

Results.?Forty patients (85%) completed the trial. The correlations between the sensory and affective dimensions of pain were non-significant, which indicates that they are two independent constructs that describe various dimensions of whiplash-related pain. High pain intensity and pain affect, more widespread pain, and high fear of movement/(re)injury corresponded to low self-efficacy. Multiple regression analyses showed that self-efficacy was the most important predictor of persistent disability contributing to 42% of the variation in the PDI score.

Conclusion.?The treatment approach for patients with subacute WAD should incorporate the multidimensional nature of pain and to prevent disability special effort should be made to enhance the patient's self-efficacy beliefs.     

The perception of pain and pain-related cognitions in subacute whiplash-associated disorders: its influence on prolonged disability

Purpose. To clarify the relations between the sensory, affective and cognitive dimensions of pain and to analyse what influence these components have on persistent disability in patients with subacute whiplash-associated disorders (WAD).

Method. The data was obtained from an on-going randomised controlled trial (RCT) on 47 patients. The sensory dimension of pain was evaluated with a visual analogue scale (VAS) diary and a Painometer®. The affective dimension was assessed using the Painometer®. The Tampa Scale for Kinesiophobia (TSK) and the Self-Efficacy Scale (SES) were used as measures of pain-related cognitions. The Pain Disability Index (PDI) was used as the outcome measure.

Results. Forty patients (85%) completed the trial. The correlations between the sensory and affective dimensions of pain were non-significant, which indicates that they are two independent constructs that describe various dimensions of whiplash-related pain. High pain intensity and pain affect, more widespread pain, and high fear of movement/(re)injury corresponded to low self-efficacy. Multiple regression analyses showed that self-efficacy was the most important predictor of persistent disability contributing to 42% of the variation in the PDI score.

Conclusion. The treatment approach for patients with subacute WAD should incorporate the multidimensional nature of pain and to prevent disability special effort should be made to enhance the patient's self-efficacy beliefs.     

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.     

Chronic pain in children and adolescents

Chronic pain is a widespread and significant clinical problem. It can result in major negative short- and long-term physical and emotional effects in multiple domains of children's and their families' lives as Pain Associated Disability Syndrome. Assessment of chronic pain is challenging but it is an essential clinical task. Management requires a multidimensional response focussing on the whole patient. Specialist pain management units and programmes use cognitive behavioural methods and promote adaptive coping and focus on the child re-engaging with normal activities. While chronic pain is not well understood, there is emerging evidence that young people and their parents can recover from chronic disability, dependency and distress, and return to a normal life.     

The influence of pain-related comorbidities on pain intensity and pain-related psychological distress in patients presenting with musculoskeletal pain

BackgroundMusculoskeletal pain (MSP) is the largest contributor to chronic pain and frequently occurs alongside other medical comorbidities.ObjectiveExplore the relationships between the presence of pain-related comorbidities, pain intensity, and pain-related psychological distress in patients with MSP.MethodsA longitudinal assessment of individuals 18–90 years old in the Midwestern United States beginning a new episode of physical therapy for MSP. Electronic medical records were assessed the full year prior for care-seeking of diagnoses for pain-related comorbidities (anxiety, metabolic disorder, chronic pain, depression, nicotine dependence, post-traumatic stress disorder, sleep apnea, and sleep insomnia). Pain intensity and pain-related psychological distress (Optimal Screening for Prediction of Referral and Outcome - Yellow Flags tool) were captured during the physical therapy evaluation. Generalized linear models were used to assess the association between pain intensity, psychological distress, and pain-related co-morbidities. Models were adjusted for variables shown in the literature to influence pain.Results532 participants were included in the cohort (56.4% female; median age of 59 years, Interquartile Range [IQR]:47, 69). Comorbid depression (beta coefficient (β) = 0.7; 95%CI: 0.2, 1.2), spine versus lower extremity pain ((β = 0.6; 95%CI: 0.1, 1.1), and prior surgery (β = 0.8, 95%CI: 0.3, 1.4) were associated with higher pain intensity scores. No pain-related comorbidities were associated with pain-related psychological distress (yellow flag count or number of domains). Female sex was associated with less pain-related psychological distress (β = −0.2, 95%CI: −0.3, −0.02).ConclusionsDepression was associated with greater pain intensity. No comorbidities were able to account for the extent of pain-related psychological distress.     

Postoperative pain assessment and management in adolescents

A 3-year study investigated the experience and management of postoperative pain following elective surgery in an adolescent sample, using a variety of valid, reliable instruments and semi-structured interviews. In addition to the adolescent subjects, the views of one parent of each adolescent were sought and a sample of health professionals comprising surgeons, anaesthetists and nurses were interviewed about acute pain in adolescent patients. This paper presents some of the main findings pertaining to pain assessment and management. Pain, experienced by most adolescents on the 1st and 3rd postoperative days, was influenced by the presence of anxiety and depression, in addition to the maturational stage; differences between in-patients and day cases are highlighted. Recommendations for practice include the need for more effective pain management and raising awareness of the importance of both psychological state and adjustment to adolescence in this age-group.     

Screening methods in the diagnosis and assessment of children and adolescents with familial hypercholesterolemia

Familial hypercholesterolemia is an autosomal dominant disorder. Heterozygous familial hypercholesterolemia (FH) has an estimated incidence of 1 per 300–500 births and is characterized by increased serum total- and low-density lipoprotein-cholesterol levels and an increased risk of coronary heart disease. Early diagnosis and cholesterol-lowering treatment are essential to prevent premature coronary heart disease. Effective screening strategies are therefore of great importance. Screening can be done as selective or general population screening. There is no generally accepted screening program for FH in children and adolescents. In The Netherlands a systematic genetic family cascade screening program has been going on since 1994. In most countries there is no systematic screening for the disease, but clinical and genetic family cascade screening has been applied. Selective screening programs have failed to identify a large number of FH cases. Recommendations for general pediatric population screening have therefore emerged. Controversy exists as to which approach should be adopted. Family cascade screening has been estimated to be the most cost-effective screening method. No general pediatric screening program has been tested on a larger scale, validated or subjected to cost–benefit analyses.     

Assessment of pain cognitions in cancer patients with chronic pain.

Although reports suggest that beliefs about pain play an important role in the adjustment and pain experience of non-cancer patients, the impact of cognitions on the pain experience is unknown in cancer patients. This study examined the factor structure, reliability, and validity of the Pain Cognition List-Experimental version, a measure developed to assess patients' self-statements about pain and the extent to which patients are effective in dealing with the pain. The Pain Cognition List-Experimental version was administered to 313 cancer patients during hospitalization. Confirmatory factor analysis was conducted to evaluate the adequacy of fit for the original five factors. Because of a failure to replicate the factors, exploratory factor analysis was conducted, finding the factors Pain Impact, Social Comparison, Acquiescence, and Outcome Efficacy. The internal consistency for the factor Pain Impact was high (r = 0.89), while the other three factors showed low reliability. The factor Catastrophizing, usually an important factor in non-cancer patients, did not emerge. No differences were found across sex. The factors Pain Impact and Acquiescence provided evidence for concurrent validity. Patients with district nursing showed higher scores on the factors Pain Impact and Acquiescence, and higher scores on Pain Impact and Acquiescence were associated with higher pain intensity scores. This study was an attempt to evaluate pain cognitions and beliefs in cancer patients. It is concluded that the Pain Cognition List for non-cancer patients cannot be easily used in cancer pain patients and that evaluation of pain cognitions in cancer patients is useful. Health care providers evaluating pain in cancer patients with chronic pain need to be aware of the impact pain cognitions have on patients' pain experience. Although more research is needed, measuring pain cognitions should be considered.     

Relationship status and quality moderate daily pain-related changes in physical disability,affect, and cognitions in women with chronic pain

The objectives of this study were to examine whether (1) daily pain-related changes in physical functioning differed between happily partnered, unhappily partnered, and unpartnered female chronic pain patients, and (2) affect and pain cognitions mediated the partner status effect on pain-related changes in physical functioning. Two hundred fifty-one women with chronic pain due to osteoarthritis and/or fibromyalgia completed 30 daily electronic diaries assessing pain, affect, pain-related cognitions, and physical functioning. Patients living with a romantic partner also completed a modified version of the Locke-Wallace Marital Adjustment Scale to assess relationship satisfaction. Multilevel modeling revealed that patients in satisfying unions showed more adaptive daily pain-related changes in physical functioning, pain coping difficulty, and catastrophizing compared to those in unsatisfying unions and those who were unpartnered. Both partnered groups also showed more adaptive pain-related changes in positive affect compared to the unpartnered group. The impact of relationship status on pain-related changes in physical functioning was partly mediated by the pain cognitions catastrophizing and coping difficulty. These results indicate that happily partnered pain patients show less pain-related physical disability and more adaptive affective and cognitive responses to daily pain changes than do unhappily partnered and unpartnered patients. Living in a happy union may bolster the capacity of patients to sustain a sense of pain coping efficacy during pain episodes, which in turn, minimizes pain-related physical activity limitations.     

Muscle pain in myophosphorylase deficiency (McArdle's disease): the role of gender, genotype, and pain-related coping

Pain characteristics were examined in 24 patients with myophosphorylase deficiency (McArdle's disease). Pain parameters were related to mutation analyses as well as psychosocial data using a pain questionnaire including an assessment of psychosocial distress and coping measures (Beck Depression Inventory BDI; Kiel Pain Inventory KPI, Multidimensional Fatique Inventory MFI). Twenty-three patients complained of pain, which was intermittent and exercise-induced in 15 patients. Eight patients complained of permanent pain, which was superimposed by exercise-induced pain in 7 patients. Patients reported 3-7 different pain characters and various localisations. Patients with permanent pain were significantly more frequently female, experienced higher impact on general activities and sleep as well as higher scores on the MFI. Furthermore, these patients revealed higher scores regarding several psychosocial risk factors including avoidance behavior whereas patients with intermittent pain predominantly showed endurance coping. There was no correlation between age or disease duration, pain intensity as well as mutation type and development of permanent or intermittent pain. In addition, severity of the clinical phenotype did not correlate with ACE polymorphism. Although McArdle's disease is a muscle glycogenosis with marked biochemical homogeneity, the clinical presentation can be quite heterogeneous. A substantial number of patients revealed permanent pain as a major clinical symptom. As permanent pain is not related to age or disease duration, it might be a clinically important subgroup of McArdle's disease. Gender-related genetic factors as well as maladaptive pain-related coping may contribute to the development of such a chronic pain symptom.     

Evaluation of back pain in children and adolescents

Back pain is fairly prevalent in healthy children and adolescents. When children or adolescents seek medical care for back pain, it is highly likely that underlying pathology will be identified. Common causes of back pain include nonspecific pain or muscle strain, herniated disk, spondylolysis, scoliosis, and Scheuermann's kyphosis. Less common causes include tumor, infection, and sickle cell crisis. If nonspecific back pain is suspected, treatment may include home-based exercise, physical therapy, or nonsteroidal anti-inflammatory drugs. If the history and physical examination suggest underlying pathology, radiography, complete blood count, erythrocyte sedimentation rate, and a C-reactive protein measurement should be performed. Follow-up magnetic resonance imaging, computed tomography, or bone scanning may be needed depending on the suspected cause. It is generally accepted that the following factors warrant immediate evaluation: patient age younger than four years, persistent symptoms, self-imposed activity limitations, systemic symptoms, increasing discomfort, persistent night-time pain, and neurologic symptoms.     

Assessment of pain coping styles: development of an inventory

The Pain Coping Style Inventory (PCSI) is an instrument designed to measure the pain coping style of individuals It is based on the pain coping model and typology described by Copp A study with a convenience sample of 145 university graduates, undergraduates, and faculty revealed a Cronbach's alpha reliability coefficient of 0 90, adequate stability, and a nine factor analysis solution representing 57% of the variance Four of Copp's five coping styles are clearly defined by the factor analysis interactive, reactive, combatant, and victim Five more coping styles are named contractor, distractor, spiritual coping, substance users, and mind over matter The development and piloting of the PCSI is a step towards empowering the nurse with the ability to provide patients with individualized pain coping strategies