Depression and functional disability in chronic pediatric pain.

OBJECTIVES: The primary aim of this study was to describe pain characteristics, coping strategies, depression, and functional disability in children and adolescents with chronic pain and to examine potential factors that are associated with functional disability in a pediatric pain population. The secondary aim of this study was to compare functional disability in two chronic pain conditions: localized musculoskeletal pain and chronic daily headaches. SUBJECTS: The participants in this study were 73 pediatric pain patients with a variety of chronic pain conditions. Subjects in the second part of the study were a subset of patients (N = 44) from the pain clinic sample with chronic localized musculoskeletal pain and a subset of patients (N = 38) from the headache center of the same hospital who had chronic daily headaches. DESIGN: Patients completed self-report measures of pain intensity, depression, coping strategies, coping efficacy, and functional disability. RESULTS: Results indicated that chronic pain had a substantial impact on the children's lives and that depression was strongly associated with functional disability. Maladaptive coping was correlated with depression and disability; however, maladaptive coping was not independently associated with functional disability. A comparison between the two groups found significant differences in pain intensity and functional disability. The localized musculoskeletal pain group reported higher levels of disability and more difficulty coping than the chronic daily headache group. CONCLUSIONS: The implications for treatment of chronic pain in children are discussed with an emphasis on greater attention to developmental issues and their relation to coping, emotional functioning, and disability in pediatric pain. Further research examining differences in coping and disability between different pediatric pain groups is also warranted.     

Psychosocial risks for disability in children with chronic back pain.

Psychosocial factors related to disability in adults with chronic back pain have been well studied, but little is known about factors associated with functional impairment in pediatric patients with chronic back pain. The purpose of this study was to examine whether 2 potential risk factors-use of catastrophizing as a coping technique and presence of a familial pain history-were associated with disability in pediatric back pain patients. Participants were 65 patients (ages 8-18) with chronic back pain seen at a multidisciplinary pain clinic. Patients completed measures of pain (visual analog scales), disability (Functional Disability Inventory), and catastrophizing (Internalizing/Catastrophizing subscale of the Pain Coping Questionnaire). Parents provided demographic information and familial pain history. Patients reported that chronic back pain caused disruptions in their daily functioning and they missed, on average, 2.5 days of school every month. Catastrophizing and familial chronic pain history both were significantly associated with greater disability, with use of catastrophizing being the stronger predictor of disability. This study presents important findings on potential psychosocial risk factors of functional disability in children and adolescents with chronic back pain. Future research might clarify mechanisms by which such coping styles are developed and explore how familial communication about pain might influence a child's coping ability. PERSPECTIVE: Pediatric patients seeking treatment for chronic back pain often present with substantial functional impairment that is not well explained by disease variables or pain intensity. Two important psychosocial variables (catastrophizing and familial pain history) may provide a context for a better understanding of pain-related disability in children.     

Understanding how disability is defined and conceptualized in the literature.

A goal of rehabilitation nursing is to advance the care of persons with chronic disabling conditions by minimizing disability. There are two distinct perpectives in the literature about how to conceptualize disability. Definitions and models of disability that inform rehabilitation nursing practice are based on a functionalist perspective of illness and locate disability as a problem of individual functioning. Alternatively, there are definitions and models that have evolved from the civil rights and social justice perspectives, and that locate the problem of disability within a disabling society. Recent attempts to integrate these two perspectives are based on earlier rehabilitation models and the functionalist assumptions remain. Rehabilitation nursing research and practice based on either of these two perspectives is fragmented and incomplete. To know how to define and approach disability-related issues, it is important to understand how people living with disability perceive its influences on their lives.     

One- and two-item measures of pain beliefs and coping strategies

Pain-related beliefs and pain coping strategies are central components of current cognitive-behavioral models of chronic pain, and have been found in numerous studies to be associated significantly with psychosocial and physical disability. However, the length of most measures of pain-related beliefs and coping restricts the ability of clinicians and researchers to perform a thorough assessment of these variables in many situations. The availability of very brief versions of existing scales would make possible the assessment of a range of important pain beliefs and coping strategies in settings where subject or patient assessment burden is an issue. In this study, one- and two-item versions of the subscales of several commonly used measures of pain beliefs and coping strategies were developed using both rational and empirical procedures. The findings support the validity of these brief subscales. The appropriate use and limitations of these measures are discussed.     

Chronic pain coping experiences of institutionalized elderly

While pain is a common problem among the elderly, a group that has grown significantly as a percentage of population in recent decades, few studies have been done to describe their chronic pain coping experiences. The aim of this qualitative study was to enhance understanding of chronic pain coping strategies adopted by elderly residents of long-term care facilities. Eighteen elderly residents were interviewed, with Lincoln and Guba's trustworthiness criteria utilized to evaluate methodological rigor. Colaizzi's phenomenological approach was used to analyze chronic pain coping data. Three themes that emerged in findings included: use of multiple pain relief strategies, use of passive pain endurance and learning to live with chronic pain. The author hopes that results of this study will provide better insight on approaches taken by the elderly to personal pain management and help guide the development of nursing guidelines for chronic pain management. Recommendations highlighted in this study include increasing chronic pain education and continued research in support of developing a Chinese version chronic pain assessment tool for the elderly.     

Attempting to solve the problem of pain: a questionnaire study in acute and chronic pain patients

When faced with the problem of pain one can attempt a solution aimed at relief (assimilation) or a solution aimed at acceptance (accommodation). Using this dual process model of adaptation to pain, this study compares acute and chronic pain patients on their approach to problem solving. Three hundred and sixty-four patients were recruited from clinical settings, 303 with chronic pain and 61 with acute pain, and completed a range of measures of both affect and pain-related behavior, including the Pain Solutions Questionnaire. The effects of overall duration of pain were also investigated. Chronic pain patients reported greater disability and catastrophic thinking about pain than acute pain patients, and assimilative coping was associated with greater disability, greater attention to pain, and more catastrophic thinking about pain, beyond the effects of demographic variables and pain severity. Pain duration did not moderate these associations. Only in the case of catastrophic thinking about pain was it found that the effects of assimilative coping were moderated by pain duration. For chronic pain patients, catastrophic thinking about pain was greater when assimilative coping was higher. These results are discussed within the context of a goal directed motivational model of adaptation to chronic pain.     

Perceived social support and coping responses are independent variables explaining pain adjustment among chronic pain patients.

The purpose of the present study was to test a hypothetical model of the relationships between perceived social support, coping responses to pain, pain intensity, depressed mood, and functional disability (functional status and functional impairment) in a population of patients with chronic pain in a Spanish Clinical Pain Unit. It was postulated that social support and pain coping responses both independently influence reported pain intensity, depressed mood, and functional disability. Analyses were performed by Structural Equation Modelling. The results indicated that satisfaction with social support is significantly associated with a depressed mood and pain intensity, but not with functional disability. Although this effect is independent of the use of active coping responses by patients, there is a modest but significant relationship between social support and passive coping strategies, indicating that higher levels of perceived social support are related to less passive pain coping strategies. The findings underscore the potential importance of psychosocial factors in adjustment to chronic pain and provide support for a biopsychosocial model of pain. PERSPECTIVE: This article tested a hypothetical model of the relationships between social support, pain coping, and chronic pain adjustment by using Structural Equation Modelling. The results indicate that perceived social support and pain coping are independent predictors of chronic pain adjustment, providing support for a biopsychosocial model of pain.     

Coping, pain severity, interference, and disability: the potential mediating and moderating roles of race and education.

Researchers have demonstrated that certain types of pain coping are correlated with less pain severity and disability and that there are differences between Caucasians and African-American pain patients in their use of specific coping strategies. However, the extent to which racial group differences exist in the associations between pain coping strategies and pain severity, interference, and disability is unclear. Furthermore, the role of education in these associations is uncertain. We recruited a diverse community sample of individuals with chronic pain and their spouses to examine this issue (N = 105). Participants completed the Coping Strategies Questionnaire, Multidimensional Pain Inventory, and Sickness Impact Profile. Results showed that African-American participants reported significantly more pain severity, interference, and disability and reported using diverting attention and prayer and hoping pain-coping strategies significantly more often than Caucasian participants; however, only the racial group difference in prayer and hoping remained when controlling for education. We also examined whether race and education interacted with coping strategies in relating to pain and disability. Significant three-way interactions were found for physical and psychosocial disability, suggesting that educational level should be included in analyses exploring racial group differences. The results suggest the need for pain treatments that take into account the educational and cultural context of pain. PERSPECTIVE: This article demonstrates that demographic variables such as race and education should be considered together when evaluating the effectiveness of coping with pain. The findings have the potential to enhance research and clinical practice with diverse groups.     

Further validation of the chronic pain coping inventory.

Multidisciplinary treatment programs for chronic pain typically emphasize the importance of decreasing maladaptive and encouraging adaptive coping responses. The Chronic Pain Coping Inventory (CPCI), developed to assess coping strategies targeted for change in multidisciplinary pain treatment, is a 64-item instrument that contains 8 subscales: Guarding, Resting, Asking for Assistance, Relaxation, Task Persistence, Exercising/Stretching, Coping Self-Statements, and Seeking Social Support. A previous validation study with 210 patients in a Canadian academic hospital setting supported an 8-factor structure for the CPCI. The current study was undertaken to validate the CPCI among 564 veterans with a more extended history of chronic pain. Patients completed the study questionnaires before multidisciplinary treatment. A confirmatory factor analysis was used to examine the factor structure of the 64-item CPCI. A series of hierarchical multiple regression analyses were performed with depression, pain interference, general activity level, disability, and pain severity as the criterion variables and the 8 CPCI factors as the predictor variables, controlling for pain severity and demographic variables. The confirmatory factor analysis results strongly supported an 8-factor model, and the regression analyses supported the predictive validity of the CPCI scales, as indicated by their association with measures of patient adjustment to chronic pain. PERSPECTIVE: This article validated the 8-factor structure of the CPCI by using a confirmatory factor analysis and a series of linear regressions. The results support the applicability and utility of the CPCI in a heterogeneous population of veterans with severe chronic pain treated in a tertiary teaching hospital. The CPCI provides an important clinical and research tool for the assessment of behavioral pain coping strategies that might have an impact on patient outcomes.     

Catastrophizing is associated with pain intensity,psychological distress,and pain-related disability among individuals with chronic pain after spinal cord injury

Little research has examined the role of patient cognitive and behavioral responses, including catastrophizing, in adjustment to chronic pain associated with spinal cord injury (SCI). The objective of this study was to examine the associations of catastrophizing and specific pain coping strategies with pain intensity, psychological distress, and pain-related disability among individuals with chronic pain and SCI, after controlling for important demographic and SCI-related variables that might affect outcomes. Participants in this study were 174 community residents with SCI and chronic pain who completed a mailed questionnaire that included the SF-36 Mental Health scale, Coping Strategies Questionnaire, and Graded Chronic Pain Scale. The pain coping and catastrophizing measures explained an additional 29% of the variance in pain intensity after adjusting for the demographic and SCI variables (P<0.001). The coping and catastrophizing scales accounted for an additional 30% of the variance in psychological distress (P<0.001) and 11% of the variance in pain-related disability (P<0.001), after controlling for pain intensity and demographic and SCI variables. Catastrophizing, but not any other single pain coping strategy, was consistently strongly and independently associated with the outcome measures. Potentially, the assessment and treatment of catastrophizing may reduce psychological distress and pain-related disability among individuals with chronic pain and SCI.     

Just world beliefs moderate the relationship of pain intensity and disability with psychological distress in chronic pain support group members

The impact of pain beliefs on coping and adjustment is well established. However, less is known about how beliefs unrelated to pain might impact upon this experience. In particular, just world beliefs could impact upon and be influenced by chronic pain, given that pain is not experienced in a vacuum but instead is experienced in a social context where justice issues are potentially salient. The focus of this study was the ability of personal and general just world beliefs to moderate the relationships psychological distress held with pain intensity and disability in chronic pain. The sample (N = 95) was recruited from members of arthritis and fibromyalgia support groups to investigate these social beliefs in a controlled community pain context. A cross‐sectional, questionnaire design was adopted. The personal just world belief was endorsed significantly more than the general just world belief, and endorsement of the personal just world belief was negatively correlated with pain intensity, disability and psychological distress, while the general just world belief was unrelated to these variables. When interaction terms relating to personal and general just world beliefs were entered simultaneously into regression analyses, the personal just world belief did not predict psychological distress. However, pain intensity positively predicted psychological distress at low but not high levels of the general just world belief, while disability predicted psychological distress at low and high levels of this belief. This suggests that a strong general just world belief has implications for psychological well‐being in chronic pain, and as such this belief may occupy a potential coping function in this context.     

Cognitions, coping and social environment predict adjustment to phantom limb pain.

Biopsychosocial models of chronic pain hypothesize a role for psychological and environmental factors in adjustment to chronic pain. To test the utility of such models for understanding phantom limb pain, 61 persons with recent amputations were administered measures of average phantom limb pain intensity, pain interference, depression, pain coping use, pain cognitions and appraisals, and social environmental variables 1 month post-amputation, and the measures of pain intensity, pain interference, and depression again 5 months later. Multiple regression analyses showed that the psychosocial predictors made a statistically significant contribution to the concurrent prediction of average phantom limb pain, pain interference, and depression at the initial assessment, and a significant contribution to the prediction of subsequent change in pain interference and depression over the course of 5 months. The results support the utility of studying phantom limb pain from a biopsychosocial perspective, and identify specific biopsychosocial factors (e.g., catastrophizing cognitions, social support, solicitous responses from family members, and resting as a coping response) that may play an important role in adjustment to phantom limb pain.     

Determinants of chronic disability related to low back pain: Towards an integrative biopsychosocial model

Purpose : Since the early 1990s, numerous prospective studies have been published on the determinants of chronic disability related to low back pain (LBP) of non-specific origin whose human and financial costs are enormous. The significant contribution of psychosocial factors is being increasingly recognized. However, additional efforts are needed to clarify their role and to improve the interventions. The purpose of this theoretical paper is to propose a coherent organization of the medical and psychosocial determinants identified in prospective studies into a conceptual framework. Method : Several models available in the field of pain and disability as well as in health psychology were reviewed. Results : A recent version of the stress coping model was chosen and adapted to the problem. The adapted model suggests that stress, particularly that caused by the pain associated with LBP, could have a negative impact on the outcome either: (1) indirectly through the negative emotional responses that it produces, which can cause biological or behavioural changes; or (2) directly through the biological or behavioural changes, which can in turn negatively affect the emotional response. Conclusions : The proposed biopsychosocial model assumes that LBP-related chronic disability is possibly, in some cases, a stress-related disorder. Its empirical verification in LBP could particularly improve the understanding of the interrelationships between certain variables.     

Determinants of chronic disability related to low back pain: Towards an integrative biopsychosocial model

Purpose : Since the early 1990s, numerous prospective studies have been published on the determinants of chronic disability related to low back pain (LBP) of non-specific origin whose human and financial costs are enormous. The significant contribution of psychosocial factors is being increasingly recognized. However, additional efforts are needed to clarify their role and to improve the interventions. The purpose of this theoretical paper is to propose a coherent organization of the medical and psychosocial determinants identified in prospective studies into a conceptual framework. Method : Several models available in the field of pain and disability as well as in health psychology were reviewed. Results : A recent version of the stress coping model was chosen and adapted to the problem. The adapted model suggests that stress, particularly that caused by the pain associated with LBP, could have a negative impact on the outcome either: (1) indirectly through the negative emotional responses that it produces, which can cause biological or behavioural changes; or (2) directly through the biological or behavioural changes, which can in turn negatively affect the emotional response. Conclusions : The proposed biopsychosocial model assumes that LBP-related chronic disability is possibly, in some cases, a stress-related disorder. Its empirical verification in LBP could particularly improve the understanding of the interrelationships between certain variables.     

Coping with chronic pain: a comparison of two measures

Cognitive-behavioral models of chronic pain hypothesize that how a person copes with pain influences how well he or she adjusts to the pain. Several measures have been developed to assess pain coping, but no studies have yet examined whether these measures are complementary or redundant. In the current study, two pain coping measures (the Chronic Pain Coping Inventory, CPCI, and the Coping Strategies Questionnaire, CSQ) were completed by a large number (N=564) of primarily male veterans referred to a chronic pain program. Regression analyses indicated that the CPCI scales did not contribute unique variance to the prediction of depression over and above the CSQ scales. The CSQ Catastrophizing scale was the single most powerful predictor of depression, although several other CSQ scales (Coping Self-Statements, Diverting Attention, and Increasing Behavioral Activities) also contributed. Both the CPCI and the CSQ contributed unique variance to the prediction of disability, although the CPCI scales appear to be more strongly related to disability than the CSQ scales. The CPCI Guarding scale was the single most powerful predictor of disability of all the coping responses assessed in this study. Other scales predicting disability were the CPCI Seeking Social Support, the CSQ Catastrophizing, and the CSQ Increasing Behavioral Activities. While both CSQ and CPCI contribute unique but modest variance to the prediction of pain severity, the CSQ Catastrophizing scale was the single most powerful predictor of pain severity. The findings of this study are consistent with cognitive-behavioral models of pain. Future research will need to determine whether changes in coping responses (catastrophizing and guarding, in particular) merely reflect, or actually influence, adjustment to chronic pain. In the meantime, clinicians would be wise to give these coping responses particular attention in chronic pain programs.     

Adolescent chronic pain: patterns and predictors of emotional distress in adolescents with chronic pain and their parents

Adolescents with chronic pain also report severe disability and emotional distress. A clinical sample of 80 adolescents and accompanying parents were investigated to first measure the extent of distress, and second to investigate the relationships between adolescent distress, parental distress and adolescent coping. Measures of pain intensity, anxiety, depression, disability and coping were obtained from adolescents. Parents completed measures including their own anxiety, depression and parenting stress. Overall, adolescents reported high levels of disability, depression and anxiety, and parents reported high levels of depression, anxiety and parenting stress. Multiple regression analyses revealed that the best predictors of adolescent emotional distress were the extent to which the adolescents catastrophize and seek social support to cope with the pain. There were no clear predictors of parental anxiety or depression but the specific pattern of parenting stress was best predicted by the younger age of the adolescent, the greater the chronicity of the problem, and the greater the extent of adolescent depression. These findings suggest that emotional coping is a critical variable in the distress associated with adolescent chronic pain. It is argued that adolescent emotional coping may best be understood within a relational context of seeking emotional support.     

A comparison of the relative utility of coping and acceptance-based measures in a sample of chronic pain sufferers.

Previous research suggests that to define the problem of chronic pain as a problem of coping may not be as useful as framing it as a problem of acceptance for some patients. The coping approach may encourage, or at least permit, a somewhat inflexible agenda of pain reduction or control while the acceptance approach may allow a more flexible agenda of willingness to have pain in some circumstances where that serves the goal of better life functioning. The purpose of this study was to continue to examine the relative utility of concepts of coping and acceptance of pain. Two hundred and thirty consecutive patients seeking assessment from a pain management service were the participants in the study. Patients completed the Coping Strategies Questionnaire (CSQ) and the Chronic Pain Acceptance Questionnaire (CPAQ). A revised scoring method was used for the CSQ (to correct for technical limitations noted in the past) and recently developed subscales of the CPAQ were examined. Correlation results showed that the acceptance variables were reliably stronger predictors of distress and disability compared with coping variables. Regression analyses confirmed that, compared with coping variables, acceptance accounted larger unique increments in variance in measures of patient functioning regardless of whether the coping variables were given priority in the regression equations. Increasing data support the view that the pain management field may benefit from evolving toward incorporating a less control-oriented and more accommodating view of aversive private experiences in some circumstances.     

Psychosocial Predictors of Chronic Musculoskeletal Pain Outcomes and their Contextual Determinants Among Black Individuals: A Narrative Review

Black communities are disproportionally affected by Chronic Musculoskeletal Pain (CMP), but little is known about the psychological predictors of CMP outcomes and their contextual determinants among Black individuals. To address this gap, we conducted a narrative review of extant literature to (1) report the major conceptual models mentioned in prior work explaining the link between contextual determinants and psychological responses to pain among Black individuals with CMP; and (2) describe psychological factors related to CMP outcomes in this population that are highlighted in the literature. We searched 4 databases (APA PsycNet, PubMed/MEDLINE, Scopus, and Google Scholar) using the following search terms: musculoskeletal pain, chronic pain, mental health, psychological, coping, health disparities, contextual factors, conceptual models, psychosocial, Black, African American, pain, disability, and outcomes. We illustrate 3 relevant conceptual models – socioecological, cumulative stress, and biopsychosocial – related to contextual determinants and several psychological factors that influence CMP outcomes among Black individuals: (1) disproportionate burden of mental health and psychiatric diagnoses, (2) distinct coping strategies, (3) pain-related perceived injustice and perceived racial/ethnic discrimination, and (4) preferences and expectations related to seeking and receiving pain care. The detailed clinical and research implications could serve as a blueprint for the providers and clinical researchers to address health disparities and improve care for Black individuals with CMP.PerspectiveThis narrative review illustrates conceptual models explaining the link between contextual determinants and psychological responses to pain among Black individuals with chronic musculoskeletal pain. We discuss 3 relevant conceptual models – socioecological, cumulative stress, biopsychosocial –, and 4 psychological factors: disproportionate burden of mental health, distinct coping strategies, perceived injustice/discrimination, preferences/expectations.     

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.     

Coping or acceptance: what to do about chronic pain?

Research and treatment of chronic pain over the past 20 or more years have tended to focus on patient coping as the primary behavioral contribution to adjustment. The purpose of the present study was to compare a coping approach to chronic pain with a different behavioral approach referred to as acceptance of chronic pain. These approaches were compared in terms of their ability to predict distress and disability in a sample of patients seeking treatment for chronic pain. Subjects were 230 adults assessed at a university pain management center. All patients completed the coping strategies questionnaire and the chronic pain acceptance questionnaire among other standard measures. Results showed that coping variables were relatively weakly related to acceptance of pain and relatively unreliably related to pain adjustment variables. On the other hand, acceptance of chronic pain was associated with less pain, disability, depression and pain-related anxiety, higher daily uptime, and better work status. Regression analyses examined the independent contributions of coping and acceptance to key adjustment indicators in relation to chronic pain. Results from these analyses demonstrated that acceptance of pain repeatedly accounted for more variance than coping variables.