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Development of chronic pain following severe accidental injury. Results of a 3-year follow-up study
Abstract
Motor vehicle accidents (MVA) and work-related injuries are two of the more common causes of chronic pain. Nevertheless, there is little evidence on predicting factors regarding the development of chronic pain following physical injury.
The present study investigated temporal associations between accident-related factors, psychological factors [symptoms of posttraumatic stress disorder (PTSD), anxiety, depression, coping], and the development of chronic pain in a sample of individuals who had sustained severe accidental injuries (N=90). Assessments were performed within 1 month of the accident, and at 6, 12, and 36 months post trauma.
A total of 40 individuals (44%) reported accident-related pain 3 years after the accident. Individuals with chronic pain showed significantly more symptoms of PTSD, depression, and anxiety, more disability, and more days off work. Analysis of temporal associations between psychological variables and the development of chronic pain indicated that the separation of the pain from the nonpain group mostly occurred between 6 (T2) and 12 months (T3). Differences were much less pronounced at T1.
The prevalence of chronic pain in severely injured patients 3 years after the accident is considerably high. The development of chronic pain is more related to psychological factors, particularly PTSD symptoms, in the aftermath of the accident, as compared to sociodemographic and accident-related variables at the time of the accident. These findings may be helpful to elucidate the problems in predicting chronic pain conditions in injured subjects and to recognize the onset of a chronic pain condition more reliably.
... The percentage of cases that requires operative intervention within a particular year Operative intervention [28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44] The percentage of cases that have any type of infection within a particular year Infection rates [28,[45][46][47][48][49][50][51][52][53] The percentage of cases admitted to the ICU within a particular year Admission rate to ICU a [30,32,33,35,38,44,[54][55][56][57][58][59][60][61][62][63][64][65][66][67] The cause-specific death rate per 100,000 population within a particular year Immediate mortality rate [32,33,[35][36][37][38][39][40][41][44][45][46]50,[54][55][56][57][58][59][60]62,[64][65][66] The average number of days spent in the ICU within a particular year ...
... Length of ICU stay [40,44,61,62,64,67,90,98,103,106] The average number of days spent in hospital for a particular year Length of hospitalization [30,31,33,34,36,[40][41][42][44][45][46][47][48]50,52,[54][55][56][61][62][63][64]68,71,72,75,76,78,87,90,98,99,[103][104][105][106][107][108][109][110][111][112][113][114][115][116][117] The cause-specific admission rate to the AED per 100,000 population for a particular year Admission rate to AED b [43,66,69,[100][101][102][117][118][119][120][121] Average amount of time required for the healing of injury-induced open wounds within 1 particular year Time for wound healing [50,109] Total number of cases that need to be referred to an inpatient rehabilitation facility within a particular year Need for rehabilitation facility [30] The percentage of cases that require inpatient hospital admissions after leaving AED per 100,000 population within a particular year Hospitalization rate after leaving AED [30,35,38,[53][54][55]58,60,61,66,69,77,83,[100][101][102]105,107,108,111,[117][118][119][120]122,123] The average number of days that the cases require intubation, a process of inserting through the mouth into the airway to assist with their breathing, within a particular year Intubation duration [30,52,62,64,80,90,103] The percentage of cases that need secondary surgical procedures within a particular year Need for secondary procedures [31][32][33][34]48,115] The average amount of time needed for the operative intervention conducted within a particular year Mean duration of operation [37] The percentage of cases that have injury-induced complications within a particular year Presence of complications [32,33,36,37,46,49,51,58,63,78,86,92,106,109,[113][114][115]124,125] The frequency of having any injury-induced disease or medical condition within a particular year Morbidity [46,60,[83][84][85]88,95] The percentage of cases discharged from the hospital within a particular year Discharge rate [70,80,[97][98][99]105,117,120,126] Total number of cases discharged to a nursing facility within a particular year Need for nursing facility [89] Functional and psychological outcome indicators ...
... The long-term outcomes of emotions and behaviors characterized by alteration of feeling tone and by physiological behavioral changes Long-term behavioral and emotional outcomes [67,135,147,155,[158][159][160][161][162] Capacities necessary for the performance of everyday selfcare competence, mobility competence, and social competence Social dependency [163,164] The possibility of having mental illnesses that affect one's mood, thinking, and behavior after experiencing a shocking, scary, or dangerous event Possibility of posttraumatic stress disorder or other mental disorders [55,67,97,131,132,135,148,151,159,162,[164][165][166] The presence of disabilities, which refer to impairments, activity limitations, and participation restrictions Presence or absence of disabilities [32,[48][49][50]56,66,74,82,93,101,103,134,135,167] The number of people taking their own life after injury per 100,000 population in a period Suicide rate [43,121,159] The consequences of the injury on one's work life and study life Effect on employment or studies [79,106,134,135,140,147,159,161,168] The distance a person is able to walk in a period, such as the 6-minute walk test Walking distance [28,138] The overall enjoyment of life, including aspects of an individual's sense of well-being, ability to perform various activities, and quality of life with domains of physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health Quality of life [28,67,70,88,110,111,124,[133][134][135][136]144,151,162,163,167,169] A measure expressed as the number of years lost because of ill health, disability, or early death used to reflect the overall disease burden Disability-adjusted life year [67,135,162] A measure used to reflect the overall disease burden by considering both the quality and quantity of the life lived ...
Background
Injury is an increasingly pressing global health issue. An effective surveillance system is required to monitor the trends and burden of injuries.
Objective
This study aimed to identify a set of valid and context-specific injury indicators to facilitate the establishment of an injury surveillance program in Hong Kong.
Methods
This development of indicators adopted a multiphased modified Delphi research design. A literature search was conducted on academic databases using injury-related search terms in various combinations. A list of potential indicators was sent to a panel of experts from various backgrounds to rate the validity and context-specificity of these indicators. Local hospital data on the selected core indicators were used to examine their applicability in the context of Hong Kong.
Results
We reviewed 142 articles and identified 55 indicators, which were classified into 4 domains. On the basis of the ratings by the expert panel, 13 indicators were selected as core indicators because of their good validity and high relevance to the local context. Among these indicators, 10 were from the construct of health care service use, and 3 were from the construct of postdischarge outcomes. Regression analyses of local hospitalization data showed that the Hong Kong Safe Community certification status had no association with 5 core indicators (admission to intensive care unit, mortality rate, length of intensive care unit stay, need for a rehabilitation facility, and long-term behavioral and emotional outcomes), negative associations with 4 core indicators (operative intervention, infection rate, length of hospitalization, and disability-adjusted life years), and positive associations with the remaining 4 core indicators (attendance to accident and emergency department, discharge rate, suicide rate, and hospitalization rate after attending the accident and emergency department). These results confirmed the validity of the selected core indicators for the quantification of injury burden and evaluation of injury-related services, although some indicators may better measure the consequences of severe injuries.
Conclusions
This study developed a set of injury outcome indicators that would be useful for monitoring injury trends and burdens in Hong Kong.
... For analysis of chronic post ICU pain (CPIP) and chronic opioid use after ICU, articles were excluded if they didn't clearly state in the methods that patients were treated in the ICU, that included pediatric patients, that did not clearly refer to chronic pain and chronic opioid use after ICU discharge. Nine articles were included for analysis of chronic pain after ICU (Granja et al., 2002;Boyle et al., 2004;Korošec Jagodič et al., 2006;Jenewein et al., 2009;Timmers et al., 2011;Battle et al., 2013;Griffiths et al., 2013;Choi et al., 2014;Baumbach et al., 2016) and one article for chronic opioid use (Yaffe et al., 2017). ...
... Other studies controlled for additional confounders such as age or gender. Study designs included comparisons to different control groups including septic vs. nonseptic patients, ICU patients with and without CPIP, and ageand gender-matched individuals from the general population (Jenewein et al., 2009;Timmers et al., 2011;Baumbach et al., 2016). One study considered the bodily location of pain, which was found in approximately a fifth of patients at the shoulder (Battle et al., 2013). ...
... Chronic pain in general is "highly comorbid with anxiety and depression" and whilst this might also be the case for CPIP, no studies found this association (Katz et al., 2015). CPIP was found to be associated with PTSD (Jenewein et al., 2009). Whilst severe accidental injury requiring ICU admission is likely to lead to physical disability it is notable that in a prospective follow up study of ICU survivors who experienced severe accidental injuries, those with CPIP had a significantly more frequent presence of physical disability, occupational invalidity and absence from work than those pain free up to 3 years following their injury (Jenewein et al., 2009). ...
Almost half of patients treated on intensive care unit (ICU) experience moderate to severe pain. Managing pain in the critically ill patient is challenging, as their pain is complex with multiple causes. Pharmacological treatment often focuses on opioids, and over a prolonged admission this can represent high cumulative doses which risk opioid dependence at discharge. Despite analgesia the incidence of chronic pain after treatment on ICU is high ranging from 33–73%. Measures need to be taken to prevent the transition from acute to chronic pain, whilst avoiding opioid overuse. This narrative review discusses preventive measures for the development of chronic pain in ICU patients. It considers a number of strategies that can be employed including non-opioid analgesics, regional analgesia, and non-pharmacological methods. We reason that individualized pain management plans should become the cornerstone for critically ill patients to facilitate physical and psychological well being after discharge from critical care and hospital.
... Persistent pain following surgery is common in the general population [7,8]. The incidence of significant persistent postoperative pain for all operation types is 11.8% at 1 year [9]. Persistent non-cancer pain is correlated with poor mental health, loss of employment and a poor quality of life [10]. ...
... The transition from acute to persistent pain has been less well investigated after trauma or following an episode of acute abdominal pain. Following traumatic injury, persistent pain is common, with 44% of patients reporting accident-related pain 3 years later in one prospective study [11]. Little is known about the development of persistent abdominal pain after the initial presentation. ...
... There are multiple risk factors for the progression from acute to persistent pain [14]. These include: type of injury; surgery or other pathology (nerve injury, tissue trauma and inflammation are all important); and a number of patientspecific factors including: sex; age; genetics; anxiety; depression and abnormal coping responses [11,15]. The presence of severe acute postoperative pain consistently correlates with the development of persistent postoperative pain [16]. ...
The effect of patient‐controlled analgesia during the emergency phase of care on the prevalence of persistent pain is unkown. We studied individuals with traumatic injuries or abdominal pain 6 months after hospital admission via the emergency department using an opportunistic observational study design. This was conducted using postal questionnaires that were sent to participants recruited to the multi‐centre pain solutions in the emergency setting study. Patients with prior chronic pain states or opioid use were not studied. Questionnaires included the EQ5D, the Brief Pain Inventory and the Hospital Anxiety and Depression scale. Overall, 141 out of 286 (49% 95%CI 44–56%) patients were included in this follow‐up study. Participants presenting with trauma were more likely to develop persistent pain than those presenting with abdominal pain, 45 out of 64 (70%) vs. 24 out of 77 (31%); 95%CI 24–54%, p < 0.001. There were no statistically significant associations between persistent pain and analgesic modality during hospital admission, age or sex. Across both abdominal pain and traumatic injury groups, participants with persistent pain had lower EQ5D mobility scores, worse overall health and higher anxiety and depression scores (p < 0.05). In the abdominal pain group, 13 out of 50 (26%) patients using patient‐controlled analgesia developed persistent pain vs. 11 out of 27 (41%) of those with usual treatment; 95%CI for difference (control – patient‐controlled analgesia) −8 to 39%, p = 0.183. Acute pain scores at the time of hospital admission were higher in participants who developed persistent pain; 95%CI 0.7–23.6, p = 0.039. For traumatic pain, 25 out of 35 (71%) patients given patient‐controlled analgesia developed persistent pain vs. 20 out of 29 (69%) patients with usual treatment; 95%CI −30 to 24%, p = 0.830. Persistent pain is common 6 months after hospital admission, particularly following trauma. The study findings suggest that it may be possible to reduce persistent pain (at least in patients with abdominal pain) by delivering better acute pain management. Further research is needed to confirm this hypothesis.
... Specifically, up to 24% of injured trauma patients report a new-onset psychiatric disorder at 12-months post-injury [14], and an estimated 10-40% develop clinically significant symptoms characteristic of Posttraumatic Stress Disorder (PTSD) [15][16][17], including intrusive experiences (e.g., nightmares, flashbacks, or triggers), avoidance of trauma-related stimuli, negative changes in beliefs and feelings, and increased physiological arousal and reactivity [18,19]. These psychological reactions are associated with chronic posttraumatic pain [20,21], even more so than injury severity or characteristics [5,9,[22][23][24][25][26][27][28]. Additionally, activation of support networks immediately after a traumatic event enhances adjustment to pain [29,30], and poor social support predicts adverse psychological outcomes ( [31,32]). ...
... Extant literature has focused largely on chronic pain/disability emerging at remote time-frames (e.g., 6-months to 3-years post-injury) among severely injured trauma patients [22,23] and/or those admitted to the hospital for their injuries. Typically, symptom monitoring and assessments do not occur until 4-to 6-weeks [6,25] ...
... Additionally, hyperarousal symptoms also increase the likelihood of developing an attentional bias to both threatening and painful stimuli [51]. As such, the presence of posttraumatic symptomology may be particularly problematic among injured populations at risk for pain chronicity [22,23], given that PTSD symptoms contribute to and/or exacerbate physical health symptoms [18,19,52] and are associated with lingering effects on health [53]. ...
Objectives
Psychosocial factors and responses to injury modify the transition from acute to chronic pain. Specifically, posttraumatic stress disorder symptoms (PTSS; reexperiencing, avoidance, and hyperarousal symptoms) exacerbate and co‐occur with chronic pain. Yet no study has prospectively considered the associations among these psychological processes and pain reports using experience sampling methods (ESM) during the acute aftermath of injury.
This study applied ESM via daily text messaging to monitor and detect relationships among psychosocial factors and post‐injury pain across the first 14‐days after emergency department (ED) discharge.
Methods
We recruited 75 adults (59% male; M age = 33) who experienced a potentially traumatic injury (i.e., involving life threat or serious injury) in the past 24‐hours from the EDs of two Level 1 trauma centers. Participants received 5 questions per day via text messaging from Day‐1 to Day‐14 post‐ED discharge; three questions measured PTSS, one question measured perceived social support, and one question measured physical pain.
Results
Sixty‐seven participants provided sufficient data for inclusion in the final analyses, and the average response rate per subject was 86%. Pain severity score decreased from a mean of 7.2 to 4.4 over 14 days and 50% of the variance in daily pain scores was within‐person. In multilevel structural equation models, pain scores decreased over time, and daily fluctuations of hyperarousal (b = 0.22, 95% CI [0.08, 0.36]) were uniquely associated with daily fluctuations in reported pain level within each person.
Conclusions
Daily hyperarousal symptoms predict same‐day pain severity over the acute post‐injury recovery period. We also demonstrated feasibility to screen and identify patients at risk for pain chronicity in the acute aftermath of injury. Early interventions aimed at addressing hyperarousal (e.g. anxiolytics) could potentially aid in reducing experience of pain.
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... The relationship between baseline hyperarousal and intrusion symptoms, and later 12-month hyperarousal and intrusion symptoms, was mediated by 3-month pain levels. In a sample of injured accident survivors (Jenewein et al., 2009), support for the Mutual Maintenance Model was found in the early aftermath of the accident. Six to 12 months post-accident the findings demonstrated that higher PTSD symptom levels were associated with increased pain intensity, but not vice versa. ...
... The finding that intrusions consistently predicted pain in the two waves, as was also reported by Liedl et al. (2010) may subscribe this effect. PTSD driving the presence of pain was earlier reported by Brown et al. (2014) and Jenewein et al. (2009). The finding that particularly intrusions predicted subsequent pain, suggests that high levels of intrusions after a traumatic burn event may be important in the development of chronic pain. ...
Pain and posttraumatic stress disorder (PTSD) frequently co-occur but underlying mechanisms are not clear. This study aimed to test the development and maintenance of pain and PTSD symptom clusters, i.e., intrusions, avoidance, and hyperarousal. The longitudinal study included 216 adults with burns. PTSD symptom clusters, indexed by the Impact of Event Scale-Revised (IES-R), and pain, using a graphic numerical rating scale (GNRS), were measured during hospitalization, 3 and 6 months post-burn. Cross-lagged panel analysis was used to test the relationships between pain and PTSD symptom clusters. Cross-lagged results showed that in-hospital intrusions predicted pain and avoidance 3 months post-burn. In-hospital pain predicted intrusions and avoidance 3 months post-burn and a trend was found for hyperarousal (90% CI). In the second wave, intrusions predicted pain and hyperarousal. Pain predicted hyperarousal. This study provides support for an entangled relationship between pain and PTSD symptoms, and particularly subscribes the role of intrusions in this bidirectional relationship. To a lesser extent, hyperarousal was unidirectionally related to pain. These results may subscribe the driving role of PTSD, particularly intrusions, which partly supports the Perpetual Avoidance Model.
... In addition, DSM-IV 2 also defined the exposure to incidents involving threat of physical integrity as a potential trauma (criterion A1), whereas there was also a demand for a response of intense fear, helplessness, or horror (criterion A2). Similarly, persistent pain is also common after a variety of traumatic injuries and events, 9,15,28,43,49 making both post-traumatic stress symptoms and post-traumatic pain common after traumatic incidents. ...
... Post-traumatic stress disorder symptomatology is also associated with increased levels of pain, pain-related disability, and psychological distress across pain populations. 1,24,46,48,50 Similarly, early levels of PTSD have been found to predict later pain and disability, 13,28,30,35 and peritraumatic pain has also been found to be a risk factor for later PTSD symptoms. 25,45 Indeed, this potential reciprocity of pain and PTSD symptomatology has been suggested in theoretical Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. ...
Following traumatic exposure, individuals are at risk of developing symptoms of both pain and posttraumatic stress disorder (PTSD). Theory and research suggest a complex and potentially mutually maintaining relationship between these symptomatologies. However, findings are inconsistent and the applied methods are not always well suited for testing mutual maintenance. Cross-lagged designs can provide valuable insights into such temporal associations, but there is a need of a systematic review to assist clinicians and researchers in understanding the nature of the relationship. Thus, the aim of this systematic review was to identify, critically appraise, and synthesize results from cross-lagged studies on pain and PTSD symptomatology in order to assess the evidence for longitudinal reciprocity and potential mediators. Systematic searches resulted in seven eligible studies that were deemed of acceptable quality with moderate risk of bias using the cohort study checklist from Scottish Intercollegiate Guidelines Network. Further, synthesis of significant pathways in the cross-lagged models showed inconsistent evidence of both bidirectional and unidirectional interaction patterns between pain and PTSD symptomatology across time, hence not uniformly supporting the theoretical framework of mutual maintenance. Additionally, the synthesis suggested that hyperarousal and intrusion symptoms may be of particular importance in these cross-lagged relationships, while there was inconclusive evidence of catastrophizing as a mediator. In conclusion, the findings suggest an entangled, but not necessarily mutually maintaining relationship between pain and PTSD symptomatology. However, major variations in findings and methodologies complicated synthesis, prompting careful interpretation and heightening the likelihood that future high quality studies will change these conclusions.
... The findings contribute valuable information about acute pain characteristics associated with chronic pain and provide insight into the importance of early and adequate acute pain treatment. Ó 2016 by the American Society for Pain Management Nursing Many patients with traumatic injuries (62%) report chronic pain, with patients with injuries to the lower extremities reporting a higher proportion of chronic pain compared to patients with injuries to other body sites (Jenewein et al., 2009;Williamson, Gabbe, Cameron, Edwards, & Richardson, 2009). While acute pain serves a protective function, chronic pain is thought to be without apparent biological value and persists beyond the normal tissue healing time, which usually lasts 3 months (International Association for the Study of Pain, 2003). ...
... While acute pain serves a protective function, chronic pain is thought to be without apparent biological value and persists beyond the normal tissue healing time, which usually lasts 3 months (International Association for the Study of Pain, 2003). The consequences of trauma-related, chronic pain are significant with patients reporting a high incidence of physical disability, work absence, and frequent health care visits (Jenewein et al., 2009). In addition, persons with posttrauma chronic pain report high levels of pain intensity, anxiety, and depression (St alnacke, 2011), and a considerable number (87%) state that pain interferes with their daily activities (Clay et al., 2010). ...
Many patients with injuries to lower extremities report chronic pain. High pain intensity at time of admission for injury is a risk factor for chronic pain, but it is not clear whether specific acute pain patterns following injury influence the development of chronic pain. To examine the relationship between the pain trajectory, the mean pain score, and the frequency of pain documentation during the immediate hospitalization following injury, with the report of chronic pain. This was a descriptive, retrospective cohort study of adults admitted with lower extremity fractures to an academic urban trauma center. Participants, 6-45 months postinjury, rated their current pain, worst pain, and average pain over the last 3 months. Pain scores from hospitalization associated with the injury were obtained through a retrospective chart review. The pain trajectory, mean pain score, and frequency of pain documentation was compared between patients with and without chronic pain. A total of 129 patients were enrolled in this study and 78% reported chronic pain at the site of injury. The mean pain score (5.1 vs. 4.2) and first pain score (5.6 vs. 3.4) were higher for patients with chronic pain compared to patients with no chronic pain. Consistent with other studies, high pain intensity at time of injury was associated with chronic pain. The findings contribute valuable information about acute pain characteristics associated with chronic pain and provide insight into the importance of early and adequate acute pain treatment.
... Incidence and intensity of chronic posttraumatic pain are important factors, but to the best of our knowledge, there are no reports in the literature on the nature and quality of the pain (eg, neuropathic vs nociceptive) and only 4 studies reported the use of analgesics. 4,14,23,27 Understanding the characteristics of chronic posttraumatic pain is important for providing appropriate pain management. ...
... The present results are consistent with findings in the trauma literature showing a relationship between PTSD symptoms and chronic pain. 14,33,37 However, the present prospective design extends these findings by examining the trajectory of the predictive relationship between PTSD symptoms and chronic neuropathic pain. Importantly, the significant contribution that symptoms of PTSD make in predicting chronic moderate-to-severe neuropathic pain is not evident immediately after injury but is evident at least 4 months later. ...
Traumatic musculoskeletal injury results in a high incidence of chronic pain, however, there is little evidence about the nature, quality, and severity of the pain. This study uses a prospective, observational, longitudinal design to (1) examine neuropathic pain symptoms, pain severity, pain interference, and pain management at hospital admission and 4 months after traumatic musculoskeletal injury (n = 205), and (2) to identify predictors of group membership for patients with differing moderate-to-severe putative neuropathic pain trajectories. Data were collected on mechanism of injury, injury severity, pain (intensity, interference, neuropathic quality), anxiety (anxiety sensitivity, general anxiety, pain catastrophizing, pain anxiety), depression, and posttraumatic stress while patients were in-hospital and 4-months after injury. A third of patients had chronic moderate-to-severe neuropathic pain 4-months after injury. Specifically, 11% of patients developed moderate-to-severe pain by 4-months and 21% had symptoms immediately following injury that persisted over time. Significant predictors of the development and maintenance of moderate-to-severe neuropathic pain included high levels of general anxiety while in-hospital immediately following injury (p <.001) and symptoms of posttraumatic stress 4-months after injury (p <.001). Few patients had adequate pharmacological, physical, or psychological pain management in-hospital and at 4-months. Future research is needed among trauma patients to better understand the development of chronic pain and to determine the best treatment approaches.
... Additionally, the patient's poor socioeconomic status resulted in financial, social, and emotional costs, worsening the patient's illness, and a measure of depression. 22 Additionally, recent research indicates that the longer an illness goes untreated, the greater the likelihood of depression. 23 However, another study found no significant link between education, socioeconomic status, and depression. ...
Depression is a common psychiatric disorder in trauma patients. Early detection of depression in a traumatized patients can help alleviate long-term symptoms and adverse effects associated with depression. This study aimed to determine the prevalence of depression and suicidal ideation in trauma patients after one month of injury.
Hospital-based cross-sectional study was carried out among 120 individuals with a history of trauma from March 2020 to May 2020. Purposive sampling was used to recruit participants over a specified period. The Beck's Depression Inventory-II (BDI-II) was used to measure depression intensity and suicidal ideation. The statistical analysis was carried out using SPSS version 20.
The study included a total of 120 participants. The prevalence of depression was 30% in study participants. In our study, 8 (44.44%) of 18 participants over the age of 60, 30 (36.59%) of 82 male participants, 9 (64.29%) of 14 separated or divorced participants, 17 (45.95%) of 37 illiterate participants, 25 (43.86%) of 57 participants from low socioeconomic backgrounds, and 23 (42.59%) of 54 participants from rural backgrounds had more depression. Twenty (46.51%) out of 43 polytrauma participants, 5 (45.45%) out of 11 participants injured due to violence, 31 (33.70%) out of 92 participants who had a history of more than 48 hrs hospitalization, and 17 (48.57%) out of 35 participants had a history of ICU admission had more depression. Twenty-one participants (58.33%) of the 36 who suffered from depression had suicidal thoughts or intentions.
Suicidal ideation and depression were more common in traumatic patients. Physicians' treatment should not be limited to early physical rehabilitation. They must also prioritise early mental rehabilitation in order to avoid long-term issues with mental and physical disabilities.
... Another study reported high risk of persistent pain in patient with high levels of general anxiety and post-traumatic stress symptoms [22]. Moreover, several studies had reported a positive relationship between post-traumatic stress symptoms and chronic pain [35][36][37][38]. ...
Background:
Musculoskeletal (MSK) injury is one of the major causes of persistent pain.
Objective:
This systematic literature review explored the factors that lead to persistent pain following a MSK injury in the general population, including athletes.
Methods:
A primary literature search of five electronic databases was performed to identify cohort, prospective, and longitudinal trials. Studies of adults who diagnosed with a MSK injury, such as sprains, strains or trauma, were included.
Results:
Eighteen studies involving 5372 participants were included in this review. Participants' ages ranged from 18-95 years. Most of the included studies were of prospective longitudinal design. Participants had a variety of MSK injuries (traumatic and non-traumatic) causing persistent pain. Multiple factors were identified as influencing the development of persistent pain following a MSK injury, including high pain intensity at baseline, post-traumatic stress syndrome, presence of medical comorbidities, and fear of movement. Scarcity of existing literature and the heterogeneity of the studies made meta-analysis not possible.
Conclusions:
This systematic review highlighted factors that might help predict persistent pain and disability following MSK injury in the general population, including athletes. Identification of these factors may help clinicians and other health care providers prevent the development of persistent pain following a MSK injury.
... This is in accordance with similar studies on trauma patients showing an association between PTS symptoms/PTSD and chronic pain. [39][40][41] In addition, we found an association between traumatic ICU memories and higher pain intensity. To our knowledge, this finding has not previously been demonstrated. ...
Background:
Pain is a serious problem for intensive care unit (ICU) patients, but we are lacking data on pain at the hospital ward after ICU discharge.
Aims and objectives:
To describe pain intensity, -interference with function and -location in patients up to 1 year after ICU discharge. To identify demographic and clinical variables and their association with worst pain intensity and pain interference.
Design:
A longitudinal descriptive secondary analysis of a randomized controlled trial on nurse-led follow-up consultations on post-traumatic stress and sense of coherence after ICU discharge.
Methods:
Pain intensity, -interference, and -location were measured using Brief Pain Inventory at the hospital ward and 3, 6, and 12 months after ICU discharge. For associations, data were analysed using multivariate linear mixed models for repeated measures.
Results:
Of 523 included patients, 68% reported worst pain intensity score above 0 (no pain) at the ward. Estimated means for worst pain intensity and -interference (from 0 to 10) after ICU discharge were 5.5 [CI 4.6-6.5] and 4.5 [CI 3.7-5.3], and decreased to 3.8 [CI 2.8-4.8] (P ≤ .001) and 2.9 [CI 2.1-3.7] after 12 months (P ≤ .001). Most common pain locations were abdomen (43%), lower lumbar back (28%), and shoulder/forearm (22%). At 12 months, post-traumatic stress (PTS) symptoms ≥25 (scale 10-70), female gender, shorter ICU stay, and more traumatic ICU memories were significantly associated with higher worst pain intensity. PTS symptoms ≥25, female gender, more traumatic ICU memories, younger age, and not having an internal medical diagnosis were significantly associated with higher pain interference.
Conclusions:
Early after ICU discharge pain was present in 68% of patients. Thereafter, pain intensity and -interference declined, but pain intensity was still at a moderate level at 12 months. Health professionals should be aware of patients' pain and identify potentially vulnerable patients.
Implication for practice:
Longitudinal assessment of factors associated with pain early after ICU discharge and the following year is a first step that could improve follow-up focus and contribute to reduced development of chronic pain.
... For the present study, only the responses in relation to having "experienced any of the following events more than 12 months ago" were analyzed. The justification for considering only life events that occurred "more than 12 months ago" was that we wanted to exclude any acute body pain that may be associated with a recent event [30]. Missing data were not included in the analyses. ...
Objective
To assess whether body pain was associated with different trauma histories (physical injury vs. interpersonal injury [IPI]) within Australian women, along with body pain and trauma history associations with biological and psychological (biopsycho) confounders.
Methods
A retrospective cross-sectional analysis was conducted on the Australian Longitudinal Study on Women’s Health (ALSWH) 1973–1978 birth cohort wave 6 data. Relevant life events were categorized into two types of traumatic experience and included as exposure variables in a multinomial regression model for body pain subgroups. Also, subgroup analyses considered trauma and pain effects and interactions on biopsycho burden.
Results
The unadjusted multinomial regression model revealed that a history of physical injury was found to be significantly associated with body pain severity, as was a history of IPI trauma. After the model was adjusted to include biopsycho confounders, the association between IPI and body pain was no longer significant, and post hoc analysis revealed the relationship was instead mediated by biopsycho confounders. Women with a history of IPI and body pain were also found to have the greatest biopsycho (physical functioning, stress, anxiety, and depression) burden.
Discussion
The relationship between IPI and body pain was found to be mediated by biopsycho burden, whereas the relationship between physical injury and body pain was not. Also, a history of IPI was associated with a greater biopsycho burden than was a history of physical injury. These results suggest there is clinical value in considering the comprehensive trauma history of patients with pain when developing their biopsychosocial model of care.
... Over the last decade, research has made considerable strides in understanding the determinants of chronic pain. Risk factors include sociodemographic factors [3,9], adverse childhood experiences [10][11][12][13][14], personality traits [15][16][17], psychological factors [18][19][20][21], and physical factors [22][23][24][25]. ...
Objectives
The FUTUREPAIN study develops a short general-purpose questionnaire, based on the biopsychosocial model, to predict the probability of developing or maintaining moderate-to-severe chronic pain 7–10 years into the future.
Methods
This is a retrospective cohort study. Two-thirds of participants in the National Survey of Midlife Development in the United States were randomly assigned to a training cohort used to train a predictive machine learning model based on the least absolute shrinkage and selection operator (LASSO) algorithm, which produces a model with minimal covariates. Out-of-sample predictions from this model were then estimated using the remaining one-third testing cohort to determine the area under the receiver operating characteristic curve (AUROC). An optimal cut-point that maximized sensitivity and specificity was determined.
Results
The LASSO model using 82 variables in the training cohort, yielded an 18-variable model with an out-of-sample AUROC of 0.85 (95% Confidence Interval (CI): 0.80, 0.91) in the testing cohort. The sum of sensitivity (0.88) and specificity (0.76) was maximized at a cut-point of 17 (95% CI: 15, 18) on a 0–100 scale where the AUROC was 0.82.
Discussion
We developed a short general-purpose questionnaire that predicts the probability of an adult having moderate-to-severe chronic pain in 7-to-10 years. It has diagnostic ability greater than 80% and can be used regardless of whether a patient is currently experiencing chronic pain. Knowing which patients are likely to have moderate-to-severe chronic pain in the future allows clinicians to target preventive treatment.
... Patients with a pre-LBP lifetime diagnosis of PTSD had a significantly increased risk of transitioning from acute to chronic LBP by 6 months. Jenewein and colleagues [31] found that PTSD was related to the development of chronic pain following motor vehicle accidents (MVA). In a second study, Jenewein and colleagues [32] found that at each of three time points, people with severe PTSD had higher pain intensity. ...
PTSD symptoms and other negative psychosocial factors have been implicated in the transition from acute to persistent pain. Women (N = 375) who presented to an inner-city Emergency Department (ED) with complaints of acute pain were followed for 3 months. They completed a comprehensive battery of questionnaires at an initial visit, and provided ratings of pain intensity at the site of pain presented in the ED during 3 monthly phone calls. Latent class growth analyses were used to detect possible trajectories of change in pain intensity from initial visit to 3 months later. A 3-trajectory solution was found which identified three groups of participants. One group (early recovery; n = 93) had recovered to virtually no pain by the initial visit, whereas a second group (delayed recovery; n = 120) recovered to no pain only after one month. A third group (no recovery; n = 162) still reported elevated pain at 3-months post ED visit. The no recovery group reported significantly greater PTSD symptoms, anger and sleep disturbance, as well as lower social support, at initial visit than both the early recovery and delayed recovery groups. Results suggest that women with high levels of PTSD symptoms, anger, sleep disturbance and low social support who experience an acute pain episode serious enough to prompt an ED visit may maintain elevated pain at this pain site for at least three months. Such an array of factors may place women at increased risk of developing persistent pain following acute pain.
... This study also points to the possible importance of early intervention in people with traumatic injury to help protect against psychological symptomology that may contribute to chronic pain development and maintenance. Prior work showed that in a sample of individuals who had sustained severe injuries, those who developed chronic pain had increased levels of PTSD symptoms and mood disturbance and that the differentiation of outcomes appeared to occur mostly within the first 12 months postinjury [54]. Other research conducted in a rehabilitation setting, suggested patients with traumatic onset of pain with high levels of psychological distress including PTSD symptoms and pain catastrophizing could most benefit from early intervention within the first 3 months [22]. ...
Background and aims
A sizable body of research has elucidated the significant role of psychological reactions to trauma on pain coping and outcomes. In order to best inform intervention development and clinical care for patients with both trauma and pain at the tertiary care level, greater clarity is needed regarding the magnitude of these effects and the specific pathways through which they may or may not function at the time of first presentation to such a treatment setting. To achieve this, the current study examined the cross-sectional relationships between traumatic etiology of pain, psychological distress (anger, depressive symptoms, and PTSD symptoms), and pain outcomes (pain catastrophizing, physical function, disability status).
Methods
Using a structural path modeling approach, analyses were conducted using a large sample of individuals with chronic pain ( n = 637) seeking new medical evaluation at a tertiary pain management center, using the Collaborative Health Outcomes Information Registry (CHOIR). We hypothesized that the relationships between traumatic etiology of pain and poorer pain outcomes would be mediated by higher levels of psychological distress.
Results
Our analyses revealed modest relationships between self-reported traumatic etiology of pain and pain catastrophizing, physical function, and disability status. In comparison, there were stronger relationships between indices of psychological distress and pain catastrophizing, but a weaker pattern of associations between psychological distress and physical function and disability measures.
Conclusions
To the relatively small extent that self-reported traumatic etiology of pain correlates with pain-related outcomes, these relationships appear to be due primarily to the presence of psychiatric symptoms and manifest most notably in the context of psychological responses to pain (i.e. catastrophizing about pain).
Implications
Findings from this study highlight the need for early intervention for patients with traumatic onset of pain and for clinicians at tertiary pain centers to include more detailed assessments of psychological distress and trauma as a component of comprehensive chronic pain treatment.
... Moreover, most people who had delayed RTW resumed employment by 12 months post-injury. Therefore, these observations may simply reflect the highly variable recovery patterns typically observed in the first 6 months after orthopaedic and major trauma, with divergent occupational outcomes only becoming apparent at 12 months post-injury [4,39]. ...
Purpose To characterise associations between fault attribution and work participation and capacity after road traffic injury. Methods People aged 15–65 years, working pre-injury, without serious brain injury, who survived to 12 months after road traffic injury were included from two Victorian trauma registries (n = 2942). Fault profiles from linked compensation claims were defined as no other at fault, another at fault, denied another at fault, claimed another at fault, and unknown. Claimant reports in the denied and claimed another at fault groups contradicted police reports. Patients reported work capacity (Glasgow outcome scale-extended) and return to work (RTW) at 6, 12 and 24 months post-injury (early and sustained RTW, delayed RTW (≥ 12 months), failed RTW attempts, no RTW attempts). Analyses adjusted for demographic, clinical and injury covariates. Results The risk of not returning to work was higher if another was at fault [adjusted relative risk ratio (aRRR) = 1.67, 95% confidence interval (CI) 1.29, 2.17] or was claimed to be at fault (aRRR = 1.58, 95% CI 1.04, 2.41), and lower for those who denied that another was at fault (aRRR = 0.51, 95% CI 0.29, 0.91), compared to cases with no other at fault. Similarly, people had higher odds of work capacity limitations if another was at fault (12m: AOR = 1.49, 95% CI 1.24, 1.80; 24m: 1.63, 95% CI 1.35, 1.97) or was claimed to be at fault (12m: AOR = 1.54, 95% CI 1.16, 2.05; 24m: AOR = 1.80, 95% CI 1.34, 2.41), and lower odds if they denied another was at fault (6m: AOR = 0.67, 95% CI 0.48, 0.95), compared to cases with no other at fault. Conclusion Targeted interventions are needed to support work participation in people at risk of poor RTW post-injury. While interventions targeting fault and justice-related attributions are currently lacking, these may be beneficial for people who believe that another caused their injury.
Graphic Abstract
... The vast majority of these individuals are discharged to home after evaluation and only about 10% are hospitalized [9]. APNS are similar in these two groups of patients [10][11][12][13][14][15][16][17][18][19][20][21][22], which means that the vast majority of APNS cases occur among ER patients who are not hospitalized. A similar pattern is found in the military, where the great majority of APNS cases are found among those who are severely injured [23][24][25][26][27][28][29]. ...
Adverse posttraumatic neuropsychiatric sequelae (APNS) are common among civilian trauma survivors and military veterans. These APNS, as traditionally classified, include posttraumatic stress, postconcussion syndrome, depression, and regional or widespread pain. Traditional classifications have come to hamper scientific progress because they artificially fragment APNS into siloed, syndromic diagnoses unmoored to discrete components of brain functioning and studied in isolation. These limitations in classification and ontology slow the discovery of pathophysiologic mechanisms, biobehavioral markers, risk prediction tools, and preventive/treatment interventions. Progress in overcoming these limitations has been challenging because such progress would require studies that both evaluate a broad spectrum of posttraumatic sequelae (to overcome fragmentation) and also perform in-depth biobehavioral evaluation (to index sequelae to domains of brain function). This article summarizes the methods of the Advancing Understanding of RecOvery afteR traumA (AURORA) Study. AURORA conducts a large-scale (n = 5000 target sample) in-depth assessment of APNS development using a state-of-the-art battery of self-report, neurocognitive, physiologic, digital phenotyping, psychophysical, neuroimaging, and genomic assessments, beginning in the early aftermath of trauma and continuing for 1 year. The goals of AURORA are to achieve improved phenotypes, prediction tools, and understanding of molecular mechanisms to inform the future development and testing of preventive and treatment interventions.
... 91,93e95 The relationship between pain and psychological distress is, however, bidirectional, which makes determining causality complex. ICU trauma patients with chronic pain report more symptoms of PTSD, depression, and anxiety, 31 and patients with chronic pain after cardiac surgery self-report lower mental health scores in the SF-36 a year after discharge. 96 However, relationships between those experiencing chronic pain and adverse psychological outcomes after ICU admission are yet to be properly explored, making it difficult to tease out the influence of the ICU environment, the cause of ICU admission, psychological factors, and pain on each other. ...
Chronic pain is an important problem after critical care admission. Estimates of the prevalence of chronic pain in the year after discharge range from 14% to 77% depending on the type of cohort, the tool used to measure pain, and the time point when pain was assessed. The majority of data available come from studies using health-related quality of life tools, although some have included pain-specific tools. Nociceptive, neuropathic, and nociplastic pain can occur in critical care survivors, but limited information about the aetiology, body site, and temporal trajectory of pain is currently available. Older age, pre-existing pain, and medical co-morbidity have been associated with pain after critical care admission. No trials were identified of interventions to target chronic pain in survivors specifically. Larger studies, using pain-specific tools, over an extended follow-up period are required to confirm the prevalence, identify risk factors, explore any association between acute and chronic pain in this setting, determine the underlying pathological mechanisms, and inform the development of future analgesic interventions.
... Lower extremity trauma (ET) is one of the most painful types of injury [1,2]. An important proportion of patients who have suffered major lower ET (i.e., patients requiring hospitalization for surgical and multidisciplinary team acute care management) [3] develop chronic pain [4][5][6][7] with substantial participation restriction in selfcare, work, and social activities for six months or more [5][6][7][8][9][10][11][12][13]. ...
Objective:
1) To assess the feasibility of research methods to test a self-management intervention aimed at preventing acute to chronic pain transition in patients with major lower extremity trauma (iPACT-E-Trauma) and 2) to evaluate its potential effects at three and six months postinjury. Design. A pilot randomized controlled trial (RCT) with two parallel groups.
Setting:
A supraregional level 1 trauma center.
Methods:
Fifty-six adult patients were randomized. Participants received the intervention or an educational pamphlet. Several parameters were evaluated to determine the feasibility of the research methods. The potential efficacy of iPACT-E-Trauma was evaluated with measures of pain intensity and pain interference with activities.
Results:
More than 80% of eligible patients agreed to participate, and an attrition rate of ≤18% was found. Less than 40% of screened patients were eligible, and obtaining baseline data took 48 hours postadmission on average. Mean scores of mild pain intensity and pain interference with daily activities (<4/10) on average were obtained in both groups at three and six months postinjury. Between 20% and 30% of participants reported moderate to high mean scores (≥4/10) on these outcomes at the two follow-up time measures. The experimental group perceived greater considerable improvement in pain (60% in the experimental group vs 46% in the control group) at three months postinjury. Low mean scores of pain catastrophizing (Pain Catastrophizing Scale score < 30) and anxiety and depression (Hospital Anxiety and Depression Scale scores ≤ 10) were obtained through the end of the study.
Conclusions:
Some challenges that need to be addressed in a future RCT include the small proportion of screened patients who were eligible and the selection of appropriate tools to measure the development of chronic pain. Studies will need to be conducted with patients presenting more serious injuries and psychological vulnerability or using a stepped screening approach.
... Lower extremity trauma (ET) is one of the most painful types of injury [1,2]. An important proportion of patients who have suffered major lower ET (i.e., patients requiring hospitalization for surgical and multidisciplinary team acute care management) [3] develop chronic pain [4][5][6][7] with substantial participation restriction in selfcare, work, and social activities for six months or more [5][6][7][8][9][10][11][12][13]. ...
Objective: To: 1) assess the feasibility of research methods to test a self-management intervention aimed at preventing acute to chronic pain transition in patients with major lower extremity trauma (iPACT-E-Trauma), and 2) evaluate its potential effects at 3 and 6 months post-injury.
Design: A pilot randomized controlled trial (RCT) with two parallel groups.
Setting: A supra-regional level-1 trauma center.
Methods: Fifty-six adult patients were randomized. Participants received the intervention or an educational pamphlet. Several parameters were evaluated to determine the feasibility of the research methods. The potential efficacy of iPACT-E-Trauma was evaluated with measures of pain intensity and pain interference with activities.
Results: More than 80% of eligible patients accepted to participate and an attrition rate ≤ 18% was found. Less than 40% of screened patients were eligible and obtaining baseline data took 48 hours post-admission on average. Mean scores of mild pain intensity and pain interference with daily activities (< 4/10) on average were obtained in both groups at 3 and 6 months post-injury. Between 20% to 30% of participants reported moderate to high mean scores (≥ 4/10) on these outcomes at the two follow-up time measures. The experimental group perceived greater considerable improvement in pain (60% in the experimental group vs 46% in the control group) at 3 months post-injury. Low mean scores of pain catastrophizing (Pain Catastrophizing Scale score < 30), anxiety and depression (Hospital Anxiety and Depression Scale scores ≤ 10) were obtained until the end of the study.
Conclusions: Some challenges that will require to be addressed in a future RCT include the small proportion of screened patients who were eligible and the selection of appropriate tools to measure the development of chronic pain. Studies will need to be conducted with patients presenting more serious injuries and psychological vulnerability or using a stepped screening approach.
... It is well documented that brain injury [8][9][10] and PTSD 11,12 commonly occur after MVC, and that chronic pain syndromes commonly develop after whiplash injuries. 13,14 These MVC-related disorders are believed to occur as a result of many of the same risk factors as those that can complicate blast injuries and other injuries that occur during combat. Pain can occur as a result of direct trauma to ligaments and tendons, with associated muscle spasm and cartilage injury that cannot be diagnosed by conventional diagnostic imaging. ...
Background
The polytrauma clinical triad (PCT) is a complex disorder composed of three comorbid diagnoses of chronic pain, post-traumatic stress disorder (PTSD), and postconcussion syndrome (PCS). PCT has been documented in veterans returning from deployment, but this is the first report on PCT prevalence in nonmilitary personnel after a motor vehicle collision (MVC).
Methods
Data were drawn from routine intake assessments completed by 71 patients referred to a community-based clinic for chronic pain management. All patients completed the post-traumatic stress disorder checklist for the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (PCL-5), and Rivermead Post-Concussion Symptoms Questionnaire (RPQ) during a standardized intake assessment. An additional modified RPQ score was derived to address previously reported symptom overlap between PCS and chronic pain.
Results
Standard and modified RPQ scores yielded PCS prevalence rates of 100% and 54.9% in our sample, respectively. Results suggest that a modified RPQ score, limited to visual and vestibular symptoms, may be more useful PCS screening criteria in patients with chronic pain. PTSD screening criteria on the PCL-5 were met by 85.9% of the patients. More than half of the patients referred for chronic pain after MVC met criteria for PCT (52.1%). Patients who met PCT criteria reported worse headache, overall pain, and sleep quality outcomes.
Conclusion
Among patients in our sample with chronic pain after MVC, more than half met criteria for PCT. A modified approach to RPQ scoring limited to visual and vestibular symptoms may be required to screen for PCS in these patients.
... Pain that persists for more than 6 months is re-conceptualized as chronic pain (Merskey & Bogduk, 1994) and serves as a reliable predictor of ongoing impairment and disability (Murgatroyd, Harris, Tram, & Cameron, 2016;O'Donnell et al., 2013). Chronic pain is a common consequence of MVCs, with estimates suggesting that between 40 and 45% of persons injured in MVCs experience chronic pain (Jenewein et al., 2009;Mayou & Bryant, 2001;McLean et al., 2014). Although there is high agreement among the prevalence estimates provided by these studies, additional large-scale studies documenting the prevalence of MVCrelated chronic pain as well as the typical course and duration of such pain are needed. ...
Motor vehicle collisions (MVCs) have a significant impact on injured persons and society. MVCs generally result in property damage, but more serious MVCs often result in physical injuries that have significant physical, psychosocial, and cognitive consequences, all of which may result in long-standing functional impairment and disability as well as marked changes in quality of life. This article represents the first part of a two-part review of MVCs; the complex and interactive array of physical, psychosocial, and cognitive changes that occur consequent to injury-causing MVCs; and the person and environmental factors that best predict functional impairment and disability following an MVC. The current article provides an overview of the scope and significance of MVCs and summarizes the literature related to the physical injuries and the physical, psychosocial, and cognitive impairments that are most commonly experienced consequent to MVCs. Physical injuries reviewed in the current article include fractures, whiplash-associated disorders (WADs), traumatic brain injury (TBI), multiple traumatic injuries or polytrauma, and chronic pain conditions. These injuries and conditions are reviewed because of the relative quantity and quality of existing research related to these injuries and conditions. This article also provides a review of those psychological disorders that more commonly begin, recur, or are exacerbated in the aftermath of an MVC. The following psychological disorders are reviewed: posttraumatic stress disorder, complex posttraumatic stress disorder, major depressive disorder, somatic symptom disorder, and major neurocognitive disorder and mild neurocognitive disorder. Finally, this article ends with a brief discussion of changes in quality of life that can occur in relation to the physical injuries and psychological and neurocognitive disorders that are common consequences of MVCs. The final section of this article will serve to introduce part II of this review of MVCs and their consequences, in which predictors of MVC-related impairment and disability are discussed.
... Although more research is warranted, this study may provide an explanation as to why individuals suffering from high traumatic stress report higher pain levels. Recent studies suggest that it is posttraumatic stress that influences (chronic) pain and not the other way around (Brown et al., 2014;Jenewein et al., 2009;Van Loey et al., 2018). A recent study showed that OT receptors in nociceptive terminals can inhibit nociceptive input (Gonzalez-Hernandez et al., 2017) suggesting avenues for pain improvement at skin level. ...
Objective:
Pain and traumatic stress symptoms often co-occur. Evidence suggests that the neuropeptide oxytocine and pro-inflammatory cytokines are associated with both stress and pain. The aim of this pilot study was to explore relations between self-reported pain and traumatic stress, oxytocin and three cytokines in burn wounds.
Methods:
An observational study in three burn centres was performed. Patients were invited to participate in the study when deep dermal injury was suspected. Patients completed the Impact of Event Scale (IES), a self-report questionnaire assessing traumatic stress symptoms, and they rated their pain the day prior to surgery. During surgery, eschar (i.e., burned tissue) was collected and stored at -80 ° C until analysis. When the data collection was complete, oxytocin and cytokine levels were analysed.
Results:
Eschar from 53 patients was collected. Pain and stress scores were available from 42 and 36 patients respectively. Spearman correlational analyses showed an association between lower oxytocin levels at wound site and a higher total IES score (r = -0.37) and pain (r = -0.32). Mann-Whitney U tests comparing groups scoring high or low on pain or stress confirmed these associations.
Conclusion:
These analyses lend support to a hormonal pathway that may explain how psychological distress affects pain at skin level in patients with traumatic stress symptoms.
... Orthopedics 36 TKA patients using chronic preoperative opioids had significantly worse pain 6 months postoperatively compared to 120 non-opioid-using controls Waljee et al. 2017 General surgery 17,577 patients using chronic preoperative opioids had significantly longer hospital LOS, increased incidence of discharge to rehabilitation facilities and hospital readmission, and generated significantly higher financial expenditures than 182,428 controls Villavicencio et al. 2017 Spine 60 TLIF patients using chronic preoperative opioids had significantly greater 12-month postoperative pain and disability compared to 33 non-opioid-using controls Rozell et al. 2017 Orthopedics 275 TKA and THA patients using chronic preoperative opioids (compared to 527 controls) were shown in a regression model to be more likely to require increase perioperative opioids and increased hospital LOS as well as suffer higher incidence of complications Chan et al. 2017 Orthopedics 36 TKA patients maintained on methadone preoperatively required greater postoperative opioids and inpatient pain management consultation, and had increased hospital LOS compared to 36 matched controls Cheah et al. 2017 Orthopedics 138 TSA patients using chronic preoperative opioids had significantly greater postoperative pain and opioid use compared to 124 non-opioid-using controls Gureje et al. 2008;Bushnell et al. 2013;Simons et al. 2014). The reported severity of such chronic pain has been shown to correlate much more closely with these psychosocial variables than with somatic contributors including injury severity, which has in fact been shown in several studies to be non-predictive (Harris et al. 2007;Jenewein et al. 2009;Trevino et al. 2013). These psychological/behavioral comorbidities have also been shown to predict chronic postoperative pain specifically (Kleiman et al. 2011;Theunissen et al. 2012;Attal et al. 2014;Hoofwijk et al. 2015). ...
... This study suggests that catastrophizing also mediated the effect of acute PTSD symptoms on chronic pain. This pathway was previously reported after whiplash injury (Andersen et al., 2016) and fits within the growing body of knowledge that, particularly after 6 months, PTSD contributes to pain, rather than the other way around (Jenewein et al., 2009;Brown et al., 2014). When acute PTSD symptoms and other consequences of the traumatic event are catastrophized, this will increase distress and produce a sense of current threat (Ehlers and Clark, 2000). ...
Background:
Pain and PTSD symptoms are significant problems in the aftermath of a burn injury and they often co-occur. Catastrophizing has been linked to both phenomena. The aim of this study was to investigate the underlying role of catastrophizing in PTSD symptoms and pain following burns.
Methods:
This prospective study included 216 patients with burns. PTSD symptoms and pain were measured during hospitalization (T1) and 6 (T2) and 12 months (T3) postburn. The Impact of Event Scale-Revised (IES-R) indexed PTSD symptoms. Acute pain (T1) was the mean pain during the first two weeks of hospitalization measured using an 11-point graphic numeric rating scale. Chronic pain was indexed using the single item 'average' pain from the Brief Pain Inventory (BPI). Catastrophizing was measured at T1 and T2 using the Cognitive Emotion Regulation Questionnaire (CERQ). Data were analyzed using structural equation modeling (SEM).
Results:
The results showed that T2 catastrophizing mediated between acute and chronic PTSD symptoms, and T3 pain. Furthermore, the study revealed significant associations between catastrophizing, PTSD symptoms and pain at the respective measurements, and significant longitudinal associations between the constructs.
Conclusion:
A negative cognitive-affective response to a burn event, such as catastrophizing, mediated the relationship acute and chronic PTSD symptoms and later chronic pain. Screening for catastrophizing and acute PTSD symptoms is recommended to identify persons at risk for chronic PTSD symptoms and pain. This article is protected by copyright. All rights reserved.
... Furthermore, in adult veterans, combat exposure and post-traumatic stress disorder (PTSD) have been shown to have the strongest statistical association with chronic pain 23,24 . PTSD, a psychiatric condition resulting from exposure to a traumatic event and characterized by hyperarousal, avoidance, and reexperiencing, is not only a risk factor for chronic pain 71,72 , but is associated with increased risk for the transition from acute to chronic pain. It is also associated with elevated pain severity and disability among abuse victims 73,74 . ...
The biopsychosocial model of pain dominates the scientific community's understanding of chronic pain. Indeed, the biopsychosocial approach describes pain and disability as a multidimensional, dynamic integration among physiological, psychological, and social factors that reciprocally influence one another. In this article, we review two categories of studies that evaluate the contributions of psychosocial factors to the experience of chronic pain. First, we consider general psychosocial variables including distress, trauma, and interpersonal factors. Additionally, we discuss pain-specific psychosocial variables including catastrophizing, expectations, and pain-related coping. Together, we present a diverse array of psychological, social, and contextual factors and highlight the need to consider their roles in the development, maintenance, and treatment of chronic pain conditions.
... Orthopedics 36 TKA patients using chronic preoperative opioids had significantly worse pain 6 months postoperatively compared to 120 non-opioid-using controls Waljee et al. 2017 General surgery 17,577 patients using chronic preoperative opioids had significantly longer hospital LOS, increased incidence of discharge to rehabilitation facilities and hospital readmission, and generated significantly higher financial expenditures than 182,428 controls Villavicencio et al. 2017 Spine 60 TLIF patients using chronic preoperative opioids had significantly greater 12-month postoperative pain and disability compared to 33 non-opioid-using controls Rozell et al. 2017 Orthopedics 275 TKA and THA patients using chronic preoperative opioids (compared to 527 controls) were shown in a regression model to be more likely to require increase perioperative opioids and increased hospital LOS as well as suffer higher incidence of complications Chan et al. 2017 Orthopedics 36 TKA patients maintained on methadone preoperatively required greater postoperative opioids and inpatient pain management consultation, and had increased hospital LOS compared to 36 matched controls Cheah et al. 2017 Orthopedics 138 TSA patients using chronic preoperative opioids had significantly greater postoperative pain and opioid use compared to 124 non-opioid-using controls Gureje et al. 2008;Bushnell et al. 2013;Simons et al. 2014). The reported severity of such chronic pain has been shown to correlate much more closely with these psychosocial variables than with somatic contributors including injury severity, which has in fact been shown in several studies to be non-predictive (Harris et al. 2007;Jenewein et al. 2009;Trevino et al. 2013). These psychological/behavioral comorbidities have also been shown to predict chronic postoperative pain specifically (Kleiman et al. 2011;Theunissen et al. 2012;Attal et al. 2014;Hoofwijk et al. 2015). ...
The practice of chronic opioid prescription for chronic non-cancer pain has come under considerable scrutiny within the past several years as mounting evidence reveals a generally unfavorable risk to benefit ratio and the nation reels from the grim mortality statistics associated with the opioid epidemic. Patients struggling with chronic pain tend to use opioids and also seek out operative intervention for their complaints, which combination may be leading to increased postoperative “acute-on-chronic” pain and fueling worsened chronic pain and opioid dependence.
Besides worsened postoperative pain, a growing body of literature, reviewed herein, indicates that preoperative opioid use is associated with significantly worsened surgical outcomes, and severely increased financial drain on an already severely overburdened healthcare budget. Conversely, there is evidence that preoperative opioid reduction may result in substantial improvements in outcome. In the era of accountable care, efforts such as the Enhanced Recovery After Surgery (ERAS) protocol have been introduced in an attempt to standardize and facilitate evidence-based perioperative interventions to optimize surgical outcomes. We propose that addressing preoperative opioid reduction as part of a targeted optimization approach for chronic pain patients seeking surgery is not only logical but mandatory given the stakes involved. Simple opioid reduction/abstinence however is not likely to occur in the absence of provision of viable and palatable alternatives to managing pain, which will require a strong focus upon reducing pain catastrophization and bolstering self-efficacy and resilience.
In response to a call from our surgical community toward that end, we have developed a simple and easy-to-implement outpatient preoperative optimization program focusing on gentle opioid weaning/elimination as well as a few other high-yield areas of intervention, requiring a minimum of resources.
... According to this model, persons with PTSD experience exacerbating pain because they use avoidance as a coping strategy, have reduced activity levels, and attentional biases towards perceiving stimuli as implying danger. This model has received some empirical support among injured patients (Jenewein et al., 2009;Liedl et al., 2010) and in persons exposed to childhood abuse (Raphael, Spatz, & Widom, 2011). ...
Background: Trauma exposure and post-traumatic stress disorder (PTSD) are risk factors for chronic pain.
Objective: This study investigated how exposure to intentional and non-intentional traumatic events and PTSD are related to pain severity and outcome of treatment in chronic pain patients.
Methods: We assessed exposure to potentially traumatizing events, psychiatric diagnosis with structured clinical interview, and pain severity in 63 patients at a secondary multidisciplinary pain clinic at the beginning of treatment, and assessed level of pain at follow up. Exposure to potentially traumatizing events and PTSD were regressed on pain severity at the initial session and at follow up in a set of multiple regression analysis.
Results: The participants reported exposure to an average of four potentially traumatizing events, and 32% had PTSD. Exposure to intentional traumatic events and PTSD were significantly associated with more severe pain, and PTSD significantly moderated the relationship between trauma exposure and pain (all p < .05). The treatment programme reduced pain moderately, an effect that was unrelated to trauma exposure and PTSD.
Conclusions: Trauma exposure is related to chronic pain in the same pattern as to mental disorders, with intentional trauma being most strongly related to pain severity. PTSD moderated the relationship between trauma exposure and pain. While pain patients with PTSD initially report more pain, they responded equally to specialist pain treatment as persons without PTSD.
... Psychological mechanisms underlying this process include exacerbated pain perception due to elevated anxiety (9). For instance, the development of chronic pain in patients with PTSD after severe accidents has been associated more strongly with PTSD symptoms than other accident-related variables, like the type of accident, or like the Injury Severity Score or Glasgow Coma Scale score immediately post accident (14,15). Others have proposed shared vulnerability underlying the comorbidity of PTSD and pain (3), like the abnormal processing of threat cues. ...
There is growing evidence that fear-learning abnormalities are involved in the development of posttraumatic stress disorder (PTSD) and chronic pain. More than 50% of PTSD patients suffer from chronic pain. This study aimed to examine the role of fear-learning deficits in the link between pain perception and PTSD. We included 19 subjects with PTSD and 21 age- and sex-matched healthy control subjects in a fear-conditioning experiment. The conditioned stimulus (CS) consisted of visual signs flashed upon a screen in front of each subject. The unconditioned stimulus was either a low or high temperature impulse delivered through a thermal contact thermode on the subjects' hand. A designation of 'CS-' was assigned to CS always followed by nonpainful low-temperature stimuli; a designation of 'CS+' was given to CS that were randomly followed by either a low or a more painful high temperature. Skin conductance was used as a physiological marker of fear. In healthy control subjects, CS+ induced more fear than CS-, and a low-temperature stimulus induced less subjective pain after CS- than after CS+. PTSD subjects failed to demonstrate such adaptive conditioning. Fear ratings after CS presentation were significantly higher in the PTSD group than in the control group. There were significant interaction effects between group and the type of CS on fear and pain ratings. Fear-learning deficits are a potentially promising, specific psychopathological factor in altered pain perception associated with PTSD. Deficits in safety learning may increase fear and, consequently, pain sensations. These findings may contribute to elucidating the pathogenesis behind the highly prevalent comorbidity that exists between PTSD and pain disorders, and to developing new treatments.
Perspective:
This study provides new insights into the pathogenesis of chronic pain in patients with PTSD. The findings may help to develop new treatment strategies for this highly prevalent comorbidity in PTSD.
... Traumatische Verletzungen sind der häufigste Grund für Behinderungen und Langzeiteinschränkungen von Patienten im arbeitsfähigen Alter [11,21]. Noch Jahre nach dem Trauma berichten Patienten regelhaft über fortbestehende Schmerzen [4,7,12,16,17,19,20]. Je nach untersuchtem Kollektiv und Untersuchungszeitpunkt leiden 33-63 % der Schwerverletzten im Langzeitverlauf unter Schmerzen [4,6,7,16,19]. Jedoch sind den Autoren keine Studien bekannt, die untersuchen, wie viele der Schwerverletzten ambulant dauerhaft Schmerzmedikamente einnehmen oder sich bei einem Schmerztherapeuten vorgestellt haben. ...
Background and objectives
Trauma patients often suffer from persisting pain even years after injury, and data on long-term pain management is lacking. The aim of this study was to evaluate the frequency of persisting pain and health-related quality of life (HrQoL) among trauma victims 2 years after injury. Furthermore, the frequency of pain specialist consultation and the quality of outpatient pain management, including phamacological management, was assessed.
Materials and methods
We analyzed prospectively collected data on severely injured adult patients treated between 2008–2011 at the Cologne Merheim Medical Center (CMMC)/Germany. Data included the ‘Polytrauma Outcome Profile’ and a standardized questionnaire on outpatient pain management. Exclusion criteria were death, inability to answer the questionnaire due to cognitive disabilities and lack of language knowledge.
Results and conclusions
207/391 (53 %) data sets were available for analysis, presenting a typical trauma collective with injury severity of ISS 19, predominantly male and a mean age of 44 years. 2 years after trauma 59 % still reported that they suffered from severe persisting pain; 53 % of these patients were under pharmacological pain medication. Only 1/5 of the patients with severe persisting pain was treated by a pain specialist. Successful treatment options do exist; improvement of treatment is required.
... In contrast to the common notion that patients with minor or no physical injury do not need active rehabilitation or follow-up, Ottosson et al. [4] found that patients with minor injuries reported a low recovery rate and that those patients more often suffered from anxiety or were depressed at the time of the injury. The most common psychological impacts following MVAs are post-traumatic stress disorder (PTSD), depression, anxiety and chronic pain [5][6][7][8][9]. It seems that females more often than males suffer from mental stress following an MVA [10]. ...
Background:
Patients who sustain a motor vehicle accident may experience long-term distress, even if they are uninjured or only slightly injured. There is a risk of neglecting patients with minor or no physical injuries, which might impact future health problems. The aim of this study was to explore patients' subjective experiences and perspectives on pain and other factors of importance after an early nursing intervention consisting of "caring touch" (tactile massage and healing touch) for patients subjected to a motor vehicle accident with minor or no physical injuries.
Methods:
A mixed method approach was used. The qualitative outcomes were themes derived from individual interviews. The quantitative outcomes were measured by visual analogue scale for pain (VAS, 0-100), sense of coherence (SOC), post-traumatic stress (IES-R) and health status (EQ-5D index and EQ-5D self-rated health). Forty-one patients of in total 124 eligible patients accepted the invitation to participate in the study. Twenty-seven patients completed follow-up after 6 months whereby they had received up to eight treatments with either tactile massage or healing touch.
Results:
Patients reported that caring touch may assist in trauma recovery by functioning as a physical "anchor" on the patient's way of suffering, facilitating the transition of patients from feeling as though their body is "turned off" to becoming "awake". By caring touch the patients enjoyed a compassionate care and experience moments of pain alleviation. The VAS pain ratings significantly decreased both immediately after the caring touch treatment sessions and over the follow-up period. The median scores for VAS (p < 0.001) and IES-R (p 0.002) had decreased 6 months after the accident whereas the EQ-5D index had increased (p < 0.001). There were no statistically significant differences of the SOC or EQ-5D self-rated health scores over time.
Conclusions:
In the care of patients suffering from a MVA with minor or no physical injuries, a caring touch intervention is associated with patients' report of decreased pain and improved wellbeing up to 6 months after the accident.
Trial registration:
ClinicalTrials.gov Id: NCT02610205 . Date 25 November 2015.
... Although more research is warranted, this study may provide an explanation as to why individuals suffering from high traumatic stress report higher pain levels. Recent studies suggest that it is posttraumatic stress that influences (chronic) pain and not the other way around (Brown et al., 2014;Jenewein et al., 2009;Van Loey et al., 2018). A recent study showed that OT receptors in nociceptive terminals can inhibit nociceptive input (Gonzalez-Hernandez et al., 2017) suggesting avenues for pain improvement at skin level. ...
Background and objective:
Traumatic injuries are among the leading causes of death and disability in the world across all age groups. This systematic review aimed to (1) describe the role of post-traumatic stress symptoms (PTSS) on the development of chronic pain and/or pain-related disability following musculoskeletal trauma, and (2) report pain and or pain-related disability by injury severity/type.
Database and data treatment:
Electronic databases were searched, from inception to 31st November 2021 and updated on the 10th May 2022, to identify studies in which: participants were adults aged ≥16 years sustaining any traumatic event that resulted in one or more musculoskeletal injuries; an outcome measure of PTSS was used within three months of a traumatic event; and the presence of pain and/or pain-related disability was recorded at a follow-up of three months or more. Two reviewers independently screened papers and assessed the quality of included studies.
Results:
Eight studies were included. Owing to between-study heterogeneity, the results were synthesised using a narrative approach. Five studies investigated the relationship between PTSS and pain. Participants with PTSS were more likely to develop persistent pain for at least 12 months post-injury. Six studies assessed the relationship between PTSS and pain-related disability. The results suggest that patients with PTSS had significantly higher disability levels for at least 12-months post-injury.
Conclusion:
Findings from this comprehensive systematic review support a clear relationship between PTSS post-injury and future pain/disability, with potential importance of certain PTSS clusters (hyper-arousal and numbing).
Objective
Pain is a common outcome after lower extremity fracture requiring surgical fixation (LEF). Although psychosocial characteristics have meaningful associations with adverse outcomes, no studies have evaluated how psychosocial characteristics throughout recovery are associated with pain outcomes. The primary purpose of this study was to determine whether psychosocial characteristics are early risk factors for pain outcomes in patients following LEF who have no history of chronic pain.
Methods
Participants were 122 patients with a LEF consented to this single center, prospective cohort study. Measurements of depression, pain self-efficacy, pain catastrophizing, and fear of movement were completed at 1 week, 6 weeks, 3 months, 6 months, and 12 months after LEF. Chronic pain development and pain intensity were assessed at 12 months. Univariate analyses assessing difference between means and corresponding effect sizes were evaluated between those individuals with and without chronic pain at 12 months. Separate logistic and linear regression models using psychosocial scores at each time point were used to determine the association with the development of chronic pain and pain intensity, respectively.
Results
Of 114 patients (93.4%) who completed the study, 51 (45%) reported chronic pain at 12 months. In the univariate analysis, all psychosocial variables at 6 weeks, 3 months, 6 months, and 12 months were significantly different between those with and those without chronic pain at 12 months (Cohen d range = 0.84 to 1.65). In the multivariate regression models, all psychosocial variables at 6 weeks, 3 months, and 6 months were associated with chronic pain development (odds ratio range = 1.04 to 1.22) and pain intensity (β range = 0.05 to 0.14) at 12 months.
Conclusions
Psychosocial scores as early as 6 weeks after surgery are associated with pain outcomes 12 months after LEF.
Impact
Physical therapists should consider adding psychosocial screening throughout recovery after LEF to identify patients at increased risk for long-term pain outcomes.
Objective
Disability is common after lower extremity fracture (LEF). While psychosocial factors have been associated with patient-reported outcomes after LEF, they have not been associated with objective measures of function. Aberrant gait patterns are important markers of function, but are poorly defined after LEF. The primary purpose of this study was to explore whether pain catastrophizing and fear of movement 6 weeks after surgery were associated with injured limb loading outcomes and 6-minute walk test (6MWT) distance 12 months after femur or tibia fracture. The secondary purpose was to determine if limb loading characteristics differed between injured and uninjured limbs.
Methods
At 6 weeks after LEF, patients completed validated measures of pain catastrophizing, fear of movement, and depression. At 12 months, patients completed a 6MWT while wearing instrumented insoles which recorded the limb loading outcomes of stance time, impulse, and loading rate. Bivariate correlations assessed how patient and psychosocial characteristics at 6 weeks were associated with injured limb loading outcomes and 6MWT distance. Multivariable regression analyses were performed to determine if psychosocial variables were associated with each outcome after controlling for depression and patient demographic and clinical characteristics. Finally, paired t tests compared limb loading outcomes between limbs.
Results
Forty-seven participants completed the 6MWT at 12 months (65%), and 38 completed the 6MWT with the instrumented insoles. Fear of movement carried a poor relationship (r = 0.11–0.32) and pain catastrophizing a moderate relationship (r = 0.46–0.54) with 12-month outcomes. The regression results indicated that pain catastrophizing continued to be associated with all outcomes. Finally, the injured limb had significantly lower limb loading outcomes than the uninjured limb at 12 months (Cohen d = 0.54–0.69).
Conclusion
Pain catastrophizing early after LEF was associated with impaired limb loading and 6MWT distance at 12 months.
Many critically ill patients admitted to an intensive care unit (ICU) experience moderate-to-severe pain during their admission. This includes pain at rest and pain experienced during common ICU procedures. Survivors of critical illness, a population that is growing due to advances in care, often experience chronic pain. While there is growing recognition of chronic pain after ICU admission, fundamental questions remain unanswered. Specifically, is acute pain during critical illness related to the chronic pain that survivors experience? Does this chronic pain, combined with frequent exposure to opioids in the critical care setting, present a risk for post-ICU opioid dependence? As critical care delivery in the twenty-first century is designed to improve both short- and long-term outcomes, these are vital questions for the bedside provider. In this chapter, we review international pain guidelines and the long-term implications of current pain management practices in the ICU. We then explore the epidemiology of pervasive pain following critical illness, with a focus on chronic pain that develops or worsens after an ICU admission. We then consider the impact of chronic post-ICU pain on quality of life and evaluate the existing data regarding changes in opioid use after critical illness. Finally, we conclude by discussing strategies to prevent and mitigate chronic post-ICU pain.
Background
: Patients with lower extremity fracture requiring surgical fixation often have poor long-term pain and disability outcomes. This indicates the need for a risk stratification tool that can inform patient prognosis early in recovery. The purpose of this study was to determine the predictive validity of the STarT-Lower Extremity Screening Tool (STarT-LE) in patients with lower extremity fracture requiring surgical fixation.
Materials and Methods
: One-hundred and twenty-two patients (41.7 ± 14.7 years, 54% male) with lower extremity fracture and no history of chronic pain were enrolled in this prospective cohort study. Patients completed the STarT-LE Screening Tool six-weeks after definitive fixation. Validated measures of chronic pain development, pain interference, and physical function were collected at 12-months. STarT-LE low, medium, and high risk subgroups were compared against each outcome measure with chi-square, one-way analysis of variance, and sensitivity and specificity analyses. Multivariable linear regression analyses determined if STarT-LE risk subgroups at six weeks were associated with each outcome at 12 months when controlling for important baseline demographics.
Results
: Twelve-month follow-up was completed by 114 patients (93.4%). Increase in STarT-LE risk subgroup at six-weeks was associated with higher frequency of chronic pain (Low: 14.7%, Medium: 48.3%, High: 85.0%), worse pain interference (Low: 48.6 ± 8.88, Medium: 56.33 ± 8.79, High: 61.65 ± 7.74), and worse physical function (Low: 50.77 ± 9.89, Medium: 42.52 ± 6.47, High: 37.44 ±7.46) at 12-months. The low risk subgroup had high sensitivity (range: 84.9%-93.9%) and the high risk subgroup had high specificity (range: 87.7%-95.2%) for dichotomized 12-month outcomes. The multivariable results showed that medium and high STarT-LE risk categories were associated with chronic pain development (Medium odds ratio: 3.90, 95%CI: 1.11 to 13.66; High odds ratio: 13.14, 95%CI: 2.25 to 76.86), worse pain interference (Medium: β:4.37, 95%CI: 0.17 to 8.58; High: β:7.01, 95%CI: 1.21 to 12.81), and worse physical function (Medium: β:-3.76, 95%CI: -7.41 to -0.11; β:-7.44, 95%CI:-12.47 to -2.41), respectively, when controlling for important baseline variables.
Conclusion
: The STarT-LE has the potential to identify patients at-risk for poor pain and functional outcomes, and may help inform the post-surgical management of patients with traumatic LE injury.
The following chapter presents the state-of-the-science on the genomics of fracture pain across fracture types and populations. The pathophysiologic underpinnings of fracture pain and transition from acute to chronic pain are discussed along with an overview of mediators that increase the risk of chronic fracture pain. A focus on current challenges in the field and areas of future discovery are provided.
Background:
Traumatic injury is a major source of chronic pain, particularly for individuals with traumatic fracture of the fibula and/or tibia (lower extremity fracture) [LEFx]. Although several factors (e.g., older age, being female sex, high pain intensity at time of initial injury) have been identified as risk factors for chronic pain associated with LEFx. Comprehensive biopsychosical models to predict the odds of transitioning from acute to chronic pain after LEFx are needed to better understand the underlying processes, predict risk for chronic pain, and develop personalized therapies for individuals at higher risk for developing chronic pain.
Objective:
To outline the study design that will be used to examine the physiological, psychological, and genetic/genomic variables. Models that predict the transition from acute to chronic pain after LEFx.
Method:
This prospective descriptive cohort study will enroll 240 participants with a fibula and/or tibia fracture and 40 controls with no of LEFx. Data will be collected during an in-hospital baseline visit, five in-person clinic visits (6, 12, 24, 52 weeks, and 24 months), and seven online between-visit surveys (2, 4, 8, 10, 16, 20 weeks, and 18 months) from participants with LEFx and at concordant intervals from controls. Measures will consist of 19 questionnaires characterizing pain and psychological status, neurophysiological testing for peripheral sensory nerve function, and peripheral blood samples collections for RNA-sequencing. Illumina standard protocols will be used to sequence RNA and read counts will be used to measure gene expression.
Analysis:
Direct-entry, multiple logistic regression will be used to produce odds ratios expressing the relative risk on each explanatory variable when controlling for other predictors/covariates in the model.
Conclusion:
This study is one of the first to longitudinally characterize the biopsychosocial variables associated with a clinically relevant problem of the transition from acute to chronic posttraumatic fracture pain in individuals with LEFx. Results from this study will be used to construct predictive risk models of physiological, psychological, and genetic/genomic variables associated with increased risk for transitioning from acute to chronic pain status after LEFx. This work will lead to a better understanding of the trajectory of pain and relevant variables over time; initiate a better understanding of variables associated with risk for transitioning from acute to chronic pain; and, in the future, could provide a foundation for the identification of novel therapeutic targets to improve the outcomes of individuals with LEFx.
Chronic opioid use and abuse continue to plague our country despite efforts to curtail their use. Patients on chronic opioids (opioids tolerant) who undergo total joint arthroplasty have been clearly shown to have higher rates of complications, infection, and early revision compared to the opioid-naïve patients. The ability to successfully wean patients off of narcotics before surgery remains challenging and fragmented at best. The utilization of a multidisciplinary team that assists with not only preoperative opioids reduction but also postoperative opioids management is critical to the successful management of these patients. This symposium focuses on the opioid-tolerant patients and a comprehensive approach to opioids optimization.
The objective of this study was to assess the current practice pattern regarding posthospitalization follow-up of trauma patients among the members of the Eastern Association for the Surgery of Trauma (EAST). An anonymous online multiple-choice survey of EAST members in 2016 was conducted. Ten questions relating to the follow-up care of injured patients were presented to the Active, Senior, and Associate members of EAST. Data were screened for quantitative concerns prior to analysis. Of the 1,610 members surveyed, 289 responded (18%). Approximately 52% of respondents stated that their institution has a dedicated trauma follow-up clinic where most injured patients are seen after discharge. Less than 20% reported that nontrauma multidisciplinary providers are present in clinics. Most (89.5%) reported that follow-up is a single visit, unless a patient has long-standing issues. Only 3 respondents stated that patients are regularly seen 3+ months out from injury, and a significant minority (17.7%) acknowledged no set follow-up timeline. Only 3.6% of participants indicated that they have a psychologist embedded in the trauma team, and 11.5% reported that no system is currently in place to manage mental health. Despite more than 20 years of literature highlighting the long-term physical and mental health sequelae after trauma, these survey results demonstrate that there is a lack of standardized and multidisciplinary follow-up. Given the improvement in outcomes with the identification and treatment of these sequelae, greater attention should be paid to functional recovery, social and psychological well-being, and chronic pain.
Chronic pain is a prevalent issue in intensive care survivors and in patients who require acute care treatments. Many adverse consequences have been associated with chronic post intensive and acute care-related pain. Hence, a growing interest for interventions aimed at preventing these pain disorders has emerged. In order to improve the understanding on the mechanisms of action of these interventions and their potential impacts, this article outlines: the pathophysiology involved in the transition from acute to chronic pain, the epidemiology and consequences of chronic post intensive and acute care-related pain as well as the risk factors for the development of chronic pain. Pharmacological, non-pharmacological and multimodal preventive interventions specific to the targeted populations and their level of evidence are presented. Important nursing implications for the prevention of chronic pain in critical and acute care patients are also discussed.
Background and aims
Chronic pain after traumatic injury and surgery is highly prevalent, and associated with substantial psychosocial co-morbidities and prolonged opioid use. It is currently unclear whether predicting chronic post-injury pain is possible. If so, it is unclear if predicting chronic post-injury pain requires a comprehensive set of variables or can be achieved only with data available from the electronic medical records. In this prospective study, we examined models to predict pain at the site of injury 3–6 months after hospital discharge among adult patients after major traumatic injury requiring surgery. Two models were developed: one with a comprehensive set of predictors and one based only on variables available in the electronic medical records.
Methods
We examined pre-injury and post-injury clinical variables, and clinical management of pain. Patients were interviewed to assess chronic pain, defined as the presence of pain at the site of injury. Prediction models were developed using forward stepwise regression, using follow-up surveys at 3–6 months. Potential predictors identified a priori were: age; sex; presence of pre-existing chronic pain; intensity of post-operative pain at 6 h; in-hospital opioid consumption; injury severity score (ISS); location of trauma, defined as body region; use of regional analgesia intra- and/or post-operatively; pre-trauma PROMIS Depression, Physical Function, and Anxiety scores; in-hospital Widespread Pain Index and Symptom Severity Score; and number of post-operative non-opioid medications. After the final model was developed, a reduced model, based only on variables available in the electronic medical record was run to understand the “value add” of variables taken from study-specific instruments.
Results
Of 173 patients who completed the baseline interview, 112 completed the follow-up within 3–6 months. The prevalence of chronic pain was 66%. Opioid use increased from 16% pre-injury to 28% at 3–6 months. The final model included six variables, from an initial set of 24 potential predictors. The apparent area under the ROC curve (AUROC) of 0.78 for predicting pain 3–6 months was optimism-corrected to 0.73. The reduced final model, using only data available from the electronic health records, included post-surgical pain score at 6 h, presence of a head injury, use of regional analgesia, and the number of post-operative non-opioid medications used for pain relief. This reduced model had an apparent AUROC of 0.76, optimism-corrected to 0.72.
Conclusions
Pain 3–6 months after trauma and surgery is highly prevalent and associated with an increase in opioid use. Chronic pain at the site of injury at 3–6 months after trauma and surgery may be predicted during hospitalization by using routinely collected clinical data.
Implications
If our model is validated in other populations, it would provide a tool that can be easily implemented by any provider with access to medical records. Patients at risk of developing chronic pain could be selected for studies on preventive strategies, thereby concentrating the interventions to patients who are most likely to transition to chronic pain.
Background:
Chronic pain is a significant problem for patients with lower extremity injuries. While pain hypersensitivity has been identified in many chronic pain conditions, it is not known whether patients with chronic pain following lower extremity fracture report pain hypersensitivity in the injured leg.
Purpose:
To quantify and compare peripheral somatosensory function and sensory nerve activation thresholds in persons with chronic pain following lower extremity fractures with a cohort of persons with no history of lower extremity fractures.
Method:
This was a cross-sectional study where quantitative sensory testing and current perception threshold testing were conducted on the injured and noninjured legs of cases and both legs of controls.
Results:
A total of 14 cases and 28 controls participated in the study. Mean time since injury at the time of testing for cases was 22.3 (standard deviation = 12.1) months. The warmth detection threshold ( p = .024) and nerve activation thresholds at 2,000 Hz ( p < .001) and 250 Hz ( p = .002), respectively, were significantly higher in cases compared to controls.
Conclusion:
This study suggests that patients with chronic pain following lower extremity fractures may experience hypoesthesia in the injured leg, which contrasts with the finding of hyperesthesia previously observed in other chronic pain conditions but is in accord with patients with nerve injuries and surgeries. This is the first study to examine peripheral sensory nerve function at the site of injury in patients with chronic pain following lower extremity fractures using quantitative sensory testing and current perception threshold testing.
Fifty-one youth athletes (n = 27 female, age = 14.53 years, SD = 1.85) presented to a local hospital outpatient concussion clinic on average 7.67 days postconcussion for standard medical assessment, including the self-report Sport-Concussion Assessment Tool-2 (Time 1). They completed follow-up symptom assessments at Time 2 (7.48 ± 1.24 days after Time 1) and Time 3 (7.63 ± 1.42 days after Time 2). We assessed the relations between theoretically relevant personal and situational variables, assessed at Time 2, and concussion symptom reports at Time 2 and Time 3. Using hierarchical regression, we also assessed relations between personal/situational factors and changes in symptom intensity from Time 1 to Time 2, Time 1 to Time 3, and Time 2 to Time 3, controlling for Time 1 postconcussion symptom intensity, age, gender, concussion history over the past 12 months, and the number of days since sustaining the current concussion. Controlling for these factors, the combined influence of the psychosocial factors predicted 43% of the variance in symptom expression at Time 3. Psychosocial factors also accounted for 27% of the variance in symptom change from Time 1 to Time 2, and 23% of the variance in symptom change from Time 1 to Time 3. Athletic identity, performance anxiety, and amotivation were the most consistent and influential person variables, each being related to more intense symptom reports and slower recovery. Results suggest the potential importance of psychological factors in concussion recovery.
Not only do anxiety and depression diagnoses tend to co-occur, but their symptoms are highly correlated. Although a plethora of research has examined longitudinal associations between anxiety and depression, this data has not yet been effectively synthesized. To address this need, the current study undertook a systematic review and meta-analysis of 66 studies involving 88,336 persons examining the prospective relationship between anxiety and depression at both symptom and disorder levels. Using mixed-effect models, results suggested that all types of anxiety symptoms predicted later depressive symptoms (r = 0.34), and all types of depressive symptoms predicted later anxiety symptoms (r = 0.31). Although anxiety symptoms more strongly predicted depressive symptoms than vice-versa, the difference in effect size for this analysis was very small and likely not clinically meaningful. Additionally, all types of diagnosed anxiety disorders predicted all types of later depressive disorders (OR = 2.77), and all depressive disorders predicted later anxiety disorders (OR = 2.73). Most anxiety and depressive disorders predicted each other with similar degrees of strength, but depressive disorders more strongly predicted social anxiety disorder (OR = 6.05) and specific phobia (OR = 2.93) than vice-versa. Contrary to conclusions of prior reviews, our findings suggest that depressive disorders may be prodromes for social and specific phobia, whereas other anxiety and depressive disorders are bidirectional risk factors for one another.
Unlabelled:
The recently proposed Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)-American Pain Society (APS) Pain Taxonomy (AAPT) provides an evidence-based, multidimensional, chronic pain classification system. Psychosocial factors play a crucial role within several dimensions of the taxonomy. In this article, we discuss the evaluation of psychosocial factors that influence the diagnosis and trajectory of chronic pain disorders. We review studies in individuals with a variety of persistent pain conditions, and describe evidence that psychosocial variables play key roles in conferring risk for the development of pain, in shaping long-term pain-related adjustment, and in modulating pain treatment outcomes. We consider "general" psychosocial variables such as negative affect, childhood trauma, and social support, as well as "pain-specific" psychosocial variables that include pain-related catastrophizing, self-efficacy for managing pain, and pain-related coping. Collectively, the complexity and profound variability in chronic pain highlights the need to better understand the multidimensional array of interacting forces that determine the trajectory of chronic pain conditions.
Perspective:
The AAPT is an evidence-based chronic pain classification system in which psychosocial concepts and processes are essential in understanding the development of chronic pain and its effects. In this article we review psychosocial processes that influence the onset, exacerbation, and maintenance of chronic pain disorders.
Objectives:
The hypotheses of this systematic review were the following: 1) Prevalence of post-traumatic stress disorder (PTSD) will differ between various types of chronic pain (CP), and 2) there will be consistent evidence that CP is associated with PTSD.
Methods:
Of 477 studies, 40 fulfilled the inclusion/exclusion criteria of this review and were grouped according to the type of CP. The reported prevalence of PTSD for each grouping was determined by aggregating all the patients in all the studies in that group. Additionally all patients in all groupings were combined. Percentage of studies that had found an association between CP and PTSD was determined. The consistency of the evidence represented by the percentage of studies finding an association was rated according to the Agency for Health Care Policy and Research guidelines.
Results:
Grouping PTSD prevalence differed ranging from a low of 0.69% for chronic low back pain to a high of 50.1% in veterans. Prevalence in the general population with CP was 9.8%. Of 19 studies, 16 had found an association between CP and PTSD (84.2%) generating an A consistency rating (consistent multiple studies). Three of the groupings had an A or B (generally consistent) rating. The veterans grouping received a C (finding inconsistent) rating.
Conclusion:
The results of this systematic review confirmed the hypotheses of this review.
Objectives Review the anesthetic considerations for complex musculoskeletal injuries including pelvic and long-bone fractures, traumatic amputations, and crush syndrome. Discuss issues related to the timing of surgical fixation of specific fractures. Discuss the impact of anesthetic management on morbidity and mortality following hip fracture. Review the pathophysiology and anesthetic concerns relating to acute compartment syndrome, fat embolism, and complex regional pain syndrome. Summarize the postoperative concerns following musculoskeletal trauma, specifically pain and delirium. Introduction Musculoskeletal injury is common in the trauma patient. While bony fractures and muscular injuries can occur anywhere on the body, the extremities are disproportionately affected. Approximately 60% of multiple trauma patients with an Injury Severity Score (ISS) of ≥ 16 have extremity injury of some type, and 18% have both lower and upper extremity injuries. Over 30% of the same population will have two or more extremity fractures. Mechanism of injury is an important epidemiologic factor – for example, those in motor vehicle collisions (MVCs) have a significantly higher prevalence of extremity injury; similarly, due to improvements in battlefield medicine and body armor, modern military combatants have a dramatically reduced rate of fatal torso injury, meaning that while more survive, they have much higher rates of serious extremity injury. While patients with isolated extremity injuries typically go on to have very good outcomes, it has been shown that orthopedic and general health outcomes become significantly poorer if the same injury is present in a polytrauma patient.
Posttraumatic stress disorder (PTSD) is a chronic and debilitating anxiety disorder. Several brain areas related to pain processing are implicated in PTSD. To our knowledge, no functional imaging study has discussed whether patients with PTSD experience and process pain in a different way than control subjects.
To examine neural correlates of pain processing in patients with PTSD.
The experimental procedure consisted of psychophysical assessment and neuroimaging with functional magnetic resonance imaging. Two conditions were assessed during functional magnetic resonance imaging in both experimental groups, one condition with administration of a fixed temperature of 43 degrees C (fixed-temperature condition) and the other condition with an individual temperature for each subject but with a similar affective label equaling 40% of the subjective pain intensity (individual temperature condition).
Academic outpatient unit in a department of military psychiatry in collaboration with an imaging center at a psychiatric hospital.
Twelve male veterans with PTSD and 12 male veterans without PTSD were recruited and matched for age, region of deployment, and year of deployment.
Changes in functional magnetic resonance imaging blood oxygenation level-dependent response to heat stimuli, reflecting increased and decreased activity of brain areas involved in pain processing.
Patients with PTSD rated temperatures in the fixed-temperature assessment as less painful compared with controls. In the fixed-temperature condition, patients with PTSD revealed increased activation in the left hippocampus and decreased activation in the bilateral ventrolateral prefrontal cortex and the right amygdala. In the individual temperature condition, patients with PTSD showed increased activation in the right putamen and bilateral insula, as well as decreased activity in the right precentral gyrus and the right amygdala.
These data provide evidence for reduced pain sensitivity in PTSD. The witnessed neural activation pattern is proposed to be related to altered pain processing in patients with PTSD.
This study assessed the reliability of a German translation of the Clinician‐Administered PTSD Scale (CAPS) by using data from 45 survivors of accidents who were hospitalized at the department of traumatology of a university hospital. Assessments were carried out 5 days (Time 1) and 6 months (Time 2) after the accident. Internal consistency proved to be comparable to that of the original English version: Cronbach's alpha was .88 at'T1 and .92 at T2 for the CAPS total score. The CAPS correlated significantly with the validated German version of the Impact of Event Scale (lES) (T1: r = .56, T2: r = .78). The data suggest that the German version of the CAPS is a reliable instrument for the assessment of posttraumatic stress disorder symptomatology in accident victims. Further studies are necessary' to validate further the questionnaire.
ABSTRACT– A self-assessment scale has been developed and found to be a reliable instrument for detecting states of depression and anxiety in the setting of an hospital medical outpatient clinic. The anxiety and depressive subscales are also valid measures of severity of the emotional disorder. It is suggested that the introduction of the scales into general hospital practice would facilitate the large task of detection and management of emotional disorder in patients under investigation and treatment in medical and surgical departments.
Several interviews are available for assessing PTSD. These interviews vary in merit when compared on stringent psychometric and utility standards. Of all the interviews, the Clinician-Administered PTSD Scale (CAPS-1) appears to satisfy these standards most uniformly. The CAPS-1 is a structured interview for assessing core and associated symptoms of PTSD. It assesses the frequency and intensity of each symptom using standard prompt questions and explicit, behaviorally-anchored rating scales. The CAPS-1 yields both continuous and dichotomous scores for current and lifetime PTSD symptoms. Intended for use by experienced clinicians, it also can be administered by appropriately trained paraprofessionals. Data from a large scale psychometric study of the CAPS-1 have provided impressive evidence of its reliability and validity as a PTSD interview.
Clinical, field, and experimental studies of response to potentially stressful life events give concordant findings: there is a general human tendency to undergo episodes of intrusive thinking and periods of avoidance. A scale of current subjective distress, related to a specific event, was based on a list of items composed of commonly reported experiences of intrusion and avoidance. Responses of 66 persons admitted to an outpatient clinic for the treatment of stress response syndromes indicated that the scale had a useful degree of significance and homogeneity. Empirical clusters supported the concept of subscores for intrusions and avoidance responses.
In epidemiologic research on chronic pain, differentiation of recurrent, persistent and disabling pain states is critical in the investigation of burden, natural history, effective intervention and causal processes. We report population-based data concerning the development and evaluation of a graded classification of pain status. In a probability sample of 1016 health maintenance organization enrollees, recurrent or persistent pain was observed in 45%; severe and persistent pain in 8%; severe and persistent pain with 7 or more days of pain-related activity limitation in 2.7%; and severe, persistent pain with activity limitation and 3 or more indicators of pain dysfunction in 1.0% of the population sample. Graded chronic pain status was associated with psychological impairment, unfavorable appraisal of health status, and frequency of use of pain medications and health care. The presence of severe and persistent pain increased the likelihood of multiple indicators of pain dysfunction, but there was considerable heterogeneity in pain dysfunction among persons with comparable pain experience. Our data suggest grading chronic pain in terms of 3 axes: time (persistence); severity; and impact (disability and dysfunctional illness behaviors).
A clinical scale has been evolved for assessing the depth and duration of impaired consciousness and coma. Three aspects of behaviour are independently measured—motor responsiveness, verbal performance, and eye opening. These can be evaluated consistently by doctors and nurses and recorded on a simple chart which has proved practical both in a neurosurgical unit and in a general hospital. The scale facilitates consultations between general and special units in cases of recent brain damage, and is useful also in defining the duration of prolonged coma.
The primary purpose of this report was to determine the extent of psychiatric morbidity and comorbidity among a sample of recent victims of motor vehicle accidents (MVAs) in comparison to a nonaccident control population. Victims of recent MVAs (N = 158), who sought medical attention as a result of the MVA, were assessed in a University-based research clinic, 1 to 4 months after the accident for acute psychiatric and psychosocial consequences as well as for pre-MVA psychopathology using structured clinical interviews (Clinician-Administered PTSD Scale, SCID, SCID-II, LIFE Base). Age- and gender-matched controls (N = 93) who had had no MVAs in the past year served as controls. Sixty-two MVA victims (39.2%) met DSM-III-R criteria for posttraumatic stress disorder (PTSD), and 55 met DSM-IV criteria. The MVA victims who met the criteria for PTSD were more subjectively distressed and had more impairment in role function (performance at work/school/homemaking, relationships with family or friends) than the MVA victims who did not meet the PTSD criteria or the controls. A high percentage (53%) of the MVA-PTSD group also met the criteria for current major depression, with most of that developing after the MVA. A prior history of major depression appears to be a risk factor for developing PTSD after an MVA (p = .0004): 50% of MVA victims who developed PTSD had a history of previous major depression, as compared with 23% of those with a less severe reaction to the MVA. A prior history of PTSD from earlier trauma also is associated with developing PTSD or a subsyndromal form of it (25.2%) (p = .0012). Personal injury MVAs exact substantial psychosocial costs on the victims. Early intervention, especially in vulnerable populations, might prevent some of this.
Previous work of the author presents a salutogenic theoretical model designed to explain maintenance or improvement of location on a health ease/dis-ease continuum. The model's core construct, the Sense of Coherence (SOC), was consciously formulated in terms which are thought to be applicable crossculturally. The SOC scale which operationalizes the construct is a 29-item semantic differential questionnaire, its design guided by Guttman's facet theory. A 13-item version of the scale has also been used. The purpose of the present paper is to present the extant evidence from studies conducted in 20 countries for the feasibility, reliability and validity of the scale, as well as normative data. In 26 studies using SOC-29 the Cronbach alpha measure of internal consistency has ranged from 0.82 to 0.95. The alphas of 16 studies using SOC-13 range from 0.74 to 0.91. The relatively few test-retest correlations show considerable stability, e.g. 0.54 over a 2-year period among retirees. The systematic procedure used in scale construction and examination of the final product by many colleagues points to a high level of content, face and consensual validity. The few data sets available point to a high level of construct validity. Criterion validity is examined by presenting correlational data between the SOC and measures in four domains: a global orientation to oneself and one's environment (19 r's); stressors (11 r's); health, illness and wellbeing (32 r's); attitudes and behavior (5 r's). The great majority of correlations are statistically significant. All available published normative data on SOC-29 and SOC-13 are presented, data which bear upon validity using the known groups technique.(ABSTRACT TRUNCATED AT 250 WORDS)
Recent studies have reported a high prevalence of symptoms of post-traumatic stress disorder (PTSD) among individuals with chronic pain. Studies suggest that persons with pain and PTSD also display higher levels of affective disturbance. In the present study we examined self-reports of pain, affective disturbance, and disability among pain patients with and without symptoms of PTSD. Patients without PTSD symptoms were further subdivided into persons whose pain was the result of an accident or insidious in onset. Thus, three groups were examined: (1) persons with accident related pain and high PTSD symptoms (Accident/High PTSD); (2) persons with no or few symptoms of PTSD whose pain was accident related (Accident/Low PTSD); and (3) patients whose pain was not accident related and did not have PTSD symptoms (No Accident). No Accident patients were older than persons with accident related injuries, and both accident related pain groups were more likely than No Accident patients to be involved in litigation or receiving compensation. Thus, these variables were controlled for in the statistical analyses. Self-report of pain was also included as a covariate in the analyses examining group differences in affective disturbance and disability. Accident/High PTSD patients displayed higher levels of self-reported pain compared to the other two groups. The Accident/High PTSD group also had the highest levels of affective disturbance. Both accident groups tended to report greater disability compared to patients whose pain was not accident related. These findings suggest that PTSD symptoms in chronic pain patients are associated with increased pain and affective distress. Accident related pain, even without the presence of PTSD symptoms, appears to be associated with greater disability. The results indicate that the identification and treatment of PTSD symptoms in refractory pain patients may be a critical albeit subtle factor in the effective management of suffering and disability in this population.
Chronic pain is recognised as an important problem in the community but our understanding of the epidemiology of chronic pain remains limited. We undertook a study designed to quantify and describe the prevalence and distribution of chronic pain in the community.
A random sample of 5036 patients, aged 25 and over, was drawn from 29 general practices in the Grampian region of the UK and surveyed by a postal self-completion questionnaire. The questionnaire included case-screening questions, a question on the cause of the pain, the chronic pain grade questionnaire, the level of expressed needs questionnaire, and sociodemographic questions.
3605 questionnaires were returned completed. 1817 (50.4%) of patients self reported chronic pain, equivalent to 46.5% of the general population. 576 reported back pain and 570 reported arthritis; these were the most common complaints and accounted for a third of all complaints. Backward stepwise logistic-regression modelling identified age, sex, housing tenure, and employment status as significant predictors of the presence of chronic pain in the community. 703 (48.7%) individuals with chronic pain had the least severe grade of pain, and 228 (15.8%) the most severe grade. Of those who reported chronic pain, 312 (17.2%) reported no expressed need, and 509 (28.0%) reported the highest expressed need.
Chronic pain is a major problem in the community and certain groups within the population are more likely to have chronic pain. A detailed understanding of the epidemiology of chronic pain is essential for efficient management of chronic pain in primary care.
The aim of this study was first to analyze the stability of Antonovsky's Sense of Coherence (SOC) as a measure of a person's world view over time; secondly, to investigate its relationship with depression and anxiety.
Data from two longitudinal studies were used: a study of severely injured accident victims (n = 96), and a study of patients suffering from rheumatoid arthritis (RA, n = 60). The 13 items short version of the SOC scale and measures of depression and anxiety (Symptom Checklist, Hospital Anxiety and Depression Scale) were administered repeatedly over 6-12 months in both studies.
In the sample of accident victims, a significant decrease in the SOC mean score was observed during the first half year after the accident. During the same time period, symptoms of anxiety and depression decreased significantly. In the second half year after the accident, SOC as well as measures of psychopathology remained stable. RA patients showed high stability of SOC and measures of anxiety and depression over time. In both samples, between-time correlations of SOC scores were high (r > or = 0. 70, p<0.01), indicating a high test-retest stability of SOC. Furthermore, in both samples, significant negative correlations of a moderate to high degree (r = -0.28 to -0.73, p<0.01) were found between SOC and measures of anxiety and depression.
SOC can be seen as a relatively stable (trait) measure. However, traumatic events such as life-threatening accidents may change a person's world view and thus their SOC, even if psychiatric symptoms abate. This suggests that SOC is not merely a proxy measure of psychopathology, but rather a partially independent, general measure of a person's world view.
This study was designed to assess the incidence of posttraumatic stress disorder (PTSD) in severely injured accident victims and to predict the presence of PTSD symptoms at a 12-month follow-up.
A longitudinal, 1-year follow-up study was carried out with 106 consecutive patients with severe accidental injuries who were admitted to the trauma surgeons' intensive care unit at a university hospital. Patients were interviewed within 1 month and 12 months after the accident. Assessments included an extensive clinical interview, the Impact of Event Scale, the Clinician-Administered PTSD Scale, the Sense of Coherence questionnaire, and the Freiburg Questionnaire of Coping With Illness.
A total of 13.4 days (SD=6.6) after the accident, five patients (4.7%) met all criteria for PTSD with the exception of the time criterion. A total of 22 other patients (20.8%) had subsyndromal PTSD. At the 1-year follow-up, two patients (1.9%) had PTSD, and 13 (12.3%) had subsyndromal PTSD. Multiple regression analysis explained 34% of the variance of PTSD symptoms 12 months after the accident. Biographical risk factors, the sense of a death threat, symptoms of intrusion, and problem-oriented coping each contributed significantly to the predictive model.
In severely injured accident victims who were healthy before experiencing trauma, the incidence of PTSD was low. One-third of the variance of PTSD symptoms at 1-year follow-up could be predicted by mainly psychosocial variables.
The authors' goal was to identify predictors of 1-year outcomes for consecutive patients in a hospital emergency department following motor vehicle accidents and to describe the prevalence and course of four types of psychiatric outcomes after such accidents.
Consecutive patients aged 17-69 years who attended a general hospital emergency department following a motor vehicle accident were identified. Medical information for these patients was extracted from case notes, and the patients completed self-report questionnaires at baseline (soon after the accident), 3 months after the accident, and 1 year after the accident. Measures included a self-report scale for posttraumatic stress disorder (PTSD), the Hospital Anxiety and Depression Scale, and questions about phobic travel anxiety. Logistic regression was used to examine predictors of outcome.
Different frequencies and courses of PTSD, phobic travel anxiety, general anxiety, and depression were reported by a third of the subjects at both 3-month and 1-year follow-up. Many of the subjects reported improvements between 3 and 12 months, but others described late onset of psychiatric outcomes after the accident. There were differences in baseline and 3-month predictors of each type of 1-year outcome.
The four types of psychiatric outcomes after a motor vehicle accident that were noted overlap, are persistent, and have different early predictors. These findings have implications for the early recognition of psychiatric consequences of motor vehicle accidents that would enable early intervention.
Common sequelae following a traumatic event include chronic pain and posttraumatic stress disorder (PTSD). Over the last decade, the literature relating to PTSD has become progressively more sophisticated, resulting in well-supported theories and treatments for sufferers. Equivalent research relating to chronic pain has more recently gathered momentum. However, to date there has been minimal attention devoted to the concurrence of the two disorders, even though high comorbidity has been noted. This review begins by briefly summarizing the literature relating to the two disorders in terms of symptoms, prevalence and comorbidity. It explicates the major psychological theories of chronic pain and PTSD and reviews the evidence relating what factors maintain the disorders. A number of pathways by which chronic pain and PTSD may be mutually maintaining are highlighted. We conclude that chronic pain and PTSD are mutually maintaining conditions and that there are several pathways by which both disorders may be involved in the escalation of symptoms and distress following trauma. Treatment implications are considered, as are issues for future research.
Little is known about the consequences of road traffic accidents.
To determine psychological and social outcome at 3 months and 1 year following a road traffic accident.
A cohort study of a 1-year sample of consecutive attenders (n=1148) aged 17-69 years at the accident and emergency department of a teaching district general hospital (excluding major head injury). Data were extracted from medica notes and from self-report at baseline, 3 months and 1 year.
Most (61%) injuries were physically minor. At 1 year 45% reported major physical problems and 32% reported psychiatric consequences. Non-injury variables were the principal predictors of outcome.
Outcome across a range of variables is considerably worse than would be expected from the nature of the physical injuries. There is a need for changes in clinical care and socio-legal policy to prevent, identify and treat distressing and disabling chronic problems.
Acute stress disorder (ASD) is still a much discussed diagnosis, and research on predictors of ASD is sparse. The aim of this study was to assess the prevalence of ASD in a random sample of accident victims and to investigate the associations between different independent variables and ASD symptomatology with the objective to find a regression model best explaining the variance in ASD symptom level.
We collected a randomized sample of hospitalized accident victims (n = 323). ASD was assessed using the Peritraumatic Dissociative Experiences Questionnaire and the Clinician-Administered Posttraumatic Stress Disorder Scale. Correlations and multiple regression analyses were computed with four groups of variables. This yielded the variables entered into a final multiple regression analysis.
Thirteen patients (4.0%) met all criteria for a diagnosis of ASD. Thirty-two patients (9.9%) met the criteria for a diagnosis of subsyndromal ASD. Thirty-eight percent of the variance in ASD symptom level was explained with a regression model including stay at the intensive care unit, preexisting psychiatric disorder, sense of coherence, sense of death threat, appraisal of accident severity, preventability of the accident by others, pain and appraisal of coping ability regarding physical recovery.
This study furthers the discussion about the requirements for the ASD diagnosis. It also points to the importance of not only assessing objective accident-related variables in the aftermath of an accident but also of giving more consideration to the subjective experience and appraisal of the accident in the prevention of ASD.
Road traffic accidents are known to have significant consequences for mental state and quality of life in the ensuing year that are largely unrelated to the nature of the injuries. Little is known of longer-term outcome in a representative population.
Questionnaires covering mental state and social adjustment were sent to 770 subjects who had previously participated in a prospective study of consecutive attenders at an emergency department following a road traffic accident and who had completed questionnaires at baseline, 3 months and 1 year. Outcomes were not predicted by measures related to injury type or severity but were predicted by baseline and later non-injury variables.
Replies were received from 507 (66%) subjects. Although 76% of injuries were medically minor bruises and lacerations, 132 (26%) reported symptoms of psychiatric disorder and 104 (21 %) moderate or severe pain at 3 years. There was little evidence of improvement in prevalence between 1 and 3 years, with continuing physical symptoms, psychiatric disorder and reported consequences for everyday life. There was a significant reduction in the number of cases of post-traumatic stress disorder (PTSD) despite there being 21 late onset cases. Psychiatric outcomes and pain were unrelated to the severity of injury and were largely predicted by post-accident variables.
Road traffic accidents have much greater consequences than would be expected from the largely minor nature of the physical injuries. There is a need for changes in medical care and in socio-legal procedures.
This study assessed the reliability of a German translation of the Clinician-Administered PTSD Scale (CAPS) by using data from 45 survivors of accidents who were hospitalized at the department of traumatology of a university hospital. Assessments were carried out 5 days (Time 1) and 6 months (Time 2) after the accident. Internal consistency proved to be comparable to that of the original English version: Cronbach's alpha was .88 at T1 and .92 at T2 for the CAPS total score. The CAPS correlated significantly with the validated German version of the Impact of Event Scale (IES) (T1: r = .56, T2: r = .78). The data suggest that the German version of the CAPS is a reliable instrument for the assessment of posttraumatic stress disorder symptomatology in accident victims. Further studies are necessary to validate further the questionnaire.
It is common for individuals with symptoms of posttraumatic stress disorder (PTSD) to present with co-occurring pain problems, and vice versa. However, the relation between these conditions often goes unrecognized in clinical settings. In this paper, we describe potential relations between PTSD and chronic pain and their implications for assessment and treatment. To accomplish this, we discuss phenomenological similarities of these conditions, the prevalence of chronic pain in patients with PTSD, and the prevalence of PTSD in patients with chronic pain. We also present several possible explanations for the co-occurrence of these disorders, based primarily on the notions of shared vulnerability and mutual maintenance. The paper concludes with an overview of future research directions, as well as practical recommendations for assessing and treating patients who present with co-occurring PTSD or chronic pain symptoms.
To describe the course of acute low back pain and sciatica and to identify clinically important prognostic factors for these conditions.
Systematic review.
Searches of Medline, Embase, Cinahl, and Science Citation Index and iterative searches of bibliographies.
Pain, disability, and return to work.
15 studies of variable methodological quality were included. Rapid improvements in pain (mean reduction 58% of initial scores), disability (58%), and return to work (82% of those initially off work) occurred in one month. Further improvement was apparent until about three months. Thereafter levels for pain, disability, and return to work remained almost constant. 73% of patients had at least one recurrence within 12 months.
People with acute low back pain and associated disability usually improve rapidly within weeks. None the less, pain and disability are typically ongoing, and recurrences are common.
Predictors of outcome following whiplash injury are limited to socio-demographic and symptomatic factors, which are not readily amenable to secondary and tertiary intervention. This prospective study investigated the predictive capacity of early measures of physical and psychological impairment on pain and disability 6 months following whiplash injury. Motor function (ROM; kinaesthetic sense; activity of the superficial neck flexors (EMG) during cranio-cervical flexion), quantitative sensory testing (pressure, thermal pain thresholds, brachial plexus provocation test), sympathetic vasoconstrictor responses and psychological distress (GHQ-28, TSK, IES) were measured in 76 acute whiplash participants. The outcome measure was Neck Disability Index scores at 6 months. Stepwise regression analysis was used to predict the final NDI score. Logistic regression analyses predicted membership to one of the three groups based on final NDI scores (<8 recovered, 10-28 mild pain and disability, >30 moderate/severe pain and disability). Higher initial NDI score (1.007-1.12), older age (1.03-1.23), cold hyperalgesia (1.05-1.58), and acute post-traumatic stress (1.03-1.2) predicted membership to the moderate/severe group. Additional variables associated with higher NDI scores at 6 months on stepwise regression analysis were: ROM loss and diminished sympathetic reactivity. Higher initial NDI score (1.03-1.28), greater psychological distress (GHQ-28) (1.04-1.28) and decreased ROM (1.03-1.25) predicted subjects with persistent milder symptoms from those who fully recovered. These results demonstrate that both physical and psychological factors play a role in recovery or non-recovery from whiplash injury. This may assist in the development of more relevant treatment methods for acute whiplash.
There has been little research examining chronic pain and posttraumatic stress symptoms in persons injured in motor vehicle accidents. The purpose of this study was to evaluate differences in physical injury and impairment, psychological distress, and pain coping strategies in litigating chronic pain patients low and high in motor vehicle accident-related posttraumatic stress symptoms.
A total of 160 consecutive chronic pain patients referred for psychological-legal assessment underwent semistructured interview and testing. The testing battery included the Minnesota Multiphasic Personality Inventory-2, the Multidimensional Pain Inventory, the Sickness Impact Profile, and the Coping Strategies Questionnaire. Using the sample-specific median split of 18 posttraumatic stress symptoms on the Minnesota Multiphasic Personality Inventory-2 Posttraumatic Stress Disorder scale, chronic pain patients were categorized as evidencing low or high levels of posttraumatic stress symptoms.
The findings indicate that participants evidencing high posttraumatic stress symptoms had more physical impairment, psychological distress, and maladaptive pain coping strategies and were more likely to be treated with antidepressants, other medications, and psychological management than participants evidencing low posttraumatic stress symptoms. A discriminant function analysis was performed using the full combination of physical injury and impairment, psychological distress, and pain coping variables in the prediction of posttraumatic stress symptom-defined group membership. The resulting discriminant function accounted for 61% of the between-group variance and correctly classified 92% of participants who were low in posttraumatic stress symptoms and 88% of participants who were high in posttraumatic stress symptoms.
Chronic pain and posttraumatic stress symptoms in litigating motor vehicle accident victims are associated with increased physical and psychological morbidity.
The symptoms of PTSD and pain frequently co-occur following a traumatic event; however, very little is known about how these two conditions are associated with physical and psychosocial functioning. The current study intended to first examine the differential association of co-occurring pain complaints and PTSD symptoms with disability in the domains of psychosocial and physical functioning, and second, to test whether perceived life control is a mediator of these relationships. All participants experienced a motor vehicle accident (MVA) and reported pain due to accident-related injuries (n=183). Structural equation modeling was used to develop two models hypothesizing a relationship between PTSD symptomatology, pain severity, and perceived life control. Separate models were constructed for psychosocial and physical functioning, based on the hypothesis that pain and PTSD would be differentially related to disability in these two domains. Results suggested that more severe PTSD symptoms and greater pain complaints were related to psychosocial impairment, however, only pain was significantly related to impairment in physical functioning. Perceptions of life control were shown to further explain these interrelationships.
Persistent pain and psychological sequelae are common after motor vehicle collision (MVC), but their etiology remains poorly understood. Such common sequelae include whiplash-associated disorders (WAD), fibromyalgia, and posttraumatic stress disorder (PTSD). Increasing evidence suggests that these disorders share overlapping epidemiologic and clinical features. A model is proposed in which central neurobiological systems, including physiologic systems and neuroanatomical structures involved in the stress response, are an important substrate for the development of all 3 disorders and interact with psychosocial and other factors to influence chronic symptom development.
Epidemiologic and clinical characteristics regarding the development of these disorders after MVC are reviewed. Evidence suggesting a role for stress response systems in the development of these disorders is presented.
Contemporary evidence supports a model of chronic symptom development that incorporates the potential for interactions between past experience, acute stress responses to trauma, post-MVC behavior, and cognitive/psychosocial consequences to alter activity within brain regions which process pain and to result in persistent pain, as well as psychological sequelae, after MVC. Such a model incorporates factors identified in prior biopsychosocial theories and places them in the landscape of our rapidly developing understanding of stress systems and CNS pain-modulating pathways.
New models are needed to stimulate deeper examination of the interacting influences of initial tissue damage, acute pain, psychosocial contingencies, and central stress pathways during chronic symptom development after MVC. Deeper understanding could contribute to improved treatment approaches to reduce the immense personal and societal burdens of common trauma-related disorders.
There is limited knowledge on prognostic factors for developing chronic low back pain (LBP) at an early stage of LBP. The objectives of this study were to investigate the clinical course of pain and disability, and prognostic factors for non-recovery after 1-year, in patients seeking help for the first time due to acute LBP. An inception cohort study included 123 patients with acute LBP lasting less than 3 weeks and consulting primary care for the first time. Main outcome measures were pain intensity, Roland-Morris disability questionnaire (RMQ), and sickness absence. Eleven patients (9%) did not return for the 12-month follow-up. There were large and significant reductions in pain intensity (P<0.001) and RMQ scores (P<0.001) during follow-up. Patients with neurological signs showed significantly less improvement in pain (P=0.001) and RMQ (P=0.004) compared with those without neurological signs. The proportions with sickness absence due to LBP at 6, 9, and 12 months were 7%, 8%, and 9%, respectively. At 12 months, 17% of patients had not fully recovered. Multivariate logistic regression analyses showed that high scores on a psychosocial screening (acute low back pain screening questionnaire) and emotional distress (Hopkin's symptom check list) were significantly associated with non-recovery at 12 months, with odds ratios of 4.4 (95% confidence interval 1.1-17.4) and 3.3 (1.1-10.2), respectively.
The purpose of this study was to evaluate the reliability and construct and predictive validity o