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Reciprocal associations of pain and post-traumatic stress symptoms after whiplash injury: A longitudinal, cross-lagged study
Abstract
Background:
The objectives of the current study were to investigate (1) the longitudinal, reciprocal associations between pain and post-traumatic stress symptoms as proposed by the mutual maintenance model, and (2) to assess the predictive value of the three clusters of post-traumatic stress, where the model revealed that post-traumatic stress symptoms maintained pain in a consecutive cohort of whiplash-injured.
Methods:
Participants (n = 253; 66.4% women) were people with WAD grades I-III following motor vehicle crashes in Australia. Pain and post-traumatic stress symptoms were assessed by questionnaires over the course of a year (at baseline (<4 weeks), 3, 6 and 12 months post-injury). The objectives were tested using auto-regressive cross-lagged modelling and two additional structural equation models.
Results:
The analyses revealed that post-traumatic stress symptoms at baseline predicted an increase in pain between baseline and 3 months and that post-traumatic stress symptoms at 6 months predicted an increase in pain between 6 and 12 months, beyond the stability of pain over time. Furthermore, hyperarousal at baseline significantly predicted pain at 3 months and hyperarousal at 6 months significantly predicted pain at 12 months with 16 and 23% explained variance, respectively.
Conclusions:
The results point to a temporal main effect of post-traumatic stress symptoms on pain over and above the stability of pain itself within the first 3 months post-injury and again in the chronic phase from 6 to 12 months with hyperarousal symptoms driving these effects. From 3 to 6 months, there was a slip in the maintenance patterns with no cross-lagged effects.
Significance:
Investigating mutual maintenance of pain and PTSS in whiplash, the present study found evidence suggesting a maintaining effect of PTSS on pain within the first 3 months post-injury and from 6 to 12 months driven by hyperarousal, highlighting the importance of addressing PTSS.
... The extant research finds consistent support that baseline levels of PTSD symptoms predict subsequent increases in physical symptoms and baseline levels of physical symptoms predict subsequent increases in PTSD symptoms with study baseline assessments ranging from 24 hours to 3 years after the traumatic event (Carty, O'Donnell, Evans, Kazantzis, & Creamer, 2011;Feinberg et al., 2017;Jenewein, Wittmann, Moergeli, Creutzig, & Schnyder, 2009;Lee et al., 2018;Liedl & Knaevelsrud, 2008;Ravn, Sterling, Lahav, & Andersen, 2018;Stratton et al., 2014). These same studies find inconsistent support that increases in PTSD (from baseline to a second time point) predict further increases in physical symptoms (from a second to a third time point) and vice versa. ...
... These same studies find inconsistent support that increases in PTSD (from baseline to a second time point) predict further increases in physical symptoms (from a second to a third time point) and vice versa. Three studies found that increases in PTSD symptoms (from baseline to the second time point) predicted increases in physical symptoms (from the second to third time point), but not vice versa (Jenewein et al., 2009;Ravn et al., 2018;Stratton et al., 2014). Two additional studies found that increases in physical symptoms (from baseline levels to the second time point) predicted increases in PTSD symptoms (from the second to third time point), but not vice versa (Carty et al., 2011;Lee et al., 2018). ...
... After, there was a unidirectional relationship where increases in physical symptoms predicted further increases in subsequent PTSD symptoms, but not vice versa. These findings are consistent with most previous research that showed a bidirectional relationship at first and a unidirectional relationship over time (Carty et al., 2011;Jenewein et al., 2009;Lee et al., 2018;Ravn et al., 2018;Stratton et al., 2014). The extant research is evenly split between whether the unidirectional relationship is between increases in PTSD predicting later increases in physical symptoms or increases in physical symptoms predicting later increases in PTSD symptoms. ...
Background: The mutual maintenance model proposes that post-traumatic stress disorder (PTSD) symptoms and chronic physical symptoms have a bi-directional temporal relationship. Despite widespread support for this model, there are relatively few empirical tests of the model and these have primarily examined patients with a traumatic physical injury.
Objective: To extend the assessment of this model, we examined the temporal relationship between PTSD and physical symptoms for military personnel deployed to combat (i.e., facing the risk of death) who were not evacuated for traumatic injury.
Methods: The current study used a prospective, longitudinal design to understand the cross-lagged relationships between PTSD and physical symptoms before, immediately after, 3 months after, and 1 year after combat deployment.
Results: The cross-lagged results showed physical symptoms at every time point were consistently related to greater PTSD symptoms at the subsequent time point. PTSD symptoms were related to subsequent physical symptoms, but only at one time-point with immediate post-deployment PTSD symptoms related to physical symptoms at three months after deployment.
Conclusion: The findings extend prior work by providing evidence that PTSD and physical symptoms may be mutually maintaining even when there is not a severe traumatic physical injury.
... Theoretically, mutual maintenance between pain and PTSD has been proposed (Liedl & Knaevelsrud, 2008;Sharp & Harvey, 2001); a view supported in recent non-systematic reviews (Beck & Clapp, 2011;Brennstuhl, Targuinio, & Montel, 2015). In a recent empirical testing of cross-lagged associations between pain and PTSD symptoms after whiplash, we found evidence of a main effect of PTSD symptoms on pain and not vice versa, suggesting only unidirectional and not bidirectional maintenance (Ravn, Sterling, Lahav, & Andersen, 2018). Hence, PTSD symptoms may contribute to poorer recovery in these patients. ...
... Further, these findings are indirectly partly supportive of the mutual maintenance proposal (Sharp & Harvey, 2001), suggesting that PTSD symptoms may contribute to a poorer recovery by negatively influencing and maintaining WAD symptoms. This is also in line with our recent study on the cross-lagged relationship between pain and PTSD symptoms after whiplash, where we found evidence of a main effect of PTSD symptoms on pain and not vice versa, suggesting that PTSD symptoms negatively affect and thereby maintain pain over time at certain time points post-injury (Ravn et al., 2018). In relation to the opposite scenario, that is, pain as a predictor of PTSD symptoms over time, the findings of Ravn et al. (2018) did not support this. ...
... This is also in line with our recent study on the cross-lagged relationship between pain and PTSD symptoms after whiplash, where we found evidence of a main effect of PTSD symptoms on pain and not vice versa, suggesting that PTSD symptoms negatively affect and thereby maintain pain over time at certain time points post-injury (Ravn et al., 2018). In relation to the opposite scenario, that is, pain as a predictor of PTSD symptoms over time, the findings of Ravn et al. (2018) did not support this. In the present study, pain was a significant predictor of group membership, but failed to distinguish between trajectories of decreasing or slightly increasing PTSD symptoms over time. ...
Background
Posttraumatic stress disorder (PTSD) symptoms are highly prevalent after whiplash and associated with pain‐related symptoms. While mutual maintenance between pain and PTSD has been suggested, knowledge on individual differences in the course of these symptoms is needed. The present study aimed to identify trajectories of PTSD symptoms following whiplash and test predictors and functional outcomes of such trajectories.
Methods
In a prospective cohort design with assessments at baseline (<4 weeks), 3 months, and 6 months post‐injury (n=229, whiplash‐grade I‐III), we identified PTSD‐trajectories using Latent Growth Mixture Modeling. Predictors (pain, fear‐avoidance‐beliefs, pain‐catastrophizing, depression, age, and gender) were tested using multinomial logistic regression, and group mean differences in physical and psychosocial pain‐related disability at 6 months after controlling for baseline levels were tested as outcomes.
Results
Three trajectories were identified: “Resilient” (75.1%) with little or no PTSD symptoms over time, “Recovering” (10.0%) with high initial PTSD symptom levels, then decreasing substantially, and “Chronic” (14.9%) with high initial PTSD symptom levels and a small increase over time. Initial higher pain and depression levels predicted the recovering and chronic trajectories, while the latter had more pain‐related disability at 6 months compared to both other trajectories.
Conclusions
Three trajectories were identified, with the chronic trajectory suggesting that a significant subset of people does not recover from PTSD symptoms. This class also reported more pain‐related disability. Pain and depression predicted membership, but did, however, not succeed in differentiating between the two high‐starting trajectories, suggesting that targeting PTSD symptoms may be important to ensure recovery.
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... None of the studies included assessment of preinjury status of the outcomes, which introduces a risk of performance bias relating to the selection of subjects, as it was generally not ensured that the participants did not have either preinjury pain or PTSD symptomatology. This was, however, partly addressed by Feinberg et al., 21 who excluded participants with non-MVCrelated axial pain above a certain threshold, and Ravn et al., 47 who excluded participants with previous whiplash-associated disorder. Most studies also had potential attrition bias with a significant subset of the sample dropping out over time, 16,29,37,56,60 with only Feinberg et al.'s 21 dropout rate not exceeding the recommended 20% and Ravn et al. 47 not reporting dropout rates at all. ...
... This was, however, partly addressed by Feinberg et al., 21 who excluded participants with non-MVCrelated axial pain above a certain threshold, and Ravn et al., 47 who excluded participants with previous whiplash-associated disorder. Most studies also had potential attrition bias with a significant subset of the sample dropping out over time, 16,29,37,56,60 with only Feinberg et al.'s 21 dropout rate not exceeding the recommended 20% and Ravn et al. 47 not reporting dropout rates at all. Four studies applied dropout analyses. ...
... Relatedly, none of the studies were explicitly clear about endorsement of criteria A1 and A2, something particularly important in studies when assessing PTSD symptomatology in samples exposed to objectively minor events. 21,47 Furthermore, there may exist potential confounding-related concerns. Although all studies included the risk of confounding to some degree in designing the study and discussing the results, this Month 2018 · Volume 00 · Number 00 www.painjournalonline.com 3 Table 1 Descriptive characteristics of included studies. ...
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 psychological status should be considered in the management of WAD, as patients present varying levels of post-traumatic stress symptoms [58]; symptoms that contribute to both the development and persistence of pain [58] and are associated to poor long-term recovery [59,60]. Moreover, some patients may have the belief that if they have suffered a serious injury, rest and allowing time to heal is the best approach [34]. ...
... The psychological status should be considered in the management of WAD, as patients present varying levels of post-traumatic stress symptoms [58]; symptoms that contribute to both the development and persistence of pain [58] and are associated to poor long-term recovery [59,60]. Moreover, some patients may have the belief that if they have suffered a serious injury, rest and allowing time to heal is the best approach [34]. ...
Objectives:
Acute as well as chronic pain syndromes are common after whiplash trauma and exercise therapy is proposed as one possible intervention strategy. The aim of the present systematic review was to evaluate the effect of exercise therapy in patients with Whiplash-Associated Disorders for the improvement of neck pain and neck disability, compared with other therapeutic interventions, placebo interventions, no treatment, or waiting list.
Content:
The review was registered in Prospero (CRD42017060356) and conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search in PubMed, Scopus and Cochrane from inception until January 13, 2020 was combined with a hand search to identify eligible randomized controlled studies. Abstract screening, full text assessment and risk of bias assessment (Cochrane RoB 2.0) were conducted by two independent reviewers.
Summary:
The search identified 4,103 articles. After removal of duplicates, screening of 2,921 abstracts and full text assessment of 100 articles, 27 articles that reported data for 2,127 patients were included. The included articles evaluated the effect of exercise therapy on neck pain, neck disability or other outcome measures and indicated some positive effects from exercise, but many studies lacked control groups not receiving active treatment. Studies on exercise that could be included in the random-effect meta-analysis showed significant short-term effects on neck pain and medium-term effects on neck disability.
Outlook:
Despite a large number of articles published in the area of exercise therapy and Whiplash-Associated Disorders, the current evidence base is weak. The results from the present review with meta-analysis suggests that exercise therapy may provide additional effect for improvement of neck pain and disability in patients with Whiplash-Associated Disorders.
... The findings of the present study join a growing body of research showing a significant relation between pain severity and PTSS in individuals with pain conditions [10,54,64]. Several explanations have been put forward to account for the relation between pain and PTSS. ...
Background
The present study assessed the role of perceived injustice in the experience and persistence of post-traumatic stress symptoms (PTSS) following work-related musculoskeletal injury.
Methods
The study sample consisted of 187 individuals who were absent from work as a result of a musculoskeletal injury. Participants completed measures of pain severity, perceived injustice, catastrophic thinking, post-traumatic stress symptoms, and disability on three occasions at three-week intervals.
Results
Consistent with previous research, correlational analyses revealed significant cross-sectional relations between pain and PTSS, and between perceived injustice and PTSS. Regression analysis on baseline data revealed that perceived injustice contributed significant variance to the prediction of PTSS, beyond the variance accounted for by pain severity and catastrophic thinking. Sequential analyses provided support for a bi-directional relation between perceived injustice and PTSS. Cross-lagged regression analyses showed that early changes in perceived injustice predicted later changes in PTSS and early changes in PTSS predicted later changes in perceived injustice.
Conclusions
Possible linkages between perceived injustice and PTSS are discussed. The development of effective intervention techniques for targeting perceptions of injustice might be important for promoting recovery of PTSS consequent to musculoskeletal injury.
... 21,46,164,165 Individuals with FND also have high rates of comorbid posttraumatic stress disorder where hyperarousal is a core symptom. 5 Elevated arousal, particularly when paired with negative valence, is known to trigger increased muscle tension that may relate to chronic pain 166,167 ; similar associations are also well accepted for gastrointestinal distress. 168 Additionally, it has been proposed that mood disorders including major depression also relate to allostatic mismanagement. ...
Functional neurological disorder (FND) reflects impairments in brain networks leading to distressing motor, sensory, and/or cognitive symptoms that demonstrate positive clinical signs on examination incongruent with other conditions. A central issue in historical and contemporary formulations of FND has been the mechanistic and etiological role of emotions. However, the debate has mostly omitted fundamental questions about the nature of emotions in the first place. In this perspective article, we first outline a set of relevant working principles of the brain (e.g., allostasis, predictive processing, interoception, and affect), followed by a focused review of the theory of constructed emotion to introduce a new understanding of what emotions are. Building on this theoretical framework, we formulate how altered emotion category construction can be an integral component of the pathophysiology of FND and related functional somatic symptoms. In doing so, we address several themes for the FND field including: 1) how energy regulation and the process of emotion category construction relate to symptom generation, including revisiting alexithymia, “panic attack without panic”, dissociation, insecure attachment, and the influential role of life experiences; 2) re-interpret select neurobiological research findings in FND cohorts through the lens of the theory of constructed emotion to illustrate its potential mechanistic relevance; and 3) discuss therapeutic implications. While we continue to support that FND is mechanistically and etiologically heterogenous, consideration of how the theory of constructed emotion relates to the generation and maintenance of functional neurological and functional somatic symptoms offers an integrated viewpoint that cuts across neurology, psychiatry, psychology, and cognitive-affective neuroscience.
... Ulirsch and colleagues [61] found that the avoidance symptom cluster was predictive for the number of regions with new pain symptoms in a sample of sexual assault survivors. Ravn et al. [62] identified the hyperarousal symptom cluster as a driving force behind the association of PTSD and pain. While the current study supports the finding that hyperarousal symptoms play a crucial role in the connection of PTSD and somatic symptoms, it also highlights the complexity of symptom interaction that cannot be reduced to sum-scores without loss of relevant information. ...
Co-occurrence of mental disorders including severe PTSD, somatic symptoms, and dissociation in the aftermath of trauma is common and sometimes associated with poor treatment outcomes. However, the interrelationships between these conditions at symptom level are not well understood. In the present study, we aimed to explore direct connections between PTSD, somatic symptoms, and dissociation to gain a deeper insight into the pathological processes underlying their comorbidity that can inform future treatment plans. In a sample of 655 adult inpatients with a diagnosis of severe PTSD following childhood abuse (85.6% female; mean age = 47.57), we assessed symptoms of PTSD, somatization, and dissociation. We analyzed the comorbidity structure using a partial correlation network with regularization. Mostly positive associations between symptoms characterized the network structure. Muscle or joint pain was among the most central symptoms. Physiological reactivation was central in the full network and together with concentrations problems acted as bridge between symptoms of PTSD and somatic symptoms. Headaches connected somatic symptoms with others and derealization connected dissociative symptoms with others in the network. Exposure to traumatic events has a severe and detrimental effect on mental and physical health and these consequences worsen each other trans-diagnostically on a symptom level. Strong connections between physiological reactivation and pain with other symptoms could inform treatment target prioritization. We recommend a dynamic, modular approach to treatment that should combine evidence-based interventions for PTSD and comorbid conditions which is informed by symptom prominence, readiness to address these symptoms and preference.
... Here, the psychological component of the integrative intervention aimed to target early PTSS on the basis of evidence that acute PTSS is an important psychological risk factor for poor recovery and, in a later stage, a significant precipitating and perpetuating factor for the condition. 32,42,43 Further, secondary mediation analysis showed that the effects of the integrated intervention on disability were exerted through decreased stress symptoms, the target of the intervention (Elphinston et al). 44 ...
Patients classified as having whiplash-associated disorder (WAD) grade II, which reflects approximately 93% of patients with WAD who are commonly managed by health care professionals, exhibit both physical (eg, pain and disability) and psychological (eg, fear of movement, anxiety, posttraumatic stress) problems that, in approximately 50% of cases, persist beyond 3 months. There is still much ongoing debate regarding factors predictive of poor recovery. The strongest associations have been found for high initial pain and disability following whiplash injury. In addition, a growing body of evidence supports the clinical importance of characteristic features, such as disturbed nociceptive processing (eg, local or general hyperalgesia to cold and mechanical stimuli), inefficient cognitions and beliefs about pain/movement/recovery, and posttraumatic stress symptoms, in the development and maintenance of physical and psychological manifestations in patients with WAD. For this reason, the field shifted away from single interventions that mainly follow a biomedical approach, such as exercise therapy and activity programs, to gold standard multimodal care (at least 2 distinct therapeutic modalities given by 1 or more health care professionals) that acknowledges the biopsychological nature of WAD. To date, there exist several multimodal care approaches to managing WAD; however, for most the efficacy has been found to be rather limited. One may argue that the limited success of some approaches can be attributed to the fact that they focused mainly on rehabilitating the physical symptoms (eg, pain, disability) rather than also the associated cognitive (eg, catastrophizing) and psychological (eg, posttraumatic stress symptoms) symptoms of the condition, leaving much room for improvement. In this article, current and previous evidence is used to explain why and how a comprehensive and multimodal treatment for people with WAD—consisting of a combination of pain neuroscience education, cognition-targeted exercise therapy, and stress management—can be applied in clinical practice.
... WAD is a condition that mainly results from road-traffic accidents after the acceleration/deceleration moment of the neck (Sterling, 2014). Persons suffering from WAD often complain of neck pain, stiffness, and associated symptoms, such as dizziness, nausea, balance and visual disturbances, and post-traumatic stress (Foreman & Croft, 2002;Mercer, Jackson, & Moore, 2007;Ravn, Sterling, Lahav, & Andersen, 2018;Sterling, 2014). The traumatic and sometimes frightening nature of the preceding event can also lead to fear and distress (Russell & Nicol, 2009). ...
Conceptual discussions related to clinical reasoning and decision making have evolved over the years from biomedical to incorporating more holistic approach to reasoning. Empirical studies exploring clinical reasoning and decision making in physiotherapy practice have mostly focused on aspects of managing persons with low back pain, such as exercise prescription, education and communicating diagnosis. There is a paucity of studies exploring decision making in whiplash‐associated disorder (WAD); thus, the aim of this study was to explore the physiotherapists' lived experiences of decision making related to treating persons with WAD.
A qualitative research design based on hermeneutic phenomenological methodology was used in this study. Five participants (physiotherapists) were purposefully recruited, and data are collected via semistructured interviews, which were recorded and transcribed verbatim. Interpretative phenomenological analysis (IPA) was used as a method for analysing the data. Emergent, superordinate and master themes emerged from the data to illuminate the lived experiences under exploration.
Three master themes were identified: (1) sense of collaboration; (2) sense of being out of control; and (3) sense of emotional engagement (subthemes: feeling of satisfaction and feelings of distress and uncertainty).
A sense of collaboration revealed varied meaning related to the role of persons receiving care, suggesting a lack of conceptual clarity related to shared‐decision making. A perceived loss of a sense of being in control was related to experienced emotions, such as feelings of distress and uncertainty. The findings of this study highlight the importance of providing space for reflection and mentoring in the workplace.
... A recent study was conducted to clarify the relationship between PTSD symptoms and pain in people with whiplash injuries (Ravn 2018). It was established that PTSD symptoms predicted levels of pain both in the first 3 months and from 6 months onwards. ...
More than 68 million people worldwide have been forcibly displaced and one-third of these are refugees. This article offers an overview of the current literature and reviews the epidemiology and evidence-based psychological and pharmacological management of post-traumatic stress disorder (PTSD), sleep disturbance and pain in refugees and asylum seekers. It also considers the relationship between sleep disturbance and PTSD and explores concepts of pain in relation to physical and psychological trauma and distress. During diagnosis, clinicians must be aware of ethnic variation in the somatic expression of distress. Treatments for PTSD, pain and sleep disturbance among refugees and asylum seekers are essentially the same as those used in the general population, but treatment strategies must allow for cultural and contextual factors, including language barriers, loss of freedom and threat of repatriation.
LEARNING OBJECTIVES
After reading this article you will be able to: • recognise the challenges faced by the large number of refugees worldwide
• understand the relationship between PTSD, sleep disturbance and pain in refugees
• broadly understand the evidence for psychological and pharmacological therapy for treating PTSD, sleep disturbance and pain in refugees.
DECLARATION OF INTEREST
None.
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).
Background
There is a high prevalence of posttraumatic stress disorder (PTSD) in patients with chronic pain. However, different patients are identified depending on the diagnostic system used. Moreover, it is unclear if the conceptualizations of PTSD are differently associated with outcomes of pain rehabilitation. Hence, the aims of the present study were first to explore the prevalence rates and diagnostic agreement of probable PTSD according to the ICD-11 and the DSM-5 screening tools (International Trauma Questionnaire [ITQ] vs. PTSD Checklist [PCL-5]), and secondly, to explore the associations of probable PTSD determined by ITQ and PCL-5 with psychological distress measures at baseline, and thirdly, the associations with pain and disability after pain rehabilitation adjusting for psychological covariates.
Methods
A consecutive cohort of patients with chronic non-malignant pain (n = 152) referred to a Danish interdisciplinary pain center was assessed at baseline prior to their first visit and at follow-up three days after completed treatment.
Results
The estimated probable PTSD baseline prevalence rates were 15.8% (ITQ) and 16.4% (PCL-5). However, the diagnostic agreement between the PCL-5 and the ITQ was only moderate (k = 0.64). Overall, compared to the ITQ probable PTSD according to the PCL-5 correlated more strongly with psychological distress. Only the ITQ was associated with poorer outcomes after rehabilitation, explaining alone 7–8% of the variance in disability and pain intensity adjusted for covariates.
Conclusions
The results underline the importance of taking the conceptualization and assessment of PTSD into consideration when investigating the impact of PTSD on pain rehabilitation.
Significance
There is a high prevalence of probable PTSD in patients with chronic pain. However, different patients with probable PTSD are identified depending on the diagnostic system used. Although similar probable PTSD prevalence rates (about 16%) were found using DSM-5 and ICD-11 PTSD screening tools (PCL-5 and ITQ, respectively), the diagnostic agreement between the systems was only moderate (k = 0.64). At the same time, only probable PTSD estimated according to the ITQ and not the PCL-5 was a significant predictor of disability after pain rehabilitation.
Comorbidity of pain and posttraumatic stress disorder is well recognized, but the reason for this association is unclear. This study investigated the direction of the relationship between pain and traumatic stress and the role that pain-related fear plays, for patients with acute whiplash-associated disorder. Participants (n = 99) used an electronic diary to record hourly ratings of pain, traumatic stress, and fear of pain (FOP) symptoms over a day. Relationships between pain, traumatic stress, and pain-related fear symptoms were investigated through multilevel models including variables lagged by 1 hour. Traumatic stress was associated with previous pain, even after controlling for previous traumatic stress and current pain; current pain was not associated with previous traumatic stress. The relationship between traumatic stress and previous pain became negligible after controlling for FOP, except for traumatic stress symptoms of hyperarousal that were driven directly by pain. Overall, these results support a pain primacy model, and suggest that pain-related fear is important in the maintenance and development of comorbid pain and traumatic stress symptoms. They also confirm that traumatic stress symptoms of hyperarousal are central in this relationship. Differences between this study and others that reported mutual maintenance can be understood in terms of different stages of whiplash-associated disorder and different intervals between repeated measurements. Traumatic stress may affect pain over longer time intervals than measured in this study. Future research could explore how relationships between traumatic stress symptoms, pain, and FOP change over time, and whether previous experiences of traumatic stress influence these relationships.
Objective
There are few effective treatments for acute whiplash-associated disorders (WAD). Early symptoms of postinjury stress predict poor recovery. This randomised controlled trial (StressModex) investigated whether physiotherapist-led stress inoculation training integrated with exercise is more effective than exercise alone for people with acute WAD.
Methods
108 participants (<4 weeks) at risk of poor recovery (moderate pain-related disability and hyperarousal symptoms) were randomly assigned by concealed allocation to either physiotherapist-led stress inoculation training and guideline-based exercise (n=53) or guideline-based exercise alone (n=55). Both interventions comprised 10 sessions over 6 weeks. Participants were assessed at 6 weeks and at 6 and 12 months postrandomisation. Analysis was by intention to treat using linear mixed models.
Results
The combined stress inoculation training and exercise intervention was more effective than exercise alone for the primary outcome of pain-related disability at all follow-up points. At 6 weeks, the treatment effect on the 0–100 Neck Disability Index was (mean difference) −10 (95% CI −15.5 to −9.0), at 6 months was −7.8 (95% CI −13.8 to −1.8) and at 12 months was −10.1 (95% CI −16.3 to −4.0). A significant benefit of the stress inoculation and exercise intervention over exercise alone was also found for some secondary outcomes.
Conclusion
A physiotherapist-led intervention of stress inoculation training and exercise resulted in clinically relevant improvements in disability compared with exercise alone—the most commonly recommended treatment for acute WAD. This contributes to the case for physiotherapists to deliver an early psychological intervention to patients with acute WAD who are otherwise at high risk of a poor outcome.
Trial registration number
ACTRN12614001036606.
Purpose:
The purpose of this study was to assess the psychometric properties of a Swedish version of the Posttraumatic Diagnostic Scale (PDS); to investigate the prevalence of traumatic experiences, trauma types, and posttraumatic stress disorder (PTSD) in a sample of patients seeking treatment for chronic pain; and to examine how indices of pain-related functioning vary with a history of traumatic exposure and PTSD diagnostic status.
Method:
Participants were 463 consecutive patients with chronic pain referred for assessment at the Pain Rehabilitation Unit at Skåne University Hospital.
Results:
The translated version of the PDS demonstrated high levels of internal consistency and a factor structure similar to that reported in previous validation studies using samples identified because of trauma exposure (not chronic pain), both of which provide preliminary support for the validity of this translated version. Based on their responses to the PDS, most patients (71.8%) reported one or more traumatic events with 28.9% fulfilling criteria for a current PTSD diagnosis. The patients with PTSD also reported significantly higher levels of pain interference, kinesiophobia, anxiety, and depression and significantly lower levels of life control, compared to patients exposed to trauma and not fulfilling criteria for PTSD and patients with no history of traumatic exposure.
Conclusion:
Consistent with previous research, a significant proportion of patients seeking treatment for chronic pain reported a history of traumatic exposure and nearly one third of these met current criteria for PTSD according to a standardized self-report measure. The presence of PTSD was associated with multiple indictors of poorer functioning and greater treatment need and provides further evidence that routine screening of chronic pain patients for PTSD is warranted. Self-report measures like the PDS appear to be valid for use in chronic pain samples and offer a relative low-cost method for screening for PTSD.
Cross-lagged panel analysis is an analytical strategy used to describe reciprocal relationships, or directional influences, between variables over time. Cross-lagged panel models (CLPM), also referred to as cross-lagged path models and cross-lagged regression models, are estimated using panel data, or longitudinal data where each observation or person is recorded at multiple points in time. The models are considered "crossed" because they estimate relationships from one variable to another and vice-versa. They are considered "lagged" because they estimate relationships between variables across different time points. Taken together, cross-lagged panel models estimate the directional influence variables have on each other over time. The primary goal of cross-lagged panel models is to examine the causal influences between variables. In essence, cross-lagged panel analysis compares the relationship between variable X at Time 1 and variable Y at Time 2 with the relationship between variable Y at Time 1 and X at Time 2. It is widely used to examine the stability and relationships between variables over time to better understand how variables influence each other over time. This entry discusses cross-lagged panel analysis, an analytical strategy used in longitudinal communication research. It describes its rationales and origins in research. It also describes modern path-analytic approaches to cross-lagged panel analysis. Finally, this entry discusses some important assumptions and issues with cross-lagged panel analysis. Directional Influences Basic methods for testing causality have several limitations. Correlational analysis relies on theoretical inferences to make arguments about causality.
Chronic pain and post-traumatic stress disorder (PTSD) are frequently observed within the Department of Veterans Affairs healthcare system and are often associated with a significant level of affective distress and physical disability. Clinical practice and research suggest that these two conditions co-occur at a high rate and may interact in such a way as to negatively impact the Course of either disorder; however, relatively little research has been conducted in this area. This review summarizes the current literature pertaining to the prevalence and development of chronic pain and PTSD. Research describing the comorbidity of both conditions is reviewed, and several theoretical models are presented to explain the mechanisms by which these two disorders may be maintained. Future directions for research and clinical implications are discussed.
PurposeThis paper presents a literature review of post-traumatic stress disorder (PTSD) and its link to chronic pain.Design and Methods
Twenty-four papers are reviewed (included research and reviews), with the goal of improving and updating our understanding on this issue and its theoretical and clinical repercussions.FindingsThe tight interdependence of symptoms that can be observed in both PTSD and chronic pain syndromes lends support to the idea that these disorders both constitute a reactive disorder.Practice ImplicationsVarious forms of therapy and treatment focus on PTSD, but chronic pain symptoms must also be assessed.
the type of models we discuss in this chapter fall under the larger heading of structural equation models (SEMs) for longitudinal data. Many different names have been used for these models, including causal models (Bentler, 1980; Kenny, 1979), cross-lagged panel models (Mayer, 1986), linear panel models (Greenberg & Kessler, 1982), and autoregres-sive cross-lagged models (Bollen & Curran, 2006). These models are also related to the autoregressive model and the simplex model. For simplicity, we refer to these models as panel models. What all these hold in common is that they are used to examine the struc-tural relations of repeatedly measured constructs. Recently, several authors have critiqued the frequent use of panel models. We believe that, although many of the criticisms are justi-fied, the panel model remains a useful tool for developmental scientists. Figure 16.1 shows a path diagram for a two-wave, two-variable panel model. Here two latent variables, X and Y, are measured on two occasions. For convenience, only the struc-tural portion of the model is displayed, and the underlying measurement model with mul-tiple indicators is omitted. See Little (in press) and Little, Preacher, Selig, and Card (2007) for a thorough treatment of measurement models for longitudinal data. This model can be described with the two following equations: Here, X and Y are two different constructs measured at two time points (denoted with a subscript 1 for time 1 and 2 for time 2). The linear regression coefficients b 1 and b 3 describe the autoregressive effects, or the effect of a construct on itself measured at a later time. The autoregressive effects describe the stability of the constructs from one occasion to the next.
Given the challenges of chronic musculoskeletal pain and disability, establishing a clear prognosis in the acute stage has become increasingly recognized as a valuable approach to mitigate chronic problems. Neck pain represents a condition that is common, potentially disabling, and has a high rate of transition to chronic or persistent problems. As a field of research, prognosis in neck pain has stimulated several empirical primary research papers, and a number of systematic reviews. As part of the International Consensus on Neck (ICON) project, we sought to establish the general state of knowledge in the area through a structured, systematic review of systematic reviews (overview).
An exhaustive search strategy was created and employed to identify the 13 systematic reviews (SRs) that served as the primary data sources for this overview. A decision algorithm for data synthesis, which incorporated currency of the SR, risk of bias assessment of the SRs using AMSTAR scoring and consistency of findings across SRs, determined the level of confidence in the risk profile of 133 different variables. The results provide high confidence that baseline neck pain intensity and baseline disability have a strong association with outcome, while angular deformities of the neck and parameters of the initiating trauma have no effect on outcome. A vast number of predictors provide low or very low confidence or inconclusive results, suggesting there is still much work to be done in this field. Despite the presence of multiple SR and this overview, there is insufficient evidence to make firm conclusions on many potential prognostic variables. This study demonstrates the challenges in conducting overviews on prognosis where clear synthesis critieria and a lack of specifics of primary data in SR are barriers.
In more than 90% of whiplash accidents a good explanation regarding the association between trauma mechanism, organic pathology, and persistent symptoms has failed to be provided.
We predicted that the severity of chronic whiplash-associated disorder (WAD), measured as number of whiplash symptoms, pain duration, pain-related disability, and degree of somatisation would be associated with the number of post-traumatic stress disorder symptoms (PTSD). Secondly, we expected attachment-anxiety to be a vulnerability factor in relation to both PTSD and WAD.
Data were collected from 1,349 women and 360 men suffering from WAD from the Danish Society for Polio, Traffic, and Accident Victims. The PTSD symptoms were measured by the Harvard Trauma Questionnaire. All three core PTSD clusters were included: re-experiencing, avoidance, and hyperarousal. Attachment security was measured along the two dimensions, attachment-anxiety and attachment-avoidance, by the Revised Adult Attachment Scale.
PTSD symptoms were significantly related to the severity of WAD. In particular, the PTSD clusters of avoidance and hyperarousal were associated with the number of whiplash symptoms, disability, and somatisation. Attachment-anxiety was significantly related to PTSD symptoms and somatisation but not to pain and disability. A co-morbidity of 38.8% was found between the PTSD diagnosis and WAD, and about 20% of the sample could be characterised as securely attached.
The PTSD clusters of avoidance and hyperarousal were significantly associated with severity of WAD. The study emphasises the importance of assessing PTSD symptomatology after whiplash injury. Furthermore, it highlights that attachment theory may facilitate the understanding of why some people are more prone to develop PTSD and WAD than others.
A number of theories have proposed possible mechanisms that may explain the high rates of comorbidity between posttraumatic stress disorder (PTSD) and persistent pain; however, there has been limited research investigating these factors.
The present study sought to prospectively examine whether catastrophizing predicted the development of PTSD symptoms and persistent pain following physical injury.
Participants (N=208) completed measures of PTSD symptomatology, pain intensity and catastrophizing during hospitalization following severe injury, and 3 and 12 months postinjury. Cross-lagged path analysis explored the longitudinal relationship between these variables.
Acute catastrophizing significantly predicted PTSD symptoms but not pain intensity 3 months postinjury. In turn, 3-month catastrophizing predicted pain intensity, but not PTSD symptoms 12 months postinjury. Indirect relations were also found between acute catastrophizing and 12-month PTSD symptoms and pain intensity. Relations were mediated via 3-month PTSD symptoms and 3-month catastrophizing, respectively. Acute symptoms did not predict 3-month catastrophizing and catastrophizing did not fully account for the relationship between PTSD symptoms and pain intensity.
Findings partially support theories that propose a role for catastrophizing processes in understanding vulnerability to pain and posttrauma symptomatology and, thus, a possible mechanism for comorbidity between these conditions.
The assessment of mediation in dyadic data is an important issue if researchers are to test process models. Using an extended version of the actor–partner interdependence model the estimation and testing of mediation is complex, especially when dyad members are distinguishable (e.g., heterosexual couples). We show how the complexity of the model can be reduced by assuming specific dyadic patterns. Using structural equation modeling, we demonstrate how specific mediating effects and contrasts among effects can be tested by phantom models that permit point and bootstrap interval estimates. We illustrate the assessment of mediation and the strategies to simplify the model using data from heterosexual couples.
This study aimed to evaluate processes from the mutual maintenance model in relation to daily functioning in patients with both chronic pain and a history of a traumatic experience. The mechanism illustrated the structural relations for daily functioning among pain intensity, hyperarousal, re-experiencing, trauma avoidance, and pain avoidance.
Archival data (N = 214) was used for this study and data were analyzed for 142 chronic pain patients reporting a traumatic experience and seeking treatment at a tertiary pain clinic in Korea.
The results indicated that pain intensity, hyperarousal, and pain avoidance had significant direct effects on daily functioning. Also, pain intensity showed significant indirect effects on daily functioning through hyperarousal and pain avoidance; and hyperarousal through pain avoidance.
Results suggest a direct contribution of high levels of pain, hyperarousal symptoms of PTSD, and pain avoidance behaviors to reduced daily functioning. Also, elevated pain as reminders of the trauma may trigger high levels of hyperarousal symptoms of PTSD. Subsequently, avoidant coping strategies may be used to minimize pain so that the trauma would not be re-experienced, thus inhibiting the activation of hyperarousal symptoms of PTSD. However, prolonged use of such strategies may contribute to decline in daily functioning.
The aims of this study were: to describe the frequency of whiplash-related symptoms and psychological factors in persons 5 years after a whiplash injury; to study the relationship between symptoms and psychological factors; to examine gender differences; and to investigate the cause of sick leave.
Questionnaires addressing neck pain, pain intensity, whiplash-related symptoms, post-traumatic stress, depression, social support and life satisfaction were used.
Neck pain was reported by 59% of subjects, whiplash-related symptoms (Rivermead Post-Concussion Symptoms Questionnaire, RPQ) by 76%, depression (Beck's Depression Inventory, BDI) by 22%, and post-traumatic stress (Impact of Event Scale, IES), by 38%. The scores of pain intensity and RPQ were correlated to BDI, IES and LiSat-11 scores. Men reported a lower level of quality of social support than women. Men reporting many symptoms also reported reduced availability of social interaction, whereas women with many symptoms reported reduced availability of attachment (i.e. lack of intimate partner, close family and friends). A multivariate logistic regression showed an association between sick leave and depression.
These findings indicate the importance of assessing possible relationships between symptoms, depression and post-traumatic stress in persons with long-term problems after whiplash injury, and of treating existing symptoms, especially depression. Because social support may play a role in recovery, social relationships should also be examined.
Two classes of modern missing data procedures, maximum likelihood (ML) and multiple imputation (MI), tend to yield similar results when implemented in comparable ways. In either approach, it is possible to include auxiliary variables solely for the purpose of improving the missing data procedure. A simulation was presented to assess the potential costs and benefits of a restrictive strategy, which makes minimal use of auxiliary variables, versus an inclusive strategy, which makes liberal use of such variables. The simulation showed that the inclusive strategy is to be greatly preferred. With an inclusive strategy not only is there a reduced chance of inadvertently omitting an important cause of missingness, there is also the possibility of noticeable gains in terms of increased efficiency and reduced bias, with only minor costs. As implemented in currently available software, the ML approach tends to encourage the use of a restrictive strategy, whereas the MI approach makes it relatively simple to use an inclusive strategy.
Post-traumatic stress disorder (PTSD) symptoms and pain after traumatic events such as motor vehicle collision (MVC) have been proposed to be mutually promoting. We performed a prospective multicenter study that enrolled 948 individuals who presented to the emergency department (ED) within 24 hours of MVC and were discharged home after evaluation. Follow-up evaluations were completed 6 weeks, 6 months, and 1 year after MVC. Path analysis results supported the hypothesis that axial pain after MVC consistently promotes the maintenance of hyperarousal and intrusive symptoms, from the early weeks post-injury through 1 year. In addition, path analysis results supported the hypothesis that one or more PTSD symptom clusters had an influence on axial pain outcomes throughout the year after MVC, with hyperarousal symptoms most influencing axial pain persistence in the initial months after MVC. The influence of hyperarousal symptoms on pain persistence was only present among individuals with genetic vulnerability to stress-induced pain, suggesting specific mechanisms by which hyperarousal symptoms may lead to hyperalgesia and allodynia. Further studies are needed to better understand the specific mechanisms by which pain and PTSD symptoms enhance one another after trauma, and how such mechanisms vary among specific patient subgroups, to better inform the development of secondary preventive interventions.
The fear avoidance model (FAM) has been proposed to explain the development of chronic disability in a variety of conditions including whiplash associated disorders (WAD). The FAM does not account for symptoms of posttraumatic stress and sensory hypersensitivity which are associated with poor recovery from whiplash injury. The aim of this study was to explore a model for the maintenance of pain and related disability in people with WAD including symptoms of PTSD, sensory hypersensitivity and FAM components. The relationship between individual components in the model and disability and how these relationships changed over the first 12 weeks post-injury were investigated.We performed a longitudinal study of 103 (74 female) patients with WAD. Measures of pain intensity, cold and mechanical pain thresholds, symptoms of posttraumatic stress, pain catastrophising, kinesiophobia and fear of cervical spine movement were collected within 6 weeks of injury and at 12 weeks post injury. Mixed model analysis using Neck Disability Index (NDI) scores and average 24 hour pain intensity as the dependent variables revealed that overall model fit was greatest when measures of fear of movement, post-traumatic stress and sensory hypersensitivity were included. The interactive effects of time with catastrophising, and time with fear of activity of the cervical spine were also included in the best model for disability. These results provide preliminary support for the addition of neurobiological and stress system components to the FAM to explain poor outcome in patients with WAD.
Background:
Knowledge about the course of recovery after whiplash injury is important. Most valuable is identification of prognostic factors that may be reversed by intervention. The mutual maintenance model outlines how post-traumatic stress symptoms (PTSS) and pain may be mutually maintained by attention bias, fear, negative affect and avoidance behaviours. In a similar vein, the fear-avoidance model describes how pain-catastrophizing (PCS), fear-avoidance beliefs (FA) and depression may result in persistent pain. These mechanisms still need to be investigated longitudinally in a whiplash cohort.
Methods:
A longitudinal cohort design was used to assess patients for pain intensity and psychological distress after whiplash injury. Consecutive patients were all contacted within 3 weeks after their whiplash injury (n = 198). Follow-up questionnaires were sent 3 and 6 months post-injury. Latent Growth Mixture Modelling was used to identify distinct trajectories of recovery from pain.
Results:
Five distinct trajectories were identified. Six months post-injury, 64.6% could be classified as recovered and 35.4% as non-recovered. The non-recovered (the medium stable, high stable and very high stable trajectories) displayed significantly higher levels of PTSS, PCS, FA and depression at all time points compared to the recovered trajectories. Importantly, PCS and FA mediated the effect of PTSS on pain intensity.
Conclusions:
The present study adds important knowledge about the development of psychological distress and pain after whiplash injury. The finding, that PCS and FA mediated the effect of PTSS on pain intensity is a novel finding with important implications for prevention and management of whiplash-associated disorders. WHAT DOES THIS STUDY ADD?: The study confirms the mechanisms as outlined in the fear-avoidance model and the mutual maintenance model. The study adds important knowledge of pain-catastrophizing and fear-avoidance beliefs as mediating mechanisms in the effect of post-traumatic stress on pain intensity. Hence, cognitive behavioural techniques targeting avoidance behaviour and catastrophizing may be beneficial preventing the development of chronic pain.
Objective:
Whiplash associated disorders (WAD) are common and incur substantial personal and economic costs. Research has shown that persistent posttraumatic stress reactions predict poorer functional recovery in WAD; however, the specific mechanism through which this occurs is unclear. The current study is the first to examine the direct impact of PTSD symptoms in WAD using laboratory tested pain measures.
Methods:
A mixed experimental design was used to examine the impact of exposure to accident cues on chronic WAD individuals with (n=33) and without (n=39) PTSD. Groups were compared at baseline and post accident cue on self-reported pain and negative affect and laboratory tested arousal and sensory pain threshold measures.
Results:
At baseline, WAD individuals with PTSD reported greater disability, negative affect, pain, arousal and lower pain thresholds than those without PTSD. As expected, exposure to accident cues resulted in greater increases in arousal and negative affect for those with PTSD. Changes in sensory pain thresholds revealed a hyperalgesic effect in cold pain thresholds for the PTSD group compared to the No PTSD group and mixed findings for pressure pain thresholds.
Discussion:
Findings from the current study highlight the negative impact of PTSD on both physical and psychological outcomes in chronic WAD. From a clinical perspective, data suggest that patients exposed to accident-cues may experience arousal that lowers their threshold to certain pain stimuli. Further investigation of effective multidisciplinary interventions and in particular the treatment of PTSD in WAD is identified as an important area of further investigation.
Unlabelled:
Military personnel returning from conflicts in Iraq and Afghanistan often endorse pain and posttraumatic stress disorder (PTSD) symptoms, either separately or concurrently. Associations between pain and PTSD symptoms may be further complicated by blast exposure from explosive munitions. Although many studies have reported on the prevalence and disability associated with polytraumatic injuries following combat, less is known about symptom maintenance over time. Accordingly, this study examined longitudinal interactive models of co-occurring pain and PTSD symptoms in a sample of 209 military personnel (mean age = 27.4 years, standard deviation = 7.6) who experienced combat-related blast exposure. Autoregressive cross-lagged analysis examined longitudinal associations between self-reported pain and PTSD symptoms over a 1-year period. The best-fitting covariate model indicated that pain and PTSD were significantly associated with one another across all assessment periods, χ² (3) = 3.66, P = .30, Tucker-Lewis index = .98, comparative fit index = 1.00, root mean squared error of approximation = .03. PTSD symptoms had a particularly strong influence on subsequent pain symptoms. The relationship between pain and PTSD symptoms is related to older age, race, and traumatic brain injury characteristics. Results further the understanding of complex injuries among military personnel and highlight the need for comprehensive assessment and rehabilitation efforts addressing the interdependence of pain and co-occurring mental health conditions.
Perspective:
This longitudinal study demonstrates that pain and PTSD symptoms strongly influence one another and interact across time. These findings have the potential to inform the integrative assessment and treatment of military personnel with polytrauma injuries and who are at risk for persistent deployment-related disorders.
The tendency to respond with fear and avoidance can be seen as a shared vulnerability contributing to the development of post-traumatic stress disorder (PTSD) and chronic pain. Although several studies have examined which specific symptoms of PTSD (re-experiencing, avoidance, emotional numbing and hyperarousal) are associated with chronic pain, none has considered this association within the framework of fear-avoidance models.
Seven hundred fourteen patients with chronic musculoskeletal pain were assessed. Of these, 149 patients were selected for the study based upon the following inclusion criteria: exposure to a traumatic event before the onset of pain (with scores equal to or higher than 8 points on the fear and hopelessness scales of the Stressful Life Event Screening Questionnaire Revised) and scores equal to or higher than 30 on the Davidson Trauma Scale.
Structural equation modelling was used to test the association between PTSD symptoms and pain outcomes (pain intensity and disability) using the mediating variables considered in the fear-avoidance models. The results show that emotional numbing and hyperarousal symptoms, but neither re-experiencing nor avoidance, affected pain outcome via anxiety sensitivity (AS), catastrophizing and fear of pain. PTSD symptoms increased the levels of AS, which predisposes to catastrophizing and, in turn, had an effect on the tendency of pain patients to respond with more fear and avoidance.
This study provides empirical support for the potential role of PTSD symptoms in fear-avoidance models of chronic pain and suggests that AS is a relevant variable in the relationship between both disorders.
Many traumatic events leave lingering physical injuries and chronic pain in their wake, in addition to trauma-related psychopathology. In this review, we provide an overview of developments in the recent literature on comorbid posttraumatic stress disorder (PTSD) and chronic pain. Starting with the conceptual models presented by Sharp and Harvey (2001) and Asmundson, Coons, Taylor, and Klatz (2002), this review summarizes newer studies that examine prevalence of these comorbid conditions. Additionally, we present an updated synthesis of research on factors that may maintain both chronic physical pain and PTSD in trauma survivors. Consideration of the impact of this comorbidity on psychosocial assessment and treatment also is discussed, with particular attention to issues that warrant additional research.
Recovery following a whiplash injury is varied, approximately: 50% of individuals fully recover, 25% develop persistent moderate/severe pain and disability, and 25% experience milder levels of disability. Identification of individuals likely to develop moderate/severe disability or to fully recover may help direct therapeutic resources and optimise treatment. A clinical prediction rule (CPR) is a research-generated tool used to predict outcomes such as likelihood of developing moderate/severe disability or experiencing full recovery from whiplash injury. The purpose of this study was to assess the plausibility of developing a CPR. Participants from two prospective, longitudinal studies that examined prognostic factors for poor functional recovery following whiplash injury were used to derive this tool. Eight factors, previously identified as predictor variables of poor recovery, were included in the analyses: initial neck disability index (NDI), initial neck pain (VAS), cold pain threshold, range of neck movement, age, gender, presence of headache and posttraumatic stress symptoms (PDS). An increased probability of developing chronic moderate/severe disability was predicted in the presence of older age, and initially higher levels of NDI and hyperarousal symptoms (PDS) (positive predictive value (PPV)=71%). The probability of full recovery was increased in younger individuals with initially lower levels of neck disability (PPV= 71%). This study provides initial evidence for a CPR to predict both chronic moderate/severe disability and full recovery following a whiplash injury. Further research is needed to validate the tool, determine the acceptability of the proposed CPR by practitioners, and assess the impact of inclusion in practice.
Context:
There are limited studies and few theoretical models addressing the interaction between pain and symptoms of post-traumatic stress disorder, with none concerning this interaction in survivors of torture, who frequently report persistent pain.
Objectives:
We aimed to explore the relationship between persistent pain and re-experiencing of traumatic events in survivors of torture.
Methods:
Nine torture survivors were interviewed about their experiences of pain and re-experiencing, and the results analyzed using interpretative phenomenological analysis. Levels of pain and post-traumatic stress were assessed.
Results:
Four superordinate themes emerged, namely "pain is the enemy," "pain and intrusive memories are connected," "changed identity," and "resilience and resources." These themes showed a complex relationship between torture, pain, re-experiencing, and other aspects of individual experience, such as the multiple losses experienced by torture survivors. Both pain and post-traumatic stress disorder symptoms were shown to have profound impacts on the everyday lives of participants.
Conclusion:
The results suggest that the relationship between pain and re-experiencing requires a broad model that considers the impact of a range of individual, social, and environmental factors on the interaction between pain and traumatic stress symptoms in survivors of torture. The study has clinical implications, most notably the need to attempt more integrated treatment of pain and traumatic symptoms where they occur together, and to consider the meaning and impact of pain when treating survivors of torture. Further investigation of the relationship between pain and traumatic stress symptoms in torture survivors is needed, as are studies of combined treatment for pain and trauma.
The present article reports on the development and validation of a self-report measure of posttraumatic stress disorder (PTSD), the Posttraumatic Diagnostic Scale (PTDS), that yields both a PTSD diagnosis according to
Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994
DSM-IV) criteria and a measure of PTSD symptom severity. Two-hundred forty-eight participants who had experienced a wide variety of traumas (e.g., accident, fire, natural disaster, assault, combat) were administered the PTSD module of the Structured Clinical Interview (SCID; Spitzer, Williams, Gibbons, & First, 1990), the PTDS, and scales measuring trauma-related psychopathology. The PTDS demonstrated high internal consistency and test-retest reliability, high diagnostic agreement with SCID, and good sensitivity and specificity. The satisfactory validity of the PTDS was further supported by its high correlations with other measures of trauma-related psychopathology. Therefore, the PTDS appears to be a useful tool for screening and assessing current PTSD in clinical and research settings. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
To review findings from recent research in consideration of relevant theoretical models between post-traumatic stress disorder (PTSD) and pain, and to review emerging interventions and prevention options for PTSD in individuals with whiplash.
A traumatic accident may lead to whiplash injury, but can also frequently lead to post-traumatic stress. There is concern that this occurrence is more problematic than each disorder separately. Furthermore, it is unclear why this might occur. This review addresses two mechanisms that might explain this, specifically arousal and pain.
There is a growing body of research revealing relationships between injury, pain and psychological trauma with important implications for the prevention and management of chronic pain and post-traumatic reactions. Intervention for PTSD in the context of whiplash has been shown to be effective, and seems to have a beneficial effect on the whiplash injury. The intervention for traumatic stress in acute whiplash presents further challenges.
This chapter will review findings from recent research in consideration of relevant theoretical models between PTSD and pain in general and more specifically in the case of pain resulting from whiplash injury. A review of emerging interventions and prevention options for PTSD in individuals with whiplash will also be discussed to provide a basis for treatment of individuals and future research.
Recent work in this area suggests that stress, pain and arousal interact through the effects of tissue injury and the distress in response to perceived threat. Post-traumatic stress plays an important role in a significant proportion of whiplash sufferers as its presence seems to deleteriously impact recovery.
Intervention for PTSD in the context of whiplash has been shown to be effective, and seems to have a beneficial effect on the whiplash injury. The intervention for traumatic stress in acute whiplash presents further challenges.
Pain and Post Traumatic Stress Disorder (PTSD) are highly comorbid conditions. Patients with chronic pain have higher rates of PTSD. Likewise, patients with PTSD are often diagnosed with numerous chronic pain conditions. Despite the high pain-PTSD comorbidity, the neurobehavioral mechanisms underlying this phenomenon are incompletely understood and only recently researchers have started investigating it using experimental models. In this article, we systematically review the substantial clinical evidence on the co-occurrence of pain and PTSD, and the limited experimental evidence of pain processing in this disorder. We provide a detailed overview of the psychophysical and brain imaging experiments that compared somatosensory and pain processing in PTSD and non-PTSD populations. Based on the presented evidence, an extensive body of literature substantiates the clinical coexistence of pain and PTSD in patients but the limited experimental data show inconsistent results highlighting the need for well-controlled future studies. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.
Distinct developmental trajectories for neck disability and posttraumatic stress disorder (PTSD) symptoms after whiplash injury have recently been identified. This study aimed to identify baseline predictors of membership to these trajectories and to explore their dual development. In a prospective study, 155 individuals with whiplash were assessed at <1 month, 3, 6, and 12 months postinjury. Outcomes at each time point were assessed according to the Neck Disability Index and the Posttraumatic Stress Diagnostic Scale. Baseline predictor variables were age, gender, initial pain (based on a visual analogue scale [VAS]), pressure pain thresholds (PPT), cold pain thresholds (CPT), and sympathetic vasoconstrictor responses. Group-based trajectory analytical techniques were used to parameterise the optimal trajectories and to identify baseline predictors. A dual trajectory analysis was used to explore probabilities of conditional and joint trajectory group membership. CPT > or = 13° C (OR = 26.320, 95% CI = 4.981-139.09), initial pain level (VAS) (OR = 4.3, 95% CI = 4.98-139.1), and age (OR = 1.109, 95% CI = 1.043-1.180) predicted a chronic/severe disability trajectory. The same baseline factors also predicted chronic moderate/severe PTSD (CPT > or = 13° C, OR = 9.7, 95% CI = 2.22-42.44; initial pain level [VAS]: OR = 2.13, 95% CI = 1.43-3.17; age: OR = 1.07, 95% CI = 1.01-1.14). There was good correspondence of trajectory group for both disability and PTSD. These findings support the proposal of links between the development of chronic neck related disability and PTSD after whiplash injury. Developmental trajectories of disability and posttraumatic stress disorder (PTSD) after whiplash injury are mostly in synchrony, and similar factors predict their membership. This suggests links between the development of chronic neck pain-related disability and PTSD.
Recent models of the relationship between posttraumatic stress and whiplash pain suggest that psychological stress relating to a motor vehicle crash may influence pain perception. The mechanisms of this relationship may be through more direct, psychological pathways, or through factors proposed by the fear-avoidance models of chronic pain. This study sought to investigate the relative contribution of fear-of-pain and trauma symptomatology to daily pain and time spent in an upright posture (uptime) in chronic whiplash-associated disorder (WAD).
Hourly electronic-diary reports were used to explore the within-day relationship of psychological trauma symptoms and fear-of-pain to same-hour and next-hour pain reports and next-hour uptime (measured by accelerometers) in 32 individuals with a chronic WAD. Within-person effects were analyzed for 329 diary entries using multilevel modeling with fixed slopes and random intercepts.
Reports of trauma-related hyperarousal were associated with greater same-hour pain, and this relationship was mediated by fear-of-pain. Fear-of-pain and uptime were independently associated with reports of increased next-hour pain (controlling for first-order serial autocorrelation). Fear-of-pain was unrelated to next-hour uptime, but trauma-related avoidance symptoms were associated with reduced uptime. This study supports the relationship between psychological trauma responses and pain, suggesting behavioral (avoidance) pathways and effects on pain perception through fear-of-pain. These findings reinforce the need to evaluate traumatic stress as a factor in recovery from WAD.
To (1) use structural equation modeling (SEM) to examine relationships proposed in Turk's diathesis-stress model of chronic pain and disability as well as (2) investigate what role, if any, posttraumatic stress symptoms (PTSS) play in predicting pain disability, relative to some of the other factors in the model.
The study sample consisted of 208 patients scheduled for general surgery, 21 to 60 years of age (mean age=47.18 y, SD=9.72 y), who reported experiencing persistent pain for an average of 5.56 years (SD=7.90 y). At their preadmission hospital visit, patients completed the Anxiety Sensitivity Index, Pain Catastrophizing Scale, Pain Anxiety Symptoms Scale-20, Pain Disability Index, posttraumatic stress disorder Checklist, and rated the average intensity of their pain (0 to 10 numeric rating scale). SEM was used to test a model of chronic pain disability and to explore potential relationships between PTSS and factors in the diathesis-stress model.
SEM results provided support for a model in which anxiety sensitivity predicted fear of pain and catastrophizing, fear of pain predicted escape/avoidance, and escape/avoidance predicted pain disability. Results also provided support for a feedback loop between disability and fear of pain. SEM analyses provided preliminary support for the inclusion of PTSS in the diathesis-stress model, with PTSS accounting for a significant proportion of the variance in pain disability.
Results provide empirical support for aspects of Turk's diathesis-stress model in a sample of patients with persistent pain. Findings also offer preliminary support for the role of PTSS in fear-avoidance models of chronic pain.
This study aimed to identify distinctive trajectories for pain/disability and posttraumatic stress disorder (PTSD) symptoms following whiplash injury and to examine the effect of injury compensation claim lodgement on the trajectories. In a prospective study, 155 individuals with whiplash were assessed at <1month, 3, 6 and 12months post injury. Outcomes at each time point were Neck Disability Index (NDI) and the Posttraumatic Stress Diagnostic Scale (PDS). Group-based trajectory analytical techniques were used to identify outcome profiles. The analyses were then repeated after including third party compensation claim lodgment as a binary time-changing covariate. Three distinct NDI trajectories were determined: (1) Mild: mild or negligible pain/disability for the entire 12 months (45%), (2) Moderate: initial moderate pain/disability that decreased to mild levels by 3 months (39%) and (3) Chronic-severe: severe pain/disability persisting at moderate/severe levels for 12 months (16%). Three distinct PTSD trajectories were also identified: (1) Resilient: mild symptoms throughout (40%), (2) Recovering: initial moderate symptoms declining to mild levels by 3months (43%) and (3) Chronic moderate-severe: persistent moderate/severe symptoms throughout 12 months (17%). Claim submission had a detrimental effect on all trajectories (p<0.001) except for the Chronic-severe NDI trajectory (p=0.098). Following whiplash injury, there are distinct pathways of recovery for pain/ disability and PTSD symptoms. Management of whiplash should consider the detrimental association of compensation claim with psychological recovery and recovery of those with mild to moderate pain/disability levels. However, claim lodgement has no significant association with a more severe pain and disability trajectory.
The relationship between acute stress disorder (ASD), posttraumatic stress disorder symptoms (PTSD), and chronic pain was investigated in a longitudinal study of injured accident victims (N = 323, 64.7% men). Assessments took place 5 days (T1), 6 (T2) months, and 12 (T3) months postaccident. Relations between pain and posttraumatic stress symptoms were tested by structural equation modeling. Subjects diagnosed with full or subsyndromal PTSD at T2 and at T3 (14 and 19%) reported significantly higher pain intensity. Cross-lagged panel analysis yielded a mutual maintenance of pain intensity and ASD or PTSD symptoms across T2. Across the second half year, PTSD symptoms impacted significantly on pain but not vice versa. Clinicians need to pay careful attention to PTSD symptoms in accident survivors suffering from chronic pain.
Pain and post-traumatic stress disorder (PTSD) are frequently co-morbid in the aftermath of a traumatic event. Although several models attempt to explain the relationship between these two disorders, the mechanisms underlying the relationship remain unclear. The aim of this study was to investigate the relationship between each PTSD symptom cluster and pain over the course of post-traumatic adjustment.
In a longitudinal study, injury patients (n=824) were assessed within 1 week post-injury, and then at 3 and 12 months. Pain was measured using a 100-mm Visual Analogue Scale (VAS). PTSD symptoms were assessed using the Clinician-Administered PTSD Scale (CAPS). Structural equation modelling (SEM) was used to identify causal relationships between pain and PTSD.
In a saturated model we found that the relationship between acute pain and 12-month pain was mediated by arousal symptoms at 3 months. We also found that the relationship between baseline arousal and re-experiencing symptoms, and later 12-month arousal and re-experiencing symptoms, was mediated by 3-month pain levels. The final model showed a good fit [chi2=16.97, df=12, p>0.05, Comparative Fit Index (CFI)=0.999, root mean square error of approximation (RMSEA)=0.022].
These findings provide evidence of mutual maintenance between pain and PTSD.
Posttraumatic Stress Disorder (PTSD) and chronic pain are frequently seen in the aftermath of a traumatic experience. Torture survivors have an increased risk to suffer from these two disorders. Although many studies report high comorbidity,there is still insufficient knowledge on the mechanisms of the development and maintenance of PTSD and chronic pain. After providing an overview of the current literature concerning the comorbidity of these two disorders, we will present the "Perpetual Avoidance Model" (PAM). This model provides an explanation of the reciprocal maintenance of both disorders and offers treatment implications.
The assessment of a measure of chronic pain, should be reliable, valid and sensitive to change. Our study evaluated the reliability of 3 pain scales, visual analogue scale (VAS), numerical rating scale (NRS) and verbal rating scale (VRS) in literate and illiterate patients with rheumatoid arthritis (RA). Patients with RA attending an outpatient rheumatology clinic were interviewed and asked to score their pain levels on the 3 pain scales. The scales were presented in random order, twice, before and just after a regular medical consultation. Ninety-one patients were studied (25 illiterate and 66 literate). The Pearson product moment correlation between first and second assessment was 0.937 for VAS, 0.963 for NRS and 0.901 for VRS in the literate patient group and 0.712 for VAS, 0.947 for NRS and 0.820 for VRS in the illiterate patient group. These results indicate that the NRS has the higher reliability in both groups of patients.
Among 43 patients referred to a psychiatrist for evaluation of their pain, 27 had organic disease related to their complaint and another 16 patients had pain but did not have related organic disease. The group with organic disease had been shown to have evidence of anxiety and depression. The experience of pain of the patients in both groups was investigated using a scale of clinical descriptions, a 10 cm analogue scale, an audiometric method recommended by Peck, and a pressure algometer. The groups were alike in respect of the level of the subjective estimates of severity of pain. There was a very significant positive correlation between the descriptive method and the ten cm analogue scale and a less marked correlation between each of the two latter techniques and the audiometric method.
Visual analogue scales (VAS) of sensory intensity and affective magnitude were validated as ratio scale measures for both chronic and experimental pain. Chronic pain patients and healthy volunteers made VAS sensory and affective responses to 6 noxious thermal stimuli (43, 45, 47, 48, 49 and 51 degrees C) applied for 5 sec to the forearm by a contact thermode. Sensory VAS and affective VAS responses to these temperatures yielded power functions with exponents 2.1 and 3.8, respectively; these functions were similar for pain patients and for volunteers. The power functions were predictive of estimated ratios of sensation or affect produced by pairs of standard temperatures (e.g. 47 and 49 degrees C), thereby providing direct evidence for ratio scaling properties of VAS. Vas sensory intensity responses to experimental pain, VAS sensory intensity responses to different levels of chronic pain, and direct temperature (experimental pain) matches to 3 levels of chronic pain were all internally consistent, thereby demonstrating the valid use of VAS for the measurement of and comparison between chronic pain and experimental heat pain.
In an attempt to explain how and why some individuals with musculoskeletal pain develop a chronic pain syndrome, Lethem et al. (Lethem J, Slade PD, Troup JDG, Bentley G. Outline of fear-avoidance model of exaggerated pain perceptions. Behav Res Ther 1983; 21: 401-408).ntroduced a so-called 'fear-avoidance' model. The central concept of their model is fear of pain. 'Confrontation' and 'avoidance' are postulated as the two extreme responses to this fear, of which the former leads to the reduction of fear over time. The latter, however, leads to the maintenance or exacerbation of fear, possibly generating a phobic state. In the last decade, an increasing number of investigations have corroborated and refined the fear-avoidance model. The aim of this paper is to review the existing evidence for the mediating role of pain-related fear, and its immediate and long-term consequences in the initiation and maintenance of chronic pain disability. We first highlight possible precursors of pain-related fear including the role negative appraisal of internal and external stimuli, negative affectivity and anxiety sensitivity may play. Subsequently, a number of fear-related processes will be discussed including escape and avoidance behaviors resulting in poor behavioral performance, hypervigilance to internal and external illness information, muscular reactivity, and physical disuse in terms of deconditioning and guarded movement. We also review the available assessment methods for the quantification of pain-related fear and avoidance. Finally, we discuss the implications of the recent findings for the prevention and treatment of chronic musculoskeletal pain. Although there are still a number of unresolved issues which merit future research attention, pain-related fear and avoidance appear to be an essential feature of the development of a chronic problem for a substantial number of patients with musculoskeletal pain.
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.
Reliable and valid measures of pain are needed to advance research initiatives on appropriate and effective use of analgesia in the emergency department (ED). The reliability of visual analog scale (VAS) scores has not been demonstrated in the acute setting where pain fluctuation might be greater than for chronic pain. The objective of the study was to assess the reliability of the VAS for measurement of acute pain.
This was a prospective convenience sample of adults with acute pain presenting to two EDs. Intraclass correlation coefficients (ICCs) with 95% confidence intervals (95% CIs) and a Bland-Altman analysis were used to assess reliability of paired VAS measurements obtained 1 minute apart every 30 minutes over two hours.
The summary ICC for all paired VAS scores was 0.97 [95% CI = 0.96 to 0.98]. The Bland-Altman analysis showed that 50% of the paired measurements were within 2 mm of one another, 90% were within 9 mm, and 95% were within 16 mm. The paired measurements were more reproducible at the extremes of pain intensity than at moderate levels of pain.
Reliability of the VAS for acute pain measurement as assessed by the ICC appears to be high. Ninety percent of the pain ratings were reproducible within 9 mm. These data suggest that the VAS is sufficiently reliable to be used to assess acute pain.
This study investigates the relationship between posttraumatic stress disorder (PTSD) symptoms (avoidance, reexperiencing, and hyperarousal) and the presence, severity, and duration of neck complaints after motor vehicle accidents.
Individuals who had been involved in traffic accidents and had initiated compensation claim procedures with a Dutch insurance company were sent questionnaires (Q1) containing complaint-related questions and the Self-Rating Scale for PTSD. Of the 997 questionnaires that were dispatched, 617 (62%) were returned. Only car accident victims were included in this study (n=240). Complaints were monitored using additional questionnaires that were administered 6 months (Q2) and 12 months (Q3) after the accident.
PTSD was related to the presence and severity of concurrent post-whiplash syndrome. More specifically, the intensity of hyperarousal symptoms that were related to PTSD at Q1 was found to have predictive validity for the persistence and severity of post-whiplash syndrome at 6 and 12 months follow-up.
Results are consistent with the idea that PTSD hyperarousal symptoms have a detrimental influence on the recovery and severity of whiplash complaints following car accidents.
Chronic whiplash-associated disorder (WAD) represents a major medical and psycho-social problem. The typical symptomatology presented in WAD is to some extent similar to symptoms of post traumatic stress disorder. In this study we examined if the acute stress reaction following a whiplash injury predicted long-term sequelae. Participants with acute whiplash-associated symptoms after a motor vehicle accident were recruited from emergency units and general practitioners. The predictor variable was the sum score of the impact of event scale (IES) completed within 10 days after the accident. The main outcome-measures were neck pain and headache, neck disability, general health, and working ability one year after the accident. A total of 737 participants were included and completed the IES, and 668 (91%) participated in the 1-year follow-up. A baseline IES-score denoting a moderate to severe stress response was obtained by 13% of the participants. This was associated with increased risk of considerable persistent pain (OR=3.3; 1.8-5.9), neck disability (OR=3.2; 1.7-6.0), reduced working ability (OR=2.8; 1.6-4.9), and lowered self-reported general health one year after the accident. These associations were modified by baseline neck pain intensity. It was not possible to distinguish between participants who recovered and those who did not by means of the IES (AUC=0.6). In conclusion, the association between the acute stress reaction and persistent WAD suggests that post traumatic stress reaction may be important to consider in the early management of whiplash injury. However, the emotional response did not predict chronicity in individuals.
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