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Cognitive processing of itch and pain: the role of attention and expectations.
... Cognitive processes, such as attention, cognitions, and beliefs, play an important role in the processing of somatosensory input, also for itch. Although only a few studies are available, studies confirm that cognitive processes play a prominent role in the experience of itch Van Laarhoven, Peerdeman, Van Ryckeghem, & Evers, 2020). Below, we discuss what is known about the role of attention and cognition in itch. ...
... The capture of attention by itch may be adaptive in the short term, but when itch is persistent, the attentional capture may become dysfunctional and worsen symptoms Verhoeven et al, 2008). Although heightened attention towards somatosensory signals is well documented in the field of pain (e.g., Van Laarhoven et al, 2020), this is not yet the case for patients with chronic itch and evidence in healthy individuals does not point towards attention allocation towards the itch location . Nevertheless, studies have revealed that itch stimuli can hinder concurrent performance of tasks , that more attention to bodily sensation seems associated with higher experimental itch sensitivity (Van Laarhoven, Kraaimaat, Wilder-Smith, & Evers, 2010), and that patients with chronic itch bias their attention to itch-related words . ...
... Nevertheless, studies have revealed that itch stimuli can hinder concurrent performance of tasks , that more attention to bodily sensation seems associated with higher experimental itch sensitivity (Van Laarhoven, Kraaimaat, Wilder-Smith, & Evers, 2010), and that patients with chronic itch bias their attention to itch-related words . Also, visual and audio-representations of itch sensations, such as insects crawling on the skin, people talking about itch, or pictures of scratching people, draw attention and lead to itch (Schut, Grossman, Gieler, Kupfer, & Yosipovitch, 2015;Van Laarhoven et al, 2020). These "contagious itch" effects seem to be more pronounced in patients than in healthy individuals (Schut et al, 2015). ...
Itch is a common and burdensome symptom in various somatic and psychiatric conditions, and its experience is influenced by various psychological factors, including cognitions, behavior, and emotions. Moreover, psychological factors can be both a cause and a consequence of itch. Optimal itch management is multidisciplinary in nature and aims to combine medical treatment with interventions to change psychological influencing factors. In this chapter, the evidence for psychological influences on itch, and how these can be assessed and addressed in psychological interventions, is discussed. Based on new insights from clinical and experimental research, future directions for research and clinical practice are explored.
... Focusing attention on potential threat is essential to sort its nocifensive function and protect skin integrity (9,10). Since attention may play a central role in the vicious circle of itch amplification (11) and psychological burden (12)(13)(14)(15)(16), interventions targeting attention to itch seem promising. ...
... Additionally, of the individual characteristics, only neuroticism was associated with a larger training effect, specifically with an increase in mechanically evoked itch in the condition trained towards itch. In sum, although we expected ABM-training to be promising for itch, given the contagiousness and attention-capturing characteristics of itch (6,13,15), we can conclude that the hypotheses could not be confirmed. Given the novelty of an ABM-training for itch, comparing current findings with findings of previous ABM-trainings for pain may provide some further insight. ...
Itch draws our attention to allow imposing action against bodily harm (e.g., remove insects). At the same time, itch is found to interfere with ongoing tasks and daily life goals. Despite the key role of attention in itch processing, interventions that train individuals to automatically disengage attention from itch cues are lacking. The present proof-of-principle attention bias modification (ABM) training study was aimed at investigating whether attention to itch as well as sensitivity to mild itch can be changed. Healthy volunteers were randomized over three ABM-training conditions. Training was done via a modified pictorial dot-probe task. In particular, participants were trained to look away from itch stimuli ( n = 38), toward itch stimuli ( n = 40) or not trained toward or away from itch at all (sham training, n = 38). The effects of the ABM-training were tested primarily on attention to itch pictures. Secondarily, it was investigated whether training effects generalized to alterations in attention to itch words and mechanical itch sensitivity. The ABM-training did not alter attention toward the itch pictures, and there was no moderation by baseline levels of attention bias for itch. Also, attention bias to the itch words and itch sensitivity were not affected by the ABM-training. This study was a first step toward trainings to change attention toward itch. Further research is warranted to optimize ABM-training methodology, for example increasing motivation of participants. Eventually, an optimized training could be used in patient populations who suffer most from distraction by their symptoms of itch.
Clinical Trial Registration: Identifier: NL6134 (NTR6273). The website URL is: https://www.trialregister.nl/
... Psychological processes play an important role in how itch is experienced. A biopsychosocial model of itch has been proposed that emphasizes the role of psychological factors in itch experience (8,9). For instance, stress and anxiety exacerbate chronic itch in patients with dermatological conditions (10,11). ...
Contagious itch can be evoked by observing people scratching. Verbal suggestions about to-be-received itch can influence itch intensity, as shown by placebo research, but it is unknown whether this extends to contagious itch. The current study aimed to replicate prior findings that listening to scratching and rubbing sounds elicits contagious itch, and to investigate whether suggestions can modulate this process. Healthy participants (n=140) received positive or negative suggestions about itch in response to the sounds (aimed to decrease or increase expected itch, respectively), or no specific suggestions as a control. Participants listened to a number of audio fragments with scratching and rubbing sounds. The amount of expected itch as well as itch sensation after each audio fragment were measured by self-report. Suggestions had no effect on the expected itch. Both rubbing and scratching sounds significantly elicited itch in all groups. Scratching sounds induced more itch than rubbing sounds exclusively in the control group. These findings indicate that short suggestions might be not effective enough to modify the expectations of people regarding contagious itch. Furthermore, suggestions modulate contagious itch to some degree, but not in the hypothesized direction. Potential similarities and differences in the neurobiological mechanisms of contagious itch and nocebo effects are discussed.
... However, as these effects could not be replicated within the current more fine-grained time segment analyses this effects needs replication in the future. Cognitivemotivational models of pain, which can be translated to itch [52] , state that pain overrules competing attentional demands, such as daily activities, in order to alarm the individual of potential bodily harm and activate related behavioral strategies, for example, avoidance, which makes sense for itch and pain, and could explain why the interference of a vibrotactile stimulus vanishes after a few seconds [1,3,4,6,53,54] . ...
Introduction
Attentional processes are involved in the experience of itch and pain. They interrupt task performance (ie, attentional interference) or bias allocation of attention toward the somatosensory stimulation, that is, attentional bias (AB). Research on AB toward pain is mostly focused on stimuli with short durations; hampering generalization to tonic pain sensations. Evidence for AB toward itch is lacking so far. This study investigated attentional interference by—and AB toward—experimentally induced tonic itch and pain.
Methods
Fifty healthy volunteers performed a somatosensory attention task (SAT), that measured attentional interference and AB during tonic (35 s duration) pain, itch and vibrotactile stimuli. In addition, a dot-probe task measured AB toward visual representations of itch and pain, a Flanker task was used to assess attentional inhibition, and self-reported characteristics were measured.
Results
Attentional interference during itch and pain stimuli compared with vibrotactile stimuli was found during the SAT. Exploration of shorter time segments within one tonic stimulus showed slowed responses for all three stimulus types during the first 5 seconds of stimulation. However, no prolonged interference in the following time segments was found. There was no AB toward somatosensory and visual stimuli. Furthermore, there was no association between any of the attentional measures and self-reported characteristics.
Discussion
These findings suggest that the beginning of any somatosensory stimulus is interfering with cognitive performance, but the results for prolonged interference by itch and pain are equivocal. There was no indication for biased attention allocation. Whether this pattern is different in patients remains to be investigated in the future.
... Alternatively, observational learning may be an effective process for inducing nocebo effects on pain, but not on itch, at least in healthy individuals. In healthy participants the threat from pain may be seen as greater than that of itch, and therefore itch may not attract the same attention necessary for observational learning as pain does (29). Finally, as the sample size was calculated based on research assessing an effect for live classical conditioning with verbal suggestion, future studies with sufficient statistical power to test for an effect of observational learning are needed to assess the role it may play in nocebo effects on itch. ...
To investigate learning processes underlying nocebo effects on itch, this study measured the efficacy of classical conditioning and observational learning for inducing nocebo effects on cowhage-evoked itch and scratching behaviour. A total of 58 healthy female participants were assigned to classical conditioning, observational learning, or sham conditioning groups. In the classical conditioning group, experimenters associated the application of an inert gel with increased itch intensity themselves. In the observational learning group, a video of the conditioning paradigm was shown. Nocebo effects were measured as the difference in itch or scratching between control and nocebo test phase trials, compared between learning and control groups. Compared with sham conditioning, classical conditioning induced a significant nocebo effect on itch, while observational learning did not. No nocebo effect on scratching was detected. These results highlight the role that learning through direct experiences plays in pruritic symptoms. Future research should investigate how a patient's history of unsuccessful treatments shapes treatment outcomes.
Introduction
Itch is unpleasant and induces the urge to scratch. This is adaptive to remove the itch-inducing stimulus from the skin. Accordingly, itch draws attention to protect our bodily integrity. Recent studies investigated whether attention is preferentially drawn towards its location, i.e., attentional bias (AB), and also whether this bias could be changed in healthy individuals. So far, results are mixed concerning the existance of an attentional bias towards itch stimuli in healthy individuals as well as the impact of modifications. However, available studies have typically focused on conscious processing and might miss preconscious aspects of attention and potential biases at these stages.
Methods
This study included 117 healthy individuals who underwent a subliminal Attentional Bias Modification (ABM)- training for itch based on a dot-probe paradigm with itch- related pictures. Participants were randomly assigned to a training towards itch group, a training away from itch group and a control group. This was done by manipulating the itch-target congruency of the dot-probe task during a training block. Pre- and post-training assessments were regular dot-probe tasks. Exploratorily, also attentional inhibition, cognitive flexibility and itch-related cognitions were assessed. Lastly, participants received an itchy stimulus on the inner forearm before and after the ABM-training to assess potential effects on itch sensitivity.
Results
Results showed no AB towards itch across groups at baseline, i.e., pre-training, but an AB away from itch, hence, avoidance of itch, post-training. Further analyses showed that this effect was driven by an attentional bias away from itch in the control group, while there were no significant effects in the experimental groups. There was no effect on itch sensitivity.
Conclusion
These findings are in line with recent studies on conscious ABM-training for itch and pain that also did not find significant training effects. Therefore, it is suggested that the field of AB might need to reconsider the current assessment of AB. Moreover, AB is probably a dynamic process that is highly dependent on current itch-related goals and relevance of itch in a specific situation. This suggests that processes probably differ in patients with chronic itch and that also ABM-training might work differently in these populations.
Clinical trial registration
https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7561, identifier NTR7561.
Introduction
Cognitive–behavioral therapy (CBT) can reduce preoperative pain catastrophizing and may improve postsurgical pain outcomes. We hypothesized that CBT would reduce pain catastrophizing more than no-CBT controls and result in improved pain outcomes.
Methods
The study was a randomized controlled trial of patients undergoing elective total knee arthroplasty between January 2013 and March 2020. In phase 1, the change in pain catastrophizing scores (PCS) among 4-week or 8-week telehealth, 4-week in person and no-CBT sessions was compared in 80 patients with a PCS >16. In phase 2, the proportion of subjects that achieved a 3-month decrease in Western Ontario and McMaster Universities Osteoarthritis (WOMAC) pain subscale >4 following 4-week telehealth CBT with no-CBT controls were compared in 80 subjects.
Results
In phase 1, 4-week telehealth CBT had the highest completion rate 17/20 (85%), demonstrated an adjusted median reduction in PCS of −9 (95% CI −1 to −14, p<0.01) compared with no-CBT and was non-inferior to 8-week telehealth CBT at a margin of 2 (p=0.02). In phase 2, 29 of 35 (83%) in the 4-week telehealth CBT and 26 of 33 (79%) subjects in the no-CBT demonstrated a decrease in the WOMAC pain subscale >4 at 3 months, difference 4% (95% CI −18% to 26%, p=0.48), despite a median decrease in the PCS for the 4-week CBT and no-CBT group of −6 (−10 to −2, p=0.02).
Conclusions
Our findings demonstrate that CBT interventions delivered prior to surgery in person or via telehealth can reduced PCS scores; however, this reduction did not lead to improved 3-month pain outcomes.
Trial registration number
ClinicalTrials.gov (NCT 01772329, registration date 21 January 2013).
A maladaptive response to surgical stress might lead to postoperative complications. A multidisciplinary approach aimed at controlling the surgical stress response may reduce procedural complications and improve patients’ quality of life in the short and long term. Several studies suggest that psychological interventions may interact with the pathophysiology of surgical stress response, potentially influencing wound repair, innate and adaptive immunity, inflammation, perception of pain, and patients’ mood. The aim of this systematic review is to summarise the effects of perioperative psychological interventions on surgical pain and/or anxiety in adult patients scheduled for elective general abdominal and/or urologic surgery.
We conducted a systematic review of controlled clinical trials and observational studies involving psychological interventions for adult patients scheduled for elective general abdominal and/or urologic surgery. Only studies reporting pain and/or anxiety among outcome measures were included in the systematic review. The following psychological interventions were considered: (1) relaxation techniques, (2) cognitive-behavioural therapies, (3) mindfulness, (4) narrative medicine, (5) hypnosis and (6) coping strategies.
We examined 2174 papers. Among these, 9 studies were considered eligible for inclusion in this systematic review (1126 patients cumulatively): 8 are randomised controlled trials and 1 is an observational prospective pre/post study.
Psychological characteristics widely influence the pathophysiological mechanisms underlying the neuroendocrine and inflammatory response to surgical stress, potentially interfering with surgical outcomes. Psychological interventions are technically feasible and realistically applicable perioperatively during abdominal and/or urologic surgery; they influence the pathophysiological mechanisms underlying maladaptive surgical stress response and might have positive effects on patients’ surgical outcomes, such as pain and anxiety.
Our aim was to assess the effect of perioperative interventions targeting psychological distress on clinical outcome after total knee arthroplasty (TKA). We searched studies on the effect of perioperative interventions focused on psychological distress used in conjunction with TKA on pain, function, and quality of life (QoL) on PubMed, Embase.com, PsycINFO/OVID, CENTRAL, the Cochrane Database of Systematic Reviews, Scopus, and Web of Science. We included 40 studies (22 RCTs, ten cohort studies, and eight quasi-experimental studies) with a total of 3846 patients. We graded the quality of evidence as low for pain and function and as moderate for QoL. Patients receiving music, education, cognitive behavioural therapy, guided imagery, pain coping skills training, Reiki, occupational therapy with self-monitoring, and biofeedback-assisted progressive muscles relaxing training had lower pain scores or declined opioid prescriptions after TKA. Pain coping skills training, audio recording-guided imagery scripts, video promoting self-confidence, psychological therapies by video, Reiki, music, occupational therapy with self-monitoring, education, and psychotherapy improved postoperative functional outcome. Education through an app improved QoL after TKA. The studies in our systematic review show that perioperative interventions targeting psychological distress for patients receiving TKA seem to have a positive effect on postoperative pain, function, and QoL. RCTs with strict methodological safeguards are still needed to determine if perioperative interventions focused on psychological distress should be used in conjunction with TKA. These studies should also assess which type of intervention will be most effective in improving patient-reported outcome measures and declining opioid prescriptions.
Background:
Acceptance and commitment therapy (ACT) is a pragmatic approach to help individuals decrease avoidable pain.
Objective:
This study aims to evaluate the effects of ACT delivered via an automated mobile messaging robot on postoperative opioid use and patient-reported outcomes (PROs) in patients with orthopedic trauma who underwent operative intervention for their injuries.
Methods:
Adult patients presenting to a level 1 trauma center who underwent operative fixation of a traumatic upper or lower extremity fracture and who used mobile phone text messaging were eligible for the study. Patients were randomized in a 1:1 ratio to either the intervention group, who received twice-daily mobile phone messages communicating an ACT-based intervention for the first 2 weeks after surgery, or the control group, who received no messages. Baseline PROs were completed. Two weeks after the operative intervention, follow-up was performed in the form of an opioid medication pill count and postoperative administration of PROs. The mean number of opioid tablets used by patients was calculated and compared between groups. The mean PRO scores were also compared between the groups.
Results:
A total of 82 subjects were enrolled in the study. Of the 82 participants, 76 (38 ACT and 38 controls) completed the study. No differences between groups in demographic factors were identified. The intervention group used an average of 26.1 (SD 21.4) opioid tablets, whereas the control group used 41.1 (SD 22.0) tablets, resulting in 36.5% ([41.1-26.1]/41.1) less tablets used by subjects receiving the mobile phone-based ACT intervention (P=.004). The intervention group subjects reported a lower postoperative Patient-Reported Outcome Measure Information System Pain Intensity score (mean 45.9, SD 7.2) than control group subjects (mean 49.7, SD 8.8; P=.04).
Conclusions:
In this study, the delivery of an ACT-based intervention via an automated mobile messaging robot in the acute postoperative period decreased opioid use in selected patients with orthopedic trauma. Participants receiving the ACT-based intervention also reported lower pain intensity after 2 weeks, although this may not represent a clinically important difference.
Trial registration:
ClinicalTrials.gov NCT03991546; https://clinicaltrials.gov/ct2/show/NCT03991546.
Background and purpose — Pain catastrophizing contributes to acute and long-term pain after total knee arthroplasty (TKA) but currently there are only limited treatment options. This study investigates the effectiveness of patient education in pain coping among patients with moderate to high pain catastrophizing score before TKA. Secondary outcomes were physical function, quality of life, self-efficacy, and pain catastrophizing.
Patients and methods — The study was a parallel-group randomized controlled trial including patients with moderate to high levels of pain catastrophizing. 60 patients were recruited from December 2015 to June 2018. The mean age of the patients was 66 (47–82) years and 40 were women. The patients were randomized to either cognitive-behavioral therapy (CBT) based pain education or usual care. The primary outcome measure was pain under activity measured with the Visual Analog Scale (VAS). All outcomes were measured preoperatively, at 3 months, and at 1 year after surgery.
Results — We found no difference in the primary outcome measure, VAS during activity, between the 2 groups but both groups had large reductions over time. The CBT-based pain education group reduced their VAS score by 37 mm (95% CI 27–46) and the control group by 40 mm (CI 31–49). We found no statistically significantly differences between the 2 groups in any of the secondary outcomes.
Interpretation — Future research is warranted to identify predictors of persistent pain and interventions for the approximately 20% of patients with persisting pain after a TKA.
Screening tools allowing to predict poor pain outcomes are widely used. Often these screening tools contain psychosocial risk factors. This review (1) identifies multidimensional screening tools that include psychosocial risk factors for the development or maintenance of pain, pain-related distress, and pain-related disability across pain problems in adults, (2) evaluates the quality of the validation studies using Prediction model Risk Of Bias ASsessment Tool (PROBAST), and (3) synthesizes methodological concerns. We identified 32 articles, across 42 study samples, validating 7 screening tools. All tools were developed in the context of musculoskeletal pain, most often back pain, and aimed to predict the maintenance of pain or pain-related disability, not pain-related distress. Although more recent studies design, conduct, analyze, and report according to best practices in prognosis research, risk of bias was most often moderate. Common methodological concerns were identified, related to participant selection (eg, mixed populations), predictors (eg, predictors were administered differently to predictors in the development study), outcomes (eg, overlap between predictors and outcomes), sample size and participant flow (eg, unknown or inappropriate handling of missing data), and analysis (eg, wide variety of performance measures). Recommendations for future research are provided.
Background:
Prehabilitation programs have led to improved postoperative outcomes in several surgical contexts, but there are presently no guidelines for the prehabilitation phase before lumbar fusion surgery.
Objective:
The objective was to investigate whether a person-centered physical therapy prehabilitation program, based on a cognitive-behavioral approach, is more effective than conventional care in reducing disability and improving functioning after lumbar fusion surgery in patients with degenerative disk disease.
Design:
This study was a randomized controlled trial.
Setting:
The study took place at 2 private spine clinics and 1 university hospital.
Patients:
We prospectively enrolled 118 patients scheduled for lumbar fusion surgery.
Intervention:
The active intervention used a person-centered perspective and focused on promoting physical activity and targeting psychological risk factors before surgery. The control group received conventional preoperative care.
Measurements:
The primary outcome was the Oswestry Disability Index score. Secondary outcomes were back and leg pain intensity, catastrophizing, kinesiophobia, self-efficacy, anxiety, depression, health-related quality of life, and patient-specific functioning, physical activity, and physical capacity. Data were collected on 6 occasions up to 6 months postoperatively. A linear mixed model was used to analyze the change scores of each outcome.
Results:
No statistically significant between-group difference was found on the primary outcome (disability) over time (baseline to 6 months). Among secondary outcome measures, a statistically significant interaction effect ("Group × Time") was seen for the European Quality of Life 5 Dimensions Questionnaire. The largest between-group difference on the European Quality of Life 5 Dimensions Questionnaire index was seen 1 week prior to surgery and favored the active intervention. The largest between-group effect sizes at the 6-month follow-up favored the active intervention, and were seen for physical activity intensity, steps per day, and the One Leg Stand Test. Both groups reached the minimal important change for the primary outcome and, in several secondary outcomes (pain intensity, back and leg; pain catastrophizing; anxiety; health-related quality of life [EQ5D VAS]), already at 8-week follow-up.
Limitations:
The participants' preoperative level of disability was lower than normative values, which suggests selection bias.
Conclusions:
Both interventions led to clinically important changes, but it is not clear what kind of prehabilitation program is the most effective.
Objective:
This study aims to assess the feasibility of digital perioperative behavioral pain medicine intervention in breast cancer surgery and evaluate its impact on pain catastrophizing, pain, and opioid cessation after surgery.
Design and setting:
A randomized controlled clinical trial was conducted at Stanford University (Palo Alto, CA, USA) comparing a digital behavioral pain medicine intervention ("My Surgical Success" [MSS]) with digital general health education (HE).
Participants:
A convenience sample of 127 participants were randomized to treatment group. The analytic sample was 68 patients (N = 36 MSS, N = 32 HE).
Main outcomes:
The primary outcome was feasibility and acceptability of a digital behavioral pain medicine intervention (80% threshold for acceptability items). Secondary outcomes were pain catastrophizing, past seven-day average pain intensity, and time to opioid cessation after surgery for patients who initiated opioid use.
Results:
The attrition rate for MSS intervention (44%) was notably higher than for HE controls (18%), but it was lower than typical attrition rates for e-health interventions (60-80%). Despite greater attrition for MSS, feasibility was demonstrated for the 56% of MSS engagers, and the 80% threshold for acceptability was met. We observed a floor effect for baseline pain catastrophizing, and no significant group differences were found for postsurgical pain catastrophizing or pain intensity. MSS was associated with 86% increased odds of opioid cessation within the 12-week study period relative to HE controls (hazard ratio = 1.86, 95% confidence interval = 1.12-3.10, P = 0.016).
Conclusions:
Fifty-six percent of patients assigned to MSS engaged with the online platform and reported high satisfaction. MSS was associated with significantly accelerated opioid cessation after surgery (five-day difference) with no difference in pain report relative to controls. Perioperative digital behavioral pain medicine may be a low-cost, accessible adjunct that could promote opioid cessation after breast cancer surgery.
Objectives
Inadequate postoperative pain control is common and is associated with poor clinical outcomes. This study aimed to identify preoperative predictors of poor postoperative pain control in adults undergoing inpatient surgery.
Design
Systematic review and meta-analysis
Data sources
MEDLINE, Embase, CINAHL and PsycINFO were searched through October 2017.
Eligibility criteria
Studies in any language were included if they evaluated postoperative pain using a validated instrument in adults (≥18 years) and reported a measure of association between poor postoperative pain control (defined by study authors) and at least one preoperative predictor during the hospital stay.
Data extraction and synthesis
Two reviewers screened articles, extracted data and assessed study quality. Measures of association for each preoperative predictor were pooled using random effects models.
Results
Thirty-three studies representing 53 362 patients were included in this review. Significant preoperative predictors of poor postoperative pain control included younger age (OR 1.18 [95% CI 1.05 to 1.32], number of studies, n=14), female sex (OR 1.29 [95% CI 1.17 to 1.43], n=20), smoking (OR 1.33 [95% CI 1.09 to 1.61], n=9), history of depressive symptoms (OR 1.71 [95% CI 1.32 to 2.22], n=8), history of anxiety symptoms (OR 1.22 [95% CI 1.09 to 1.36], n=10), sleep difficulties (OR 2.32 [95% CI 1.46 to 3.69], n=2), higher body mass index (OR 1.02 [95% CI 1.01 to 1.03], n=2), presence of preoperative pain (OR 1.21 [95% CI 1.10 to 1.32], n=13) and use of preoperative analgesia (OR 1.54 [95% CI 1.18 to 2.03], n=6). Pain catastrophising, American Society of Anesthesiologists status, chronic pain, marital status, socioeconomic status, education, surgical history, preoperative pressure pain tolerance and orthopaedic surgery (vs abdominal surgery) were not associated with increased odds of poor pain control. Study quality was generally high, although appropriate blinding of predictor during outcome ascertainment was often limited.
Conclusions
Nine predictors of poor postoperative pain control were identified. These should be recognised as potentially important factors when developing discipline-specific clinical care pathways to improve pain outcomes and to guide future surgical pain research.
PROSPERO registration number
CRD42017080682.
Chronic pain after tissue trauma is frequent and may have a lasting impact on the functioning and quality of life of the affected person. Despite this, chronic postsurgical and posttraumatic pain is underrecognised and, consequently, undertreated. It is not represented in the current International Classification of Diseases (ICD-10). This article describes the new classification of chronic postsurgical and posttraumatic pain for ICD-11. Chronic postsurgical or posttraumatic pain is defined as chronic pain that develops or increases in intensity after a surgical procedure or a tissue injury and persists beyond the healing process, ie, at least 3 months after the surgery or tissue trauma. In the classification, it is distinguished between tissue trauma arising from a controlled procedure in the delivery of health care (surgery) and forms of uncontrolled accidental damage (other traumas). In both sections, the most frequent conditions are included. This provides diagnostic codes for chronic pain conditions that persist after the initial tissue trauma has healed and that require specific treatment and management. It is expected that the representation of chronic postsurgical and posttraumatic pain in ICD-11 furthers identification, diagnosis, and treatment of these pain states. Even more importantly, it will make the diagnosis of chronic posttraumatic or postsurgical pain statistically visible and, it is hoped, stimulate research into these pain syndromes.
Attention has been theorized to play a key role in the experience of pain and associated task interference. Training attention away from pain via attention bias modification (ABM) training techniques has been proposed to improve pain-related outcomes, but evidence is inconsistent. In an experimental study, we investigated the impact of a single session ABM training -using a visual probe paradigm with idiosyncratic pain words- on cold pressor test (CPT) pain experience and task interference by pain. Fifty-eight healthy volunteers were randomly assigned to an ABM training group (N = 28; attending away from pain) and a sham training group (N = 30; no training direction). At pre-training, participants performed a baseline Random-Interval-Repetition (RIR) task and the CPT. Participants reported on sensations they experienced during the baseline CPT. Relevant descriptors were integrated in the visual probe paradigm during the training phase. At post-training, participants completed the RIR task again while experiencing CPT pain. Participants also reported on the extent they attended to the pain and the intensity/unpleasantness of the pain. Results indicated that, in contrast with our hypotheses, ABM training did also not reduce task interference due to CPT pain. Furthermore, ABM training did not change self-reported attending to CPT pain. Finally, ABM training did not reduce CPT pain intensity or pain unpleasantness. Overall, the current study provides no support for the effectiveness of a single session ABM training in improving pain-related outcomes. Future research addressing the conditions under which ABM training improves or fails to improve pain-related outcomes is warranted.
Chronic post-surgical pain (CPSP) is a well-recognized potential complication with negative personal, social and healthcare consequences. However, limited data exists on CPSP and on the course of pain over time after hysterectomy. Using data from a prospective cohort study on a consecutive sample assessed at 4 time points, pre-surgery (T1), 48 hours (T2), 4 months (T3), and 5 years post-surgery (T4), we sought to examine women's post-surgical pain trajectories using assessments of pain at T3 and T4. Additionally, this study aimed to investigate pre-surgical and post-surgical risk factors associated with an unfavourable pain trajectory (PT). Based on pain data collected at T3 and T4, three distinct trajectories of post-surgical pain (PSP) emerged: no CPSP (PT1;n=88), prolonged PSP (PT2;n=53) and CPSP (PT3;n=29). Moreover, reported CPSP prevalence at 5 years was 17.1%. Multinomial logistic regression models controlling for age, pre-surgical pain and type of hysterectomy tested for baseline and acute post-surgical predictive variables. Membership in PT2 and PT3 was predicted by pre-surgical anxiety (OR=1.131, p=0.015; OR=1.175, p=0.009, respectively), emotional representation of the surgical disease (OR=1.155, p=0.034; OR=1.213, p=0.020, respectively) and pain catastrophizing (OR=1.079, p=0.043; OR=1.143, p=0.001, respectively). Furthermore, acute post-surgical pain intensity and frequency determined membership of women in PT3 (OR=1.211, p=0.033; OR=3.000, p=0.029, respectively), and post-surgical anxiety (OR=1.182, p=0.026) also played a key predictive role. This study identified factors that can be easily screened before and after surgery, and are amenable to change through carefully designed timely and tailored interventions for women at risk of an unfavorable post-surgical pain trajectory post-hysterectomy.
Objective:
To determine the feasibility of conducting a trial of a pre-surgical psychological intervention on pain, function, and mood in people with knee osteoarthritis listed for total knee arthroplasty.
Design:
Multi-centre, mixed-methods feasibility randomized controlled trial of intervention plus usual care versus usual care.
Setting:
Participants' homes or hospital.
Participants:
Patients with knee osteoarthritis listed for total knee arthroplasty and score >7 on either subscales of Hospital Anxiety and Depression Scale.
Intervention:
Up-to 10 sessions of psychological intervention (based on cognitive behavioural therapy).
Main measures:
Feasibility outcomes (recruitment and retention rates, acceptability of trial procedures and intervention, completion of outcome measures), and standardized questionnaires assessing pain, function, and mood at baseline, and four and six months post-randomisation.
Results:
Of 222 people screened, 81 did not meet inclusion criteria, 64 did not wish to participate, 26 were excluded for other reasons, and 51 were randomized. A total of 30 completed 4-month outcomes and 25 completed 6-month outcomes. Modal number of intervention sessions completed was three (range 2-8). At 6-month follow-up, mood, pain, and physical function scores were consistent with clinically important benefits from intervention, with effect sizes ranging from small ( d = 0.005) to moderate ( d = 0.74), and significant differences in physical function between intervention and usual care groups ( d = 1.16). Feedback interviews suggested that participants understood the rationale for the study, found the information provided adequate, the measures comprehensive, and the intervention acceptable.
Conclusion:
A definitive trial is feasible, with a total sample size of 444 people. Pain is a suitable primary outcome, but best assessed 6 and 12 months post-surgery.
Background
Inadequately managed pain is a risk factor for chronic postsurgical pain (CPSP), a growing public health challenge. Multidisciplinary pain-management programs with psychological approaches, including cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based psychotherapy, have shown efficacy as treatments for chronic pain, and show promise as timely interventions in the pre/perioperative periods for the management of PSP. We reviewed the literature to identify randomized controlled trials evaluating the efficacy of these psychotherapy approaches on pain-related surgical outcomes.
Materials and methods
We searched Medline, Medline-In-Process, Embase and Embase Classic, and PsycInfo to identify studies meeting our search criteria. After title and abstract review, selected articles were rated for risk of bias.
Results
Six papers based on five trials (four back surgery, one cardiac surgery) met our inclusion criteria. Four papers employed CBT and two CBT-physiotherapy variant; no ACT or mindfulness-based studies were identified. Considerable heterogeneity was observed in the timing and delivery of psychological interventions and length of follow-up (1 week to 2–3 years). Whereas pain-intensity reporting varied widely, pain disability was reported using consistent methods across papers. The majority of papers (four of six) reported reduced pain intensity, and all relevant papers (five of five) found improvements in pain disability. General limitations included lack of large-scale data and difficulties with blinding.
Conclusion
This systematic review provides preliminary evidence that CBT-based psychological interventions reduce PSP intensity and disability. Future research should further clarify the efficacy and optimal delivery of CBT and newer psychological approaches to PSP.
Background:
Placebo effects on pain have been found to vary in size for different routes of medication administration (e.g. oral vs. injection). This has important implications for both clinical research and practice. To enhance our understanding of these differential placebo effects, research on the underlying expectations about multiple routes and symptoms other than pain is vital.
Methods:
A cross-sectional, Internet-based survey was conducted in a representative sample of the Dutch population (n = 508). Respondents rated the expected effectiveness of pain- and itch-relieving medication in six forms, representing oral, injection and topical routes of administration.
Results:
Injected medication was expected to be most effective for relieving pain, and topical medication for relieving itch. Furthermore, exploratory analyses showed that injections were expected to have the most rapid onset and long-lasting effects, and to be most frightening and expensive, while topical medication was expected to be the safest and the easiest to use, and oral medication was expected to have the most side effects. Higher expected effectiveness was moderately associated with expectations of more rapid onset and long-lasting effects, and better safety and ease of use. Associations of expected effectiveness with respondent characteristics (e.g. medication use and personality characteristics) were statistically small or nonsignificant.
Conclusions:
Expected effectiveness of medication differed depending on route of administration and targeted symptom. These findings have important implications for the design and interpretation of clinical trials and suggest that medication effects might be enhanced by prescribing medicine via the route that patients expect to be most effective for their complaint.
Significance:
Differences in the expected effectiveness of medication depend on the route of administration (oral, injection, topical) and targeted symptom (pain, itch). These findings have important implications for clinical practice and the design and interpretation of clinical trials.
Background:
Although itch and pain are distinct experiences, both are unpleasant, may demand attention, and interfere with daily activities. Research investigating the role of attention in tonic itch and pain stimuli, particularly whether attention is drawn to the stimulus location, is scarce.
Methods:
In the somatosensory attention task, fifty-three healthy participants were exposed to 35-second electrical itch or pain stimuli on either the left or right wrist. Participants responded as quickly as possible to visual targets appearing at the stimulated location (ipsilateral trials) or the arm without stimulation (contralateral trials). During control blocks, participants performed the visual task without stimulation. Attention allocation at the itch and pain location is inferred when responses are faster ipsilaterally than contralaterally.
Results:
Results did not indicate that attention was directed towards or away from the itch and pain location. Notwithstanding, participants were slower during itch and pain than during control blocks.
Conclusions:
In contrast with our hypotheses, no indications were found for spatial attention allocation towards the somatosensory stimuli. This may relate to dynamic shifts in attention over the time course of the tonic sensations. Our secondary finding that itch and pain interfere with task performance is in-line with attention theories of bodily perception.
Risk stratification for the development chronic postsurgical pain is an important tool, which may permit preventive measures or appropriate advice for patients at high risk.
Nocebo effects, i.e., adverse treatment effects which are induced by patients’ expectations, are known to contribute to the experience of physical symptoms such as pain and itch. A better understanding of how to minimize nocebo responses might eventually contribute to enhanced treatment effects. However, little is known about how to reduce nocebo effects. In the current randomized controlled study, we tested whether nocebo effects can be minimized by positive expectation induction with respect to electrical and histaminic itch stimuli. First, negative expectations about electrical itch stimuli were induced by verbal suggestion and conditioning (part 1: induction of nocebo effect). Second, participants were randomized to either the experimental group or one of the control groups (part 2: reversing nocebo effect). In the experimental group, positive expectations were induced by conditioning with verbal suggestion. In the control groups either the negative expectation induction was continued or an extinction procedure was applied. Afterwards, a histamine application test was conducted. Positive expectation induction resulted in a significantly smaller nocebo effect in comparison with both control groups. Mean change itch NRS scores showed that the nocebo effect was even reversed, indicating a placebo effect. Comparable effects were also found for histamine application. This study is the first to demonstrate that nocebo effects can be minimized and even reversed by conditioning with verbal suggestion. The results of the current study indicate that learning via counterconditioning and verbal suggestion represents a promising strategy for diminishing nocebo responses.
The central processing of itch is not completely understood. This is the first study to use functional magnetic resonance imaging (fMRI) to examine the central modulation by distraction of experimentally induced itch. A total of 33 healthy volunteers were examined with fMRI. Periods of itch induction without distraction and itch with distraction by a Stroop task were counterbalanced during the scanning to examine task-specific changes in blood oxygenation level dependent-signal. The intensity of the subjects' itch sensation, desire to scratch and pain sensation were evaluated. Distraction by a Stroop task did not reduce itch intensity or urge to scratch. However, the Stroop task led to significantly higher activation of the left brainstem when it followed the "pure" itch sensation. Itch and pain seem to have similar inhibition pathways, particularly concerning brainstem activation during distraction. But as itch sensation, in contrast to pain, could not be sufficiently reduced by distraction, both entities might have different modulation systems.
Itch is a prevalent somatosensory symptom that can be highly disabling, because it is likely to draw attention and, as a result, may interfere with the performance of daily activities. Yet, research experimentally investigating attention to itch is lacking. In this study we aimed to investigate attentional processing of itch using multiple behavioral attention tasks. Forty-one healthy participants performed (1) a modified Stroop task with itch-related words, (2) a dot-probe task with itch-related pictures, and (3) a recently developed somatosensory attention task in which the effect of experimentally induced itch on the localization of visual targets was examined. Additionally, a number of self-report questionnaires related to somatosensory attentional processing were administered. Results indicated that participants' attention was biased toward itch-related words and pictures assessed by means of the dot-probe and modified Stroop task, respectively. For the somatosensory attention task, results showed that itch did not significantly influence the allocation of attention. However, when taking into account the time course of attention during the itch stimulus, data suggested that participants tended to disengage attention away during the itch stimulus. This is the first study that indicates an attentional bias for itch, using methods that have previously been validated for other sensations such as pain. In addition, the newly developed somatosensory attention task may reflect the time course of attention toward a tonic itch stimulus.
Objective:
To investigate the clinical efficacy of open-label placebos compared with no treatment in a systematic review and meta-analysis.
Methods:
We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations (OvidSP), EMBASE (OvidSP), and clinical trials registers and screened reference lists. The search was run on April 27(th) 2015. We included all randomised controlled trials of any medical condition with open-label placebo and no-treatment groups. Authors independently assessed records and extracted data. We excluded non-randomised trials and non-clinical studies. Risk of bias was assessed using Cochrane criteria. We used random-effects model for meta-analysis.
Results:
We screened 348 publications, assessed 24 articles for eligibility and identified 5 trials (260 participants) that met inclusion criteria. The clinical conditions were: irritable bowel syndrome (IBS), depression, allergic rhinitis, back pain and attention deficit hyperactivity disorder (ADHD). The risk of bias was moderate. We found a positive effect for non-deceptive placebos (standardized mean difference 0.88, 95% CI 0.62 to 1.14, P < 0.00001, I(2) = 1%).
Conclusions:
Open-label placebos appear to have positive clinical effects compared to no treatment. Caution is warranted when interpreting these results due the limited number of trials identified, lack of assessor blinding, and the fact that positive messages were included alongside open label placebos. Larger definitive trials are now warranted to explore the potential patient benefit of open-label placebos, to investigate the relative contributions of positive suggestions, and ethical implications. This article is protected by copyright. All rights reserved.
Background: Placebo effects on pain are reliably observed in the literature. A core mechanism of these effects are response expectancies. Response expectancies can be formed by instructions, prior experiences, and observation of others. Whether mental imagery of a response can also induce placebo-like expectancy effects on pain has not yet been studied systematically.
Methods: In Study 1, 80 healthy participants were randomly allocated to 1) response imagery or 2) control imagery. In Study 2, 135 healthy participants were randomly allocated to 1) response imagery with a verbal suggestion regarding its effectiveness, 2) response imagery only, or 3) no intervention. In both studies, expected and experienced pain during cold pressor tests were measured pre- and post-intervention, along with psychological and physiological measures.
Results: Participants rated pain as less intense after response imagery than after control imagery in Study 1 (p = .044, etap2 = .054) and as less intense after response imagery (with or without verbal suggestion) than after no imagery in Study 2 (p < .001, etap2 = .154). Adding a verbal suggestion did not affect pain (p = .068, etap2 = .038). The effects of response imagery on experienced pain were mediated by expected pain.
Conclusions: Thus, in line with research on placebo effects, the current findings indicate that response imagery can induce analgesia, via its effects on response expectancies.
Objective:
Research on placebo/nocebo effects suggests that expectations can influence treatment outcomes, but placebo/nocebo effects are not always evident. This research demonstrates that a provider's social behavior moderates the effect of expectations on physiological outcomes.
Methods:
After inducing an allergic reaction in participants through a histamine skin prick test, a health care provider administered a cream with no active ingredients and set either positive expectations (cream will reduce reaction) or negative expectations (cream will increase reaction). The provider demonstrated either high or low warmth, or either high or low competence.
Results:
The impact of expectations on allergic response was enhanced when the provider acted both warmer and more competent and negated when the provider acted colder and less competent.
Conclusion:
This study suggests that placebo effects should be construed not as a nuisance variable with mysterious impact but instead as a psychological phenomenon that can be understood and harnessed to improve treatment outcomes. (PsycINFO Database Record
Background
Placebo effects contribute substantially to outcome in most fields of medicine. While clinical trials typically try to control or minimize these effects, the potential of placebo mechanisms to improve outcome is rarely used. Patient expectations about treatment efficacy and outcome are major mechanisms that contribute to these placebo effects. We aimed to optimize these expectations to improve outcome in patients undergoing coronary artery bypass graft (CABG) surgery. Methods
In a prospective three-arm randomized clinical trial with a 6 month follow-up, 124 patients scheduled for CABG surgery were randomized to either a brief psychological pre-surgery intervention to optimize outcome expectations (EXPECT); or a psychological control intervention focusing on emotional support and general advice, but not on expectations (SUPPORT); or to standard medical care (SMC). Interventions were kept brief to be feasible with a heart surgery environment; “dose” of therapy was identical for both pre-surgery interventions. Primary outcome was disability 6 months after surgery. Secondary outcomes comprised further clinical and immunological variables. ResultsPatients in the EXPECT group showed significantly larger improvements in disability (−12.6; −17.6 to −7.5) than the SMC group (−1.9; −6.6 to +2.7); patients in the SUPPORT group (−6.7; −11.8 to 1.7) did not differ from the SMC group. Comparing follow-up scores and controlling for baseline scores of EXPECT versus SUPPORT on the variable disability only revealed a trend in favor of the EXPECT group (P = 0.09). Specific advantages for EXPECT compared to SUPPORT were found for mental quality of life and fitness for work (hours per week). Both psychological pre-surgery interventions induced less pronounced increases in pro-inflammatory cytokine concentrations reflected by decreased interleukin-8 levels post-surgery compared to changes in SMC patients and lower interleukin-6 levels in patients of the EXPECT group at follow-up. Both pre-surgery interventions were characterized by great patient acceptability and no adverse effects were attributed to them. Considering the innovative nature of this approach, replication in larger, multicenter trials is needed. Conclusions
Optimizing patients’ expectations pre-surgery helps to improve outcome 6 months after treatment. This implies that making use of placebo mechanisms has the potential to improve long-term outcome of highly invasive medical interventions. Further studies are warranted to generalize this approach to other fields of medicine. Trial registrationEthical approval for the study was obtained from the IRB of the Medical School, University of Marburg, and the trial was registered at (NCT01407055) on July 25, 2011.
Perspective:
The development of chronic pain after surgery is a major clinical problem that provides an opportunity to study the transition from acute to chronic pain at epidemiologic and basic science levels. Strategic, coordinated, multidisciplinary research efforts targeting mechanisms of pain chronification can to help minimize or eliminate persistent postsurgical pain.
Objective:
The current study aimed to pilot the Perioperative Pain Self-management (PePS) intervention, based on principles of CBT, to determine feasibility and preliminary efficacy for preventing chronic pain and long-term opioid use.
Summary background data:
Surgery can precipitate the development of both chronic pain and long-term opioid use. Cognitive behavioral therapy (CBT) can reduce distress and improve functioning among patients with chronic pain. Adapting CBT to target acute pain management in the post-operative period may impact longer-term post-operative outcomes.
Methods:
This was a mixed-methods randomized controlled trial in a mixed surgical sample with assignment to standard care (SC) or PePS, with primary outcomes at 3-months post-surgery. The sample consisted of rural-dwelling United States Military Veterans.
Results:
Logistic regression analyses found a significant effect of PePS on odds of moderate-severe pain (on average over the last week) at 3-months post-surgery, controlling for pre-operative moderate-severe pain: Adjusted odds ratio = 0.25 (95% CI: 0.07 - 0.95, p < .05). At 3-months post-surgery, 15% (6/39) of SC participants and 2% (1/45) of PePS participants used opioids in the prior seven days: Adjusted Odds ratio = 0.10 (95% CI: 0.01 - 1.29, p = .08). Changes in depression, anxiety, and pain catastrophizing were not significantly different between arms.
Conclusions:
The findings from this study support the feasibility and preliminary efficacy of the PePS intervention.
Knowledge about psychological and psychosocial predictors of chronic post-surgical pain is important to identify patients at risk for poor outcomes. The objective of this systematic review with meta-analysis was to assess the effect of such predictors. A comprehensive search of the available literature on this topic was performed using the electronic databases PubMed, Scopus, Embase and PsycInfo. Estimates of the effect of each predictor were extracted and both a narrative and a quantitative synthesis of these estimates was performed. Multiple imputation was employed to take into account the effect of non-significant estimates in case they were not reported by original studies. From a sample of 8322 records, 83 articles were included in the narrative synthesis and 41 studies were employed to perform the meta-analyses. The narrative synthesis showed that evidence about the effect of psychological predictors is heterogeneous, with few expected predictors, such as optimism, mental health and surgical fear, consistently associated with chronic post-surgical pain. In contrast, the meta-analyses showed that state anxiety, trait anxiety, mental health, depression, catastrophizing and, to a lesser extent, kinesiophobia and self-efficacy, have a weak but significant association with chronic post-surgical pain. In conclusion, this study showed that psychological predictors have a significant association with chronic post-surgical pain and that state anxiety is the most explicative one.
Introduction:
Preoperative anxiety and postoperative pain are common problems in patients undergoing surgery. The aim of this study is to analyse the effect of using guided imagery prior to surgery in adults and children to reduce preoperative anxiety and acute postoperative pain, compared with conventional preoperative nursing care.
Methods:
A systematic review and meta-analysis were conducted. We searched randomised clinical trials in databases and search engines.
Results:
A total of 1101 records were identified, of which 21 were included in the qualitative synthesis. Two random model meta-analysis were performed with eight trials. Guided imagery preoperatively was shown to be effective in relieving preoperative state anxiety in children (d = -3.71), preoperative trait anxiety in adults (d = -0.64) and postoperative pain in adults (d = -0.24). Postoperative pain in children and preoperative state anxiety in adults was reduced but without significant difference.
Conclusion:
Guided imagery preoperatively is an effective, easy and low-cost intervention.
Assessment of risk of bias is regarded as an essential component of a systematic review on the effects of an intervention. The most commonly used tool for randomised trials is the Cochrane risk-of-bias tool. We updated the tool to respond to developments in understanding how bias arises in randomised trials, and to address user feedback on and limitations of the original tool.
Objective:
Oncologic breast surgeries carry a risk for persistent postsurgical pain. This study was a randomized pilot and feasibility study of a single-session Acceptance and Commitment Therapy (ACT) intervention compared to treatment as usual among women undergoing surgery for breast cancer or ductal carcinoma in situ (DCIS).
Methods:
Participants were recruited via letter of invitation and follow-up phone call from a single site in the United States from 2015-2017. Participants were at risk for persistent post-surgical pain, based on: young age (<50), a pre-existing chronic pain condition, or elevated anxiety, depression, or pain catastrophizing.
Results:
The 54 participants were female with a mean age of 52.91 years (SD=11.80). At 3-months post-surgery, 11% of the sample reported moderate-severe pain (>3 on a 0-10 numeric rating scale) in the operative breast or with arm movement. Written qualitative responses indicated that the majority of participants who received the intervention understood the concepts presented and reported continued practice of exercises learned in the session. The between group effect sizes for moderate-severe pain and elevated anxiety at 3-months post-surgery were small (Phi=0.08 and 0.16, respectively). The between group effect sizes for depression, pain acceptance, and pain catastrophizing at 3-months post-surgery were minimal.
Conclusions:
This study found small positive effects on post-surgical pain and anxiety for a single-session ACT intervention among women with breast cancer. This study supports the use of ACT with this population.
Objective:
To evaluate the efficacy of Mindfulness-Based Stress Reduction (MBSR) in improving pain and physical function following total joint arthroplasty (TJA).
Design:
Two-group, parallel-group, randomised controlled trial, conducted between September 2012 and May 2017.
Setting:
Single centre study conducted at a University-affiliated, tertiary hospital.
Intervention:
People with arthritis scheduled for TJA, with a well-being score <40 (Short Form-12 Survey) were randomly allocated to a pre-surgery eight-week MBSR program or treatment as usual (TAU).
Outcome measures:
Self-reported joint pain and function at 12 months post-surgery, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were knee stiffness and global improvement (WOMAC); physical and psychological well-being (Veterans RAND 12-item Health Survey); self-efficacy (Arthritis Self-Efficacy Scale); and mindfulness (5-Factor Mindfulness Questionnaire).
Results:
127 participants were randomised; 65 to MBSR and 62 to TAU, of which 45 participants allocated to the intervention and 56 participants allocated to usual care proceeded to surgery and 100 (99%) completed primary outcome measures. Greater improvements in knee pain (mean difference, -10.3 points, 95% CI -19.0 to -1.6; P = 0.021) and function (mean difference, -10.2 points, 95% CI -19.2 to -1.3; P = 0.025) at 12 months post-surgery were observed in the MBSR group compared to the TAU group. A between group difference in global scores (-9.5 points, 95% CI -17.9 to -1.1; P = 0.027) was also observed. No other differences in secondary outcomes were observed.
Conclusion:
MBSR improves post-surgery pain and function in people with psychological distress undergoing TJA. Further research is required to examine potential barriers to broader implementation and uptake.
Moderate-to-severe pain is a common problem experienced by patients with cancer. Although analgesic drugs are effective, adverse side effects are common and some analgesic drugs are addictive. Nonpharmacological treatment may be a way to treat cancer pain without causing negative side effects. Mindfulness is used as an effective nonpharmacological treatment to improve quality of life (QoL) and to address psychological problems including distress, anxiety, stress, and depression. However, the effect of mindfulness on pain severity has not been sufficiently investigated. Therefore, a systematic review was undertaken to describe the effectiveness of mindfulness interventions for pain and its underlying pathophysiologic mechanisms. The search was conducted in PubMed, Ovid MEDLINE, and CINAHL and included only empirical studies published from 2008 to 2017. Search terms included mindfulness, mindfulness-based intervention, meditation, cancer, pain, and cancer-related pain. Six studies met the search criteria. These studies tested several types of intervention including mindfulness-based stress reduction, mindfulness-based cognitive therapy, meditation with massage, and mindful awareness practices. Study outcomes include improved pain severity, anxiety, stress, depression, and QoL. However, most studies reviewed were conducted in the United States and Denmark. Further research is needed to test culturally appropriate mindfulness interventions to reduce pain. © 2018 Ann & Joshua Medical Publishing Co. Ltd | Published by Wolters Kluwer -Medknow.
Background:
Pain catastrophizing has been identified as a prognostic indicator of poor outcome following knee arthroplasty. Interventions to address pain catastrophizing, to our knowledge, have not been tested in patients undergoing knee arthroplasty. The purpose of this study was to determine whether pain coping skills training in persons with moderate to high pain catastrophizing undergoing knee arthroplasty improves outcomes 12 months postoperatively compared with usual care or arthritis education.
Methods:
A multicenter, 3-arm, single-blinded, randomized comparative effectiveness trial was performed involving 5 university-based medical centers in the United States. There were 402 randomized participants. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Scale, measured at baseline, 2 months, 6 months, and 12 months following the surgical procedure.
Results:
Participants were recruited from January 2013 to June 2016. In 402 participants, 66% were women and the mean age of the participants (and standard deviation) was 63.2 ± 8.0 years. Three hundred and forty-six participants (90% of those who underwent a surgical procedure) completed a 12-month follow-up. All 3 treatment groups had large improvements in 12-month WOMAC pain scores with no significant differences (p > 0.05) among the 3 treatment arms. No differences were found between WOMAC pain scores at 12 months for the pain coping skills and arthritis education groups (adjusted mean difference, 0.3 [95% confidence interval (CI), -0.9 to 1.5]) or between the pain coping and usual-care groups (adjusted mean difference, 0.4 [95% CI, -0.7 to 1.5]). Secondary outcomes also showed no significant differences (p > 0.05) among the 3 groups.
Conclusions:
Among adults with pain catastrophizing undergoing knee arthroplasty, cognitive behaviorally based pain coping skills training did not confer pain or functional benefit beyond the large improvements achieved with usual surgical and postoperative care. Future research should develop interventions for the approximately 20% of patients undergoing knee arthroplasty who experience persistent function-limiting pain.
Level of evidence:
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Studies investigating attentional biases towards pain information vary widely in both design and results. The aim of this meta-analysis was to determine the degree to which attentional biases towards pain occur when measured with the dot-probe task. A total of 2168 references were screened, resulting in a final sample of 4466 participants from 52 articles. Participants were grouped according to pain experience: chronic pain, acute pain, anticipating experimental/procedural pain, social concern for pain, or healthy people. In general, results revealed a significant, but small bias towards pain words (d= 0.136), and pain pictures (d= 0.110) in chronic pain patients, but not in those with acute pain, those anticipating pain, or healthy people. Follow-up analyses revealed an attentional bias towards sensory pain words in the chronic pain group (d= 0.198), and the acute pain group (d= 0.303), but not other groups. In contrast, attentional biases towards affective pain stimuli were not significant for any pain groups. This meta-analysis found support for attentional biases towards sensory pain stimuli in patients with chronic pain in comparison to healthy individuals across a range of common parameters. Future researchers need to consider task design when seeking to optimally measure pain-relevant attentional biases.
Perspective:
In this meta-analysis of RCTs in orthopedic surgeries, significant benefits in postoperative pain, perioperative anxiety and recovery were found, suggesting that psychosocial interventions, especially patient education and relaxation techniques, are useful in improving the clinical care.
High levels of pain, significant anxiety, or depressive symptoms before surgery put patients at elevated risk for chronic pain and prolonged opioid use following surgery. The purpose of this preliminary study was to assess the efficacy of a 1-day Acceptance and Commitment Therapy (ACT) workshop in "at-risk" veterans for the prevention of chronic pain and opioid use following orthopedic surgery. In a randomized controlled trial, 88 at-risk veterans undergoing orthopedic surgery were assigned to treatment as usual (TAU; n = 44) or TAU plus a 1-day ACT workshop (n = 44). Pain levels and opioid use were assessed up to 3 months following surgery. Pain acceptance and values-based behavior were assessed at baseline and 3-month follow-up. Participants who completed the ACT workshop reached pain and opioid cessation sooner than those in TAU. Postoperative complications exhibited a moderating effect on these outcomes, such that the effects of ACT were greater in patients without complications. Increases in pain acceptance and values-based behavior, processes targeted in ACT, were related to better outcomes. These promising results merit further investigation in a larger clinical trial. Providing an intervention before surgery for at-risk veterans has the potential to change clinical practice from a focus on management of postoperative pain to prevention of chronic pain in at-risk individuals.
Perspective:
This pilot study compared the effects of a 1-day preventive behavioral intervention (ACT) to TAU in at-risk veterans undergoing orthopedic surgery. Three months following the intervention, veterans receiving ACT exhibited quicker cessation of pain and opioid use. Focusing on preoperative pain management may help prevent chronic postsurgical pain.
Medical interventions alone have been largely unsuccessful in treating and curing disorders characterized by chronic pain like central sensitivity syndromes (CSS; e.g., fibromyalgia, chronic migraine, temporomandibular disorders, irritable bowel syndrome). In this article, we discuss how a biopsychosocial perspective adds to understanding people's experiences with chronic pain. A biopsychosocial perspective examines how biological, psychological, social, and contextual factors work independently and jointly to influence the experience, maintenance, and exacerbation of CSS and their symptoms. We highlight several key psychological and social factors relevant to many people who live with CSS, while also emphasizing the heterogeneity in people's experiences, life courses, and symptoms. Furthermore, we emphasize that the psychological, social, and contextual factors that we include are best characterized as contributors to chronic pain experience rather than causes of it.
Background
Persistent post-surgical pain affects 10–80% of individuals after common operations, and is more common among patients with psychological factors such as depression, anxiety, or catastrophising.
Methods
We conducted a systematic review and meta-analysis of randomised, controlled trials to evaluate the efficacy of perioperative psychotherapy for persistent post-surgical pain and physical impairment. Paired independent reviewers identified studies, extracted data, and assessed risk of bias. The Grading of Recommendations, Assessment, Development and Evaluation system was used to assess the quality of evidence.
Results
Our search of five electronic databases, up to September 1, 2016, found 15 trials (2220 patients) that were eligible for review. For both persistent post-surgical pain and physical impairment, perioperative education was ineffective, while active psychotherapy suggested a benefit (test of interaction P=0.01 for both outcomes). Moderate quality evidence showed that active perioperative psychotherapy (cognitive-behaviour therapy, relaxation therapy, or both) significantly reduced persistent post-surgical pain [weighted mean difference (WMD) −1.06 cm on a 10 cm visual analogue scale for pain, 95% confidence interval (CI) −1.56 to −0.55 cm; risk difference (RD) for achieving no more than mild pain (≤3 cm) 14%, 95% CI 8–21%] and physical impairment [WMD −9.87% on the 0–100% Oswestry Disability Index, 95% CI −13.42 to −6.32%, RD for achieving no more than mild disability (≤20%) 21%, 95% CI 13–29%].
Conclusions
Perioperative cognitive behavioural therapy and relaxation therapy are effective for reducing persistent pain and physical impairment after surgery. Future studies should explore targeted psychotherapy for surgical patients at higher risk for poor outcome.
In this research, we examined effects of higher versus lower threat contexts on attention biases in more and less pain-fearful chronic pain subgroups via eye-tracking methodology. Within a mixed chronic pain sample (69 women, 29 men), biases in orienting and maintenance of visual attention were assessed during the standardized image pair presentation phase (2000ms) of a modified visual dot probe task featuring painful-neutral (P-N) image pairs (lower threat context) and a parallel task in which these P-N pairs cued potential pain (higher threat context). Across both tasks, participants more often oriented towards, gazed longer at, and made more unique fixations upon pain images during P-N pair presentations. Although trait-based fear of pain was not related to any gaze bias index in either task, between task analyses indicated the sample reported more state fear, directed their initial gaze less often, and displayed longer overall gaze durations toward pain images in the higher threat context wherein P-N trials signaled potential pain. Results supported the threat interpretation model premise that persons with chronic pain have difficulty disengaging from moderately threatening visual painful cues.
Perspective
Through integrating dot-probe and impending pain task paradigms, we assessed effects of lower versus higher threat contexts on visual attention biases of persons with chronic pain via eye-tracking. Under higher threat conditions featuring possible pain, state fear levels were elevated and maintenance of attention on painful depictions was more prolonged.
Chronic itch is associated with increased stress, anxiety, and other mood disorders. In turn, stress and anxiety exacerbate itch, leading to a vicious cycle that affects patient behavior (scratching) and worsens disease prognosis and quality of life. This cycle persists across chronic itch conditions of different etiologies and even to some extent in healthy individuals, suggesting that the final common pathway for itch processing (the central nervous system) plays a major role in the relationship between itch and anxiety. Pharmacological and nonpharmacological treatments that reduce anxiety have shown promising anti-itch effects. Further research is needed to establish specific central mechanisms of the itch-anxiety cycle and provide new targets for treatment.
Significance:
Central sensitisation is an important manifestation involved in many different chronic pain conditions. Central sensitisation can be different to assess and evaluate as the manifestations vary from pain condition to pain condition. Understanding central sensitisation may promote better profiling and diagnosis of pain patients and development of new regimes for mechanism based therapy. Some of the mechanisms underlying central sensitisation can be translated from animals to humans providing new options in development of therapies and profiling drugs under development.
It has been shown repeatedly that perceiving itch-related pictures or listening to a lecture on itch can enhance itch sensation and scratching behaviour (Niemeier and Gieler, 2000; Holle et al., 2012; Lloyd et al., 2013), indicating that itch is strongly influenced by expectations. Using fMRI, we investigated the neural correlates of the itch-related nocebo effect in healthy male and female human subjects. Itch sensation on the left forearm was induced by cutaneous histamine application and thermally modulated, with cooling leading to higher itch. Nocebo-induced aggravation of histaminergic itch was achieved by ostensibly treating volunteers with “transcutaneous electrical nerve stimulation (TENS)” about which subjects were instructed that it would increase itch. During a conditioning phase subjects indeed experienced stronger itch due to slightly altered cooling and histamine concentrations, but attributed it to the alleged “TENS stimulation”. Importantly, in the subsequent test phase where no “TENS” or electrical stimulation was applied, volunteers significantly reported stronger itch during the nocebo as compared to the control condition.
Comparing BOLD responses during nocebo in contrast to control, we observed increased activity in contralateral (right) rolandic operculum. Opercular involvement was repeatedly reported in studies related to the expectation of stimulus intensification and might thus represent an early area integrating expectation information with somatosensory information. Finally, functional coupling between the insula and the periaqueductal gray (PAG) was enhanced specifically in the nocebo condition. This cortex-PAG interaction indicates that context-dependent top-down modulation during itch might represent a shared mechanism with other modalities such as pain.
Attentional strategies, such as distraction and sensory monitoring, are often offered to reduce pain and pain-related distress. However, evidence for their efficacy in chronic pain patients is equivocal. We report a meta-analysis on the efficacy of distraction and sensory monitoring in chronic pain patients, and explore possible methodological and theoretical moderators. The scientific literature was searched for relevant articles, which were coded for methodological quality and several theoretical and methodological moderator variables. Only 10 articles fulfilled the search criteria. Eight studies allowed us to compare distraction with a control condition, two studies to compare sensory monitoring with a control condition, and four studies to compare the effect of distraction with the effect of sensory monitoring. Overall, results indicate that distraction did not differ from control in altering pain experience (k=8; Hedges' g=0.10, ns) and distress (k=2; Hedges' g=0.549). Sensory monitoring did also not alter pain experience (k=2; Hedges' g=-0.21, ns) and distress (k=1; Hedges' g=-0.191, ns). We found no evidence to support the superiority of distraction or sensory monitoring in altering pain compared to control conditions. We offer guidance for future theory-driven research to investigate distraction and sensory monitoring in this largely unexplored field, albeit one replete with methodological difficulties.
Background
To evaluate the effects of a cognitive behavioral therapy (CBT) program on kinesiophobia, knee function, pain and pain catastrophizing in patients following total knee arthroplasty (TKA).
Methods
This was a parallel-group, randomized, controlled pilot study in which 100 patients who exhibited kinesiophobia after TKA were randomly assigned to participate in a CBT (experimental group) or standard care (control group) program. Each group included 50 patients. Before intervention (preintervention), 4 weeks after intervention (postintervention), and 6 months after the end of intervention (follow-up), patients were assessed via the Tampa Scale for Kinesiophobia, the Pain Catastrophizing Scale, a numerical rating scale, and the Hospital for Special Surgery knee rating scale. Repeated-measures analysis of variance was used to test the significance of each outcome measure.
Results
The CBT program had significant group (P < .001), time (P < .001), and group-by-time interaction (P < .001) effects on kinesiophobia, pain catastrophizing, and knee function, and these effects lasted for at least 6 months after the end of the intervention. Pain was reduced in both groups after the intervention, but there were significant time and group effects (P = .003) in favor of the experimental group.
Conclusion
The CBT program was superior to standard care in reducing kinesiophobia, pain catastrophizing, and knee pain and in enhancing knee function in patients who have a high level of kinesiophobia following TKA. The treatment effect was clinically significant and lasted for at least 6 months after the end of the intervention.
Attention plays a pivotal role in the experience of pain and its impact upon daily activities. Accordingly, research on the interplay between attention and pain has a long scientific history. This chapter discusses the theoretical frameworks that aim to explain the relationship between attention and pain. It argues for a motivational perspective on pain that highlights the critical role of cognitive, affective, and contextual factors in explaining the interplay between attention and pain. To substantiate this argument, the chapter provides an overview of available research addressing the bottom-up capture of attention by pain and the top-down modulation (both inhibition and facilitation) of attention for pain. It concludes with guidelines and suggestions for future research and discusses clinical implications of adopting a motivational perspective on pain.
Systematic reviews aide the analysis and dissemination of evidence, using rigorous and transparent methods to generate empirically attained answers to focused research questions. Identifying all evidence relevant to the research questions is an essential component, and challenge, of systematic reviews. Gray literature, or evidence not published in commercial publications, can make important contributions to a systematic review. Gray literature can include academic papers, including theses and dissertations, research and committee reports, government reports, conference papers, and ongoing research, among others. It may provide data not found within commercially published literature, providing an important forum for disseminating studies with null or negative results that might not otherwise be disseminated. Gray literature may thusly reduce publication bias, increase reviews’ comprehensiveness and timeliness, and foster a balanced picture of available evidence.
Gray literature's diverse formats and audiences can present a significant challenge in a systematic search for evidence. However, the benefits of including gray literature may far outweigh the cost in time and resource needed to search for it, and it is important for it to be included in a systematic review or review of evidence. A carefully thought out gray literature search strategy may be an invaluable component of a systematic review. This narrative review provides guidance about the benefits of including gray literature in a systematic review, and sources for searching through gray literature. An illustrative example of a search for evidence within gray literature sources is presented to highlight the potential contributions of such a search to a systematic review. Benefits and challenges of gray literature search methods are discussed, and recommendations made.
Background:
This is an update of a Cochrane review previously published in 2014. Acute postoperative pain is one of the most disturbing complaints in open heart surgery, and is associated with a risk of negative consequences. Several trials investigated the effects of psychological interventions to reduce acute postoperative pain and improve the course of physical and psychological recovery of participants undergoing open heart surgery.
Objectives:
To compare the efficacy of psychological interventions as an adjunct to standard care versus standard care alone or standard care plus attention control in adults undergoing open heart surgery for pain, pain medication, psychological distress, mobility, and time to extubation.
Search methods:
For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Web of Science, and PsycINFO for eligible studies up to February 2017. We used the 'related articles' and 'cited by' options of eligible studies to identify additional relevant studies. We checked lists of references of relevant articles and previous reviews. We searched the ProQuest Dissertations and Theses Full Text Database, ClinicalTrials and the WHO International Clinical Trials Registry Platform to identify any unpublished material or ongoing trials. We also contacted the authors of primary studies to identify any unpublished material. In addition, we wrote to all leading heart centres in Germany, Switzerland, and Austria to check whether they were aware of any ongoing trials.
Selection criteria:
Randomised controlled trials comparing psychological interventions as an adjunct to standard care versus standard care alone or standard care plus attention in adults undergoing open heart surgery.
Data collection and analysis:
Two review authors (SZ and SK) independently assessed trials for eligibility, estimated the risk of bias and extracted all data. We calculated effect sizes for each comparison (Hedges' g) and meta-analysed data using a random-effects model. We assessed the evidence using GRADE and created 'Summary of findings' tables.
Main results:
We added six studies to this update. Overall, we included 23 studies (2669 participants).For the majority of outcomes (two-thirds), we could not perform a meta-analysis since outcomes were not measured, or data were provided by one trial only.No study reported data on the number of participants with pain intensity reduction of at least 50% from baseline. Only one study reported data on the number of participants below 30/100 mm on the Visual Analogue Scale (VAS) in pain intensity (very low-quality evidence). Psychological interventions did not reduce pain intensity in the short-term interval (g 0.39, 95% CI -0.18 to 0.96, 2 studies, 104 participants, low-quality evidence), medium-term interval (g -0.02, 95% CI -0.24 to 0.20, 4 studies, 413 participants, moderate-quality evidence) or in the long-term interval (g 0.05, 95% CI -0.20 to 0.30, 2 studies, 200 participants, moderate-quality evidence).No study reported data on median time to re-medication or on number of participants re-medicated. Only two studies provided data on postoperative analgesic use in the short-term interval, showing that psychological interventions did not reduce the use of analgesic medication (g 1.18, 95% CI -2.03 to 4.39, 2 studies, 104 participants, low-quality evidence). Studies revealed that psychological interventions reduced mental distress in the medium-term (g 0.37, 95% CI 0.13 to 0.60, 13 studies, 1388 participants, moderate-quality evidence) and likewise in the long-term interval (g 0.32, 95% CI 0.10 to 0.53, 14 studies, 1586 participants, moderate-quality evidence). Psychological interventions did not improve mobility in the medium-term interval (g 0.23, 95% CI -0.22 to 0.67, 3 studies, 444 participants, low-quality evidence), nor in the long-term interval (g 0.09, 95% CI -0.10 to 0.28, 4 studies, 458 participants, moderate-quality evidence). Only two studies reported data on time to extubation, indicating that psychological interventions reduced the time to extubation (g 0.56, 95% CI 0.08 to 1.03, 2 studies, 154 participants, low-quality evidence).Overall, the very low to moderate quality of the body of evidence on the efficacy of psychological interventions for acute pain after open heart surgery cannot be regarded as sufficient to draw robust conclusions.Most 'Risk of bias' assessments were low or unclear. We judged selection bias (random sequence generation) and attrition bias to be mostly low risk for included studies. However, we judged the risk of selection bias (allocation concealment), performance bias, detection bias and reporting bias to be mostly unclear.
Authors' conclusions:
In line with the conclusions of our previous review, there is a lack of evidence to support or refute psychological interventions in order to reduce postoperative pain in participants undergoing open heart surgery. We found moderate-quality evidence that psychological interventions reduced mental distress in participants undergoing open heart surgery. Given the small numbers of studies, it is not possible to draw robust conclusions on the efficacy of psychological interventions on outcomes such as analgesic use, mobility, and time to extubation respectively on adverse events or harms of psychological interventions.
Several studies have used neuroimaging techniques in an attempt to characterize brain correlates of the attentional modulation of pain. Although these studies have advanced the knowledge in the field, important confounding factors such as imprecise theoretical definitions of attention, incomplete operationalization of the construct under exam, and limitations of techniques relying on measuring regional changes in cerebral blood flow have hampered the potential relevance of the conclusions. Here, we first provide an overview of the major theories of attention and of attention in the study of pain to bridge theory and experimental results. We conclude that load and motivational/affective theories are particularly relevant to study the attentional modulation of pain and should be carefully integrated in functional neuroimaging studies. Then, we summarize previous findings and discuss the possible neural correlates of the attentional modulation of pain. We discuss whether classical functional neuroimaging techniques are suitable to measure the effect of a fluctuating process like attention, and in which circumstances functional neuroimaging can be reliably used to measure the attentional modulation of pain. Finally, we argue that the analysis of brain networks and spontaneous oscillations may be a crucial future development in the study of attentional modulation of pain, and why the interplay between attention and pain, as examined so far, may rely on neural mechanisms shared with other sensory modalities.
The relationship between the conscious experience of physical symptoms and indicators of objective physiological dysfunction is highly variable and depends on characteristics of the person, the context and their interaction. This relationship often breaks down entirely in the case of “medically unexplained” or functional somatic symptoms, violating the basic assumption in medicine that physical symptoms have physiological causes. In this paper, we describe the prevailing theoretical approach to this problem and review the evidence pertaining to it. We then use the framework of predictive coding to propose a new and more comprehensive model of the body-symptom relationship that integrates existing concepts within a unifying framework that addresses many of the shortcomings of current theory. We describe the conditions under which a close correspondence between the experience of symptoms and objective physiology might be expected, and when they are likely to diverge. We conclude by exploring some theoretical and clinical implications of this new account.