The role of attentional strategies in moderating links between acute pain induction and subsequent psychological stress: Evidence for symptom-specific reactivity among patients with chronic pain versus healthy nonpatients.

Vulnerability to stressors after pain may depend on the degree to which the strategy used to process information about pain perpetuates thoughts of suffering and distress. Patients with chronic low back pain (CLBP) may show susceptibility to stress after pain through symptom-specific (lower paraspinal [LP]) muscle reactivity. Patients with CLBP (n = 100) and healthy nonpatients (n = 105) underwent a cold pressor, under sensory focus, distraction, suppression, or control conditions, and then performed mental arithmetic. Only patients under the suppression condition revealed increased LP tension during pain that was sustained during mental arithmetic and sustained systolic blood pressure after mental arithmetic. Patients with CLBP who suppress pain may detrimentally affect responses to the next noxious event, particularly through prolonged LP muscle tension, that may contribute to a cycle of pain-stress-pain. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Arousal of negative emotions and symptom-specific reactivity in chronic low back pain patients.

Anger may have greater effects on chronic pain severity than other negative emotions and may do so by increasing muscle tension near the site of injury (symptom-specific reactivity). For patients with chronic low back pain (CLBP), relevant muscles are lower paraspinals (LP). Ninety-four CLBP patients and 79 controls underwent anger and sadness recall interviews. EMG and cardiovascular activity were recorded. Patients exhibited greater LP tension increases during anger and slower recovery than controls. Only patients showed greater LP reactivity during anger than sadness. For both groups, trapezius reactivity during anger and sadness did not differ. LP reactivity to anger correlated with everyday pain severity for patients. Anger-induced symptom-specific LP reactivity may be linked to chronic pain aggravation among CLBP patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of anger suppression on pain severity and pain behaviors among chronic pain patients: Evaluation of an ironic process model.

Objective: Evidence for links between anger inhibition or suppression and chronic pain severity is based mostly on studies with correlation designs. Following from ironic process theory, we proposed that attempts to suppress angry thoughts during provocation would increase subsequent pain intensity among chronic low back pain (CLBP) patients, and do so through paradoxically enhanced accessibility of anger. Design: CLBP patients (N = 58) were assigned to suppression and nonsuppression conditions while performing a computer maze task with a harassing confederate. A structured pain behavior task (SPBT) followed. Main outcome measures: Self-reported anger, anxiety, and sadness following maze task. Self-reported pain severity and number of observed pain behaviors during SPBT. Results: Patients told to suppress during provocation: (a) reported greater anger following the maze task, reported greater pain intensity during the SPBT, and exhibited more pain behaviors than patients not suppressing; (b) postmaze anger levels significantly mediated group differences on pain behaviors. Conclusion: Attempts by CLBP patients to suppress anger may aggravate pain related to their clinical condition through ironically increased feelings of anger. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessment of stress-related psychophysiological reactions in chronic back pain patients.

Compared the relationship of paraspinal EMG reactivity to personally relevant and general stress among 17 chronic back pain (CBP) patients, 17 non-back-pain patients, and 17 healthy controls. The 3 experimental groups were matched according to sex, age, marital status, education, and employment level. 78% of the Ss were male; 72% were married. The Ss ranged in age from 23 to 73 yrs. Ss participated in a psychophysiological assessment that included 4 trials (discussions of personal stress and pain, mental arithmetic, and reciting the alphabet). Paraspinal and frontalis EMG, heart rate, and skin resistance were recorded continuously. Psychological variables (e.g., depression and perceived control) were also assessed. Results indicate that CBP Ss displayed elevations and delayed return to baseline only in their paravertebral musculature and only when discussing personally relevant stress. Neither of the other groups displayed similar response patterns. Abnormal muscular reactivity was best predicted by depression and manner of coping with pain rather than by organic variables. These results suggest that the assessment of stress-related responses may be important in the evaluation and treatment of CBP. (33 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Chronic pain and depression: Does the evidence support a relationship?

Examines the extent to which chronic pain and depression coexist by summarizing relevant literature and highlights common conceptual and methodological problems in this literature. The extent to which depression and chronic pain are associated remains a controversial issue that empirical studies have failed to resolve completely. An evaluation of relevant literature provides support for an association between the 2 syndromes and suggests that coexisting pain and depression may be a final common presentation reached by a number of potential pathways. Current biological, psychodynamic, and behavioral cognitive models of the mechanisms by which chronic pain and depression may interact are summarized. The literature suggests that a research approach is required to investigate the variety of paths by which individuals arrive at both chronic pain and depression. The usefulness of this strategy would be demonstrated if factors discriminating among subgroups of patients with both chronic pain and depression, and optimal intervention strategies for each, were determined. (2? p ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Anger management style and the prediction of treatment outcome among male and female chronic pain patients

Anger is a prominent emotion experienced by chronic pain patients. Anecdotes suggest that anger predicts poor outcome following multidisciplinary pain programs, but no empirical evidence documents this link. We expected that patient anger expression or suppression would predict poor outcome following a pain program and that gender differences would emerge. Pre- to posttreatment measures of lifting capacity, walking endurance, depression, pain severity and activity level were collected from 101 chronic pain patients. An 'anger expression x gender' interaction was found such that anger expression among males was correlated negatively with lifting capacity improvements. 'Anger suppression x gender' interactions emerged such that anger suppression among males was correlated negatively with improvements in depression and general activities. These effects remained significant after controlling for trait anger. Thus, how anger is managed may exert unique influence on outcomes apart from the effects of mere anger proneness, at least among male pain patients.     

Explaining high rates of depression in chronic pain: A diathesis-stress framework.

Depression has been observed to accompany chronic pain. Yet, controversy remains regarding the extent and nature of the relationship between these 2 disorders. The authors analyze the literature regarding depression rates in chronic pain and other chronic medical populations and argue that depression appears to be highest among chronic pain patients. Drawing from cognitive-behavioral models of depression, the authors explore the unique psychological experiences of living with chronic pain that may account for the high prevalence of depression. A diathesis-stress framework is proposed to conceptualize the development of depression in chronic pain. Clinical and heuristic implications are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A controlled evaluation of paraspinal EMG biofeedback in the treatment of chronic low back pain.

66 chronic low back pain sufferers (aged 20–65 yrs) were randomly divided into 3 equal groups. Ss completed a psychological test battery that included the Beck Depression Inventory and the State-Trait Anxiety Inventory; pain monitoring measures, including the McGill Pain Questionnaire (MPQ); and measurement of paraspinal electromyogram (EMG). One group then received paraspinal EMG biofeedback, 1 group received placebo treatment, and the 3rd group received no intervention. All Ss were reassessed immediately after treatment and at 3-mo follow-up. Results show that all groups showed significant reductions in pain, anxiety, depression, and paraspinal EMG following treatment and at follow-up, but there were no differences between groups. A regression analysis failed to identify Ss' characteristics that predicted positive outcome in the biofeedback group. However, high scores on the Evaluative scale of the MPQ and high hypnotizability were significant predictors of positive outcome for the placebo group. It is concluded that paraspinal EMG biofeedback is not a specific treatment for chronic low back pain in a nonhospitalized population. (31 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Depression among chronic pain patients: Cognitive-behavioral analysis and effect on rehabilitation outcome.

This study addressed two issues concerning the theoretical and clinical relevance of depression to chronic pain: (a) whether reliable differences among depressed, mildly depressed, and nondepressed chronic pain patients could be identified and (b) whether depression influenced participation in or outcome following a rehabilitation program. To address the first issue, four theoretical constructs were measured by multiple scales. Multivariate analyses of each construct revealed significant differences between the three groups on instrumental activities and coping skills, with more depressed individuals reporting lower levels of functioning and less support. An analysis of the second issue revealed that depressed pain patients showed a greater tendency to drop out of treatment. Outcome did not vary with depression among treatment completers. The results reveal the need to consider a cognitive-behavioral model of depression secondary to chronic pain. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Measuring treatment effects on repetitive lifting for patients with chronic low back pain: speed, style, and coordination

The purpose of this study was to determine changes in the amount of work performed and lifting speed, style, and coordination during a repetitive dynamic-lifting task for patients with chronic low back pain (CLBP) after an intensive 3 1/2-week pain rehabilitation program. Subjects included 57 CLBP patients and an age- and gender-matched control group (n = 57). Patients' work indices increased by 71%, but remained significantly less than those observed for controls. Similarly, their lifting speed also increased significantly after treatment, but remained slower than the lifting speed of controls. Patients' posttreatment coordination indices, however, were not significantly different from those of controls. This finding suggests that treatment effectively normalized the dynamic lifting motion used by the patients. These findings, along with the basic kinematic patterns developed in this study, have important implications for determining improvements in functional capacity in the treatment of patients with CLBP.     

Interpersonal psychotherapy for co-occurring depression and chronic pain.

Up to 37% of individuals experience chronic pain during their lifetimes. Approximately one fourth of primary care patients with chronic pain also meet criteria for major depression. Many of these individuals fail to receive psychotherapy or other treatment for their depression; moreover, when they do, physical pain is often not addressed directly. Women, socioeconomically disadvantaged individuals, African Americans, and Latinos all report higher rates of pain and depression compared with other groups. This article describes a version of interpersonal psychotherapy tailored for patients with comorbid depression and chronic pain, interpersonal psychotherapy for depression and pain (IPT-P). IPT-P potentially could be delivered to many patient populations in a range of clinical settings, but this article focuses on its delivery within primary care settings for socioeconomically disadvantaged women. Adaptations include a brief 8-session protocol that incorporates strategies for anticipating barriers to psychotherapy, accepting patients' conceptualization of their difficulties, encouraging patients to consider the impact of their pain on their roles and relationships, emphasizing self-care, incorporating pain management techniques, and flexible scheduling. In addition, IPT-P is designed as an adjunct to usual medical pain treatment, and seeks to engage non–treatment-seeking patients in psychotherapy by focusing on accessibility and relevance of the intervention to concerns common among patients with pain. Identifying patients with comorbid depression and chronic pain and offering IPT-P as a treatment option have the potential to improve clinical outcomes for individuals with depression and chronic pain. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Recommendations of the Brain Tumor Subcommittee for the reporting of trials. SIOP Brain Tumor Subcommittee. International Society of Pediatric Oncology

Depression was examined in 45 patients evaluated within 2 months of diagnosis of MS. At the time of testing, 40% of the MS sample met the diagnostic criteria for major depression, 22% had adjustment disorder with depressed mood and 37% showed no evidence of mood disorder. Personal and family history of depression in patients with MS was also examined and compared with a sample of patients with chronic low back pain (CLBP) who were matched for age, gender, marital and employment status and current level of depression. Fifty-two per cent of patients with MS reported experiencing a depressive episode before the onset of MS compared with 17% of patients with CLBP (P < 0.001). Sixteen patients with MS (35%) reported family history (parent or sibling) of treatment for depression compared with seven (15%) of patients with CLBP (P < 0.05). MS patients with a history of depression reported more initial symptoms than MS patients without a history of depression. Clinical and theoretical implications of the findings are discussed.     

Cognitive distortion and depression in chronic pain: Association with diagnosed disorders.

Previous studies have demonstrated that cognitive distortion is associated with increased levels of self-reported depression among chronic pain patients, suggesting that cognitive models of depression might be useful in this context. However, reliance on self-reports of depression hampers generalization of these results to clinically significant depressive disorders. To address this problem, we examined the association between depression diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) (i.e., major depression and dysthymia) and scores on the Cognitive Errors Questionnaire. Depressed chronic pain patients and depressed nonpain patients reported more cognitive distortion than did nondepressed pain patients and normal controls. These results support the relevance of cognitive theory in the explication of clinically significant depression among chronic pain patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparison between celiac plexus block and morphine treatment on quality of life in patients with pancreatic cancer pain

Twenty-one patients with pancreatic cancer pain were studied to evaluate the effectiveness of celiac plexus block (CPB) on pain relief and quality of life (QOL), compared to the traditional NSAID-morphine treatment. The criteria were morphine consumption, visual analogue pain scale (VAS), performance status (PS) determined by medical and nursing staffs, and answers to QOL questionnaires. Morphine consumption, VAS, PS, and self-assessed QOL scores were taken when the administration of morphine was necessary for pain relief and those scores were used as control. Morphine consumption and the VAS score were recorded at regular weekly intervals and the PS and QOL scores were measured every 2 weeks thereafter. CPB was performed within 2-3 days after the control measurement. The VAS scores of the patients receiving CPB (n = 10) were statistically lower for the first 4 weeks after the procedure than those of the patients receiving the standard NSAID-morphine treatment (n = 11) during the same time period after the control measurement. Morphine consumption was significantly lower in weeks 4-7 (inclusive) following the procedure in the CPB group and continued to be lower thereafter, though not significantly so. Although the PS score slightly improved at the 2nd week after CPB, it was not improved by the start of the NSAID-morphine treatment. Self-assessed QOL scores did not ameliorate statistically after CPB; however, they did deteriorate remarkably in the patients treated only with morphine-NSAID during their survival periods, while they deteriorated only slightly in the CPB group. There were fewer side effects after CPB. These results indicate CPB does not directly improve QOL in patients with pancreatic cancer pain, but it may prevent deterioration in QOL by the long-lasting analgesic effect, limitation of side effects and the reduction of morphine consumption, compared to treatment only with NSAID-morphine.     

Meta-analysis of psychological interventions for chronic low back pain.

The purpose of this meta-analysis of randomized controlled trials was to evaluate the efficacy of psychological interventions for adults with noncancerous chronic low back pain (CLBP). The authors updated and expanded upon prior meta-analyses by using broad definitions of CLBP and psychological intervention, a broad data search strategy, and state-of-the-art data analysis techniques. All relevant controlled clinical trials meeting the inclusion criteria were identified primarily through a computer-aided literature search. Two independent reviewers screened abstracts and articles for inclusion criteria and extracted relevant data. Cohen's d effect sizes were calculated by using a random effects model. Outcomes included pain intensity, emotional functioning, physical functioning (pain interference or pain-specific disability, health-related quality of life), participant ratings of global improvement, health care utilization, health care provider visits, pain medications, and employment/disability compensation status. A total of 205 effect sizes from 22 studies were pooled in 34 analyses. Positive effects of psychological interventions, contrasted with various control groups, were noted for pain intensity, pain-related interference, health-related quality of life, and depression. Cognitive-behavioral and self-regulatory treatments were specifically found to be efficacious. Multidisciplinary approaches that included a psychological component, when compared with active control conditions, were also noted to have positive short-term effects on pain interference and positive long-term effects on return to work. The results demonstrated positive effects of psychological interventions for CLBP. The rigor of the methods used, as well as the results that reflect mild to moderate heterogeneity and minimal publication bias, suggest confidence in the conclusions of this review. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Chronic pain and depression: role of perceived impact and perceived control in different age cohorts

Chronic pain adversely affects individuals' physical as well as emotional well-being. A cognitive-behavioral model has been proposed to explain the role of cognitive appraisal variables in mediating the development of emotional distress following pain of long duration. There is little evidence linking the prevalence of depression in chronic pain patients to life stage, but there are suggestions in the literature that the link between medical illness and depression may be stronger in elderly patients. One purpose of this study was to replicate the efficacy of a previous study of the cognitive-behavioral mediation model in explaining the association between pain and depressed affect. A second purpose of this study was to extend the cognitive-behavioral model to evaluate relationships among pain, cognitive appraisal variables, and depressive affect in the elderly chronic pain population. One hundred chronic pain patients were divided into two age groups (< or = 69 years and > or = 70 years). A path analysis conducted for the total sample supported the cognitive-behavioral mediation model of depression in chronic pain, in which cognitive appraisal variables mediate the pain-depression relationship. Correlations among variables in each of the two age groups, however, revealed different patterns of association. Consistent with the cognitive-behavioral model, the younger patients demonstrated a low and non-significant correlation between pain severity and depression (r = 0.01). Conversely, a strong direct association was observed in the older patients between these variables (r = 0.51). These results suggest that the relationship between pain and depression varies substantially depending upon age cohort.     

Mobilization of arachidonate and docosahexaenoate by stimulation of the 5-HT2A receptor in rat C6 glioma cells

Distraction has been found to be effective for the attenuation of experimental and acute clinical pain but its efficacy for chronic pain management remains unclear. There are even some suggestions that distraction may be a counterproductive strategy for chronic pain sufferers. In this study we found that a word shadowing distraction task increased the ability of a group of 12 female and eight male chronic low back pain (CLBP) sufferers to carry out a brief (maximum 300 s) step-up exercise that temporarily increased their pain (P < 0.05). This 15% increase in exercise time was not accompanied by an increase in reported pain after the exercise. Interestingly, the same distraction task did not increase the cold pressor (CP) tolerance time for the CLBP group but produced a 26% increase in tolerance time for a pain-free control group consisting of nine females and nine males (P < 0.05). Also, performance on the distraction task during the CP was worse for the CLBP group than the controls (P < 0.05). Although these findings should be interpreted cautiously because of the parameters of the experiment, they do suggest that distraction is a potentially useful technique to assist chronic pain sufferers.     

Differential effects of avoidant and attentional coping strategies on adaptation to chronic and recent-onset pain.

Examined the effectiveness of attentional (AT) and avoidant (AV) coping strategies for somatic, behavioral, and psychological adaptation to clinical pain among 30 chronic (CP) and 30 recent-onset pain (RP) patients. It was hypothesized that RP Ss would demonstrate greater adaptation (lower anxiety, depression, pain severity, and somatization ratings and higher levels of social activity) when employing AV rather than AT strategies. CP Ss using AT strategies were predicted to demonstrate greater adaptation than CP Ss using AV strategies. Ss completed the Coping Scale (A. G. Billings and R. H. Moos, 1981) as well as parts of the SCL-90 (Revised) and the West Haven-Yale Multidimensional Pain Inventory (R. D. Kerns et al, 1985). Results support the hypothesis. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of compensation involvement on the reporting of pain and disability by patients referred for rehabilitation of chronic low back pain

STUDY DESIGN: In this prospective, observational, cohort study of 192 individuals with chronic low back pain, the group of individuals was divided based on compensation involvement, and their presentation pain and disability, treatment recommendations, and compliance were compared. For 85 of these individuals who completed a spine rehabilitation program, their pain and disability at 3 and 12 months were compared. OBJECTIVES: To test the theory that individuals with compensation involvement presented with greater pain and disability and would report less change of pain and disability after rehabilitation efforts. BACKGROUND: Previous studies have produced conflicting results concerning this issue. METHODS: Individuals were recruited as consecutive patients referred for consultation at a spine rehabilitation center. Pain, depression, and disability were assessed using self-report questionnaires at evaluation and at 3 and 12 months. Rehabilitation services consisted of aggressive, quota-based exercises aimed at correcting impairments in flexibility, strength, endurance, and lifting capacity, identified through quantification of back function. Multifactoral analysis of variance models were used to control for baseline differences between compensation and noncompensation patients during analysis of target variables. RESULTS: The compensation group included 96 patients; these patients reported more pain, depression, and disability than the 96 patients without compensation involvement. These differences persisted when baseline differences were controlled for with multifactoral analysis of variance models. Treatment recommendations and compliance were not affected by compensation. For patients completing the spine rehabilitation program, length of treatment, flexibility, strength, lifting ability, and lower extremity work performance before and after treatment and patient satisfaction ratings were similar for the compensation and noncompensation groups. At 3 and 12 months, improvements in depression and disability were noted for both groups, but were statistically and clinically less substantial for the compensation group. At the 12 month follow-up visit, pain scores improved for the noncompensation group, but not for the compensation group. CONCLUSIONS: In chronic low back pain, compensation involvement may have an adverse effect on self-reported pain, depression, and disability before and after rehabilitation interventions.     

Chronic pain: primary care treatment of the older patient

The prevalence of chronic diseases associated with pain increases with age, and pain prevalence appears to increase with the level of functional dependence. Chronic pain in older patients is associated with sleep disorders, impaired physical and social function, and increased healthcare utilization. Symptoms of pain, anxiety, and depression are often associated and may intensify each other. Because a complete resolution of chronic pain is unlikely, it is important to establish early in therapy the level of pain that the patient would find acceptable. The goal of therapy is to treat chronic pain while minimizing side effects and optimizing the patient's functional status.