Total hip and knee arthroplasty after lower extremity amputation in a military population.

INTRODUCTION: The military includes lower extremity amputees requiring arthroplasty; however, there is little literature on this population. The primary aim of this study was to report demographics and clinical factors in amputees who undergo total hip or knee arthroplasty (THA/TKA) in the Military Health System (MHS). Second, patient-reported outcome measures (PROMs) are reported. METHODS: The Military Data Repository was queried for patients with lower extremity amputations and TKA or THA between 1 October 2014 and 12 October 2020. The medical records were reviewed and patients were contacted to complete PROMs. Mean follow-up for TKA and THA was 5.5 and 2.5 years, respectively. RESULTS: Nineteen TKAs (76%) and eight THAs (28%) were performed in 25 patients. Mean age of TKA and THA patients at the time of arthroplasty was 57 years old. A majority of TKA (68%) and THA (57%) patients underwent amputations secondary to trauma. Nearly all TKAs were performed on the contralateral side to the amputation (95%), while half of THAs were performed on the ipsilateral side (50%). Two THAs (29%) were revised due to periprosthetic fractures, whereas six TKAs (32%) were revised or reoperated on due to infection. Ten TKA patients completed PROMs. The mean score on Knee Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) was 41.8 and Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS-10) was 41.6 (Global Physical Health) and 49.6 (Global Mental Health). CONCLUSIONS: Most TKAs were performed on the contralateral limb, suggesting increased demand on the joint. The most common indication for amputation and post-TKA complication was trauma and infection, respectively. KOOS JR may not accurately capture the outcomes of this population, or they simply do worse. However, PROMIS-10 scores were similar to the non-amputee population, suggesting that the PROMIS-10 may be more useful than the KOOS JR.

Sex differences in the decoding of pain-related body postures.

BACKGROUND: Pain can be detected through nonverbal cues, including facial expressions, vocalisations, and body posture. While there are sex differences in how emotional expressions are recognized, these differences have not always been found for pain. One reason for this inconsistency may be methodological, as pain studies tend not to be designed to investigate individual differences in expression recognition. Also, few studies consider sex differences outside facial expression. METHODS: This study applied an image degradation method used to examine individual differences in emotion recognition, to investigate sex differences in the decoding of pain body postures. Forty participants (20 male) were presented with a series of body posture images depicting pain at differing levels of image degradation. Happiness, anger and sadness expressions were also included for comparison. RESULTS: Results showed significant effects of image degradation, affect type, and actor sex. Females were rated as presenting more intense pain than males; this pattern was also found for fear, but not anger or happiness. The accuracy of pain intensity judgements was reduced as image clarity decreased. Male actors depicting pain were recognized with greater accuracy than female actors. Interestingly, similar patterns were found for anger and fear expressions. CONCLUSIONS: We conclude that sex has a significant influence on pain decoding under certain conditions, and while there are similarities with the way pain and core emotions are decoded, this may depend on the type of emotion presented. This also suggests that sex-related effects in the recognition of pain expressions may include body postural cues. SIGNIFICANCE: Observer's judgements of pain displayed through body postures are driven by the sex of the person in pain.

Systematic review of management of chronic pain after surgery.

BACKGROUND: Pain present for at least 3 months after a surgical procedure is considered chronic postsurgical pain (CPSP) and affects 10-50 per cent of patients. Interventions for CPSP may focus on the underlying condition that indicated surgery, the aetiology of new-onset pain or be multifactorial in recognition of the diverse causes of this pain. The aim of this systematic review was to identify RCTs of interventions for the management of CPSP, and synthesize data across treatment type to estimate their effectiveness and safety. METHODS: MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library were searched from inception to March 2016. Trials of pain interventions received by patients at 3 months or more after surgery were included. Risk of bias was assessed using the Cochrane risk-of-bias tool. RESULTS: Some 66 trials with data from 3149 participants were included. Most trials included patients with chronic pain after spinal surgery (25 trials) or phantom limb pain (21 trials). Interventions were predominantly pharmacological, including antiepileptics, capsaicin, epidural steroid injections, local anaesthetic, neurotoxins, N-methyl-d-aspartate receptor antagonists and opioids. Other interventions included acupuncture, exercise, postamputation limb liner, spinal cord stimulation, further surgery, laser therapy, magnetic stimulation, mindfulness-based stress reduction, mirror therapy and sensory discrimination training. Opportunities for meta-analysis were limited by heterogeneity. For all interventions, there was insufficient evidence to draw conclusions on effectiveness. CONCLUSION: There is a need for more evidence about interventions for CPSP. High-quality trials of multimodal interventions matched to pain characteristics are needed to provide robust evidence to guide management of CPSP.

Biased interpretations of ambiguous bodily threat information in adolescents with chronic pain.

Adult patients with chronic pain are consistently shown to interpret ambiguous health and bodily information in a pain-related and threatening way. This interpretation bias may play a role in the development and maintenance of pain and disability. However, no studies have yet investigated the role of interpretation bias in adolescent patients with pain, despite that pain often first becomes chronic in youth. We administered the Adolescent Interpretations of Bodily Threat (AIBT) task to adolescents with chronic pain (N = 66) and adolescents without chronic pain (N = 74). Adolescents were 10 to 18 years old and completed the study procedures either at the clinic (patient group) or at school (control group). We found that adolescents with chronic pain were less likely to endorse benign interpretations of ambiguous pain and bodily threat information than adolescents without chronic pain, particularly when reporting on the strength of belief in those interpretations being true. These differences between patients and controls were not evident for ambiguous social situations, and they could not be explained by differences in anxious or depressive symptoms. Furthermore, this interpretation pattern was associated with increased levels of disability among adolescent patients, even after controlling for severity of chronic pain and pain catastrophizing. The current findings extend our understanding of the role and nature of cognition in adolescent pain, and provide justification for using the AIBT task in longitudinal and training studies to further investigate causal associations between interpretation bias and chronic pain.

Child attention to pain and pain tolerance are dependent upon anxiety and attention control: An eye-tracking study.

BACKGROUND: Pain is common and can be debilitating in childhood. Theoretical models propose that attention to pain plays a key role in pain outcomes, however, very little research has investigated this in youth. This study examined how anxiety-related variables and attention control interacted to predict children's attention to pain cues using eye-tracking methodology, and their pain tolerance on the cold pressor test (CPT). METHODS: Children aged 8-17 years had their eye-gaze tracked whilst they viewed photographs of other children displaying painful facial expressions during the CPT, before completing the CPT themselves. Children also completed self-report measures of anxiety and attention control. RESULTS: Findings indicated that anxiety and attention control did not impact children's initial fixations on pain or neutral faces, but did impact how long they dwelled on pain versus neutral faces. For children reporting low levels of attention control, higher anxiety was associated with less dwell time on pain faces as opposed to neutral faces, and the opposite pattern was observed for children with high attention control. Anxiety and attention control also interacted to predict pain outcomes. For children with low attention control, increasing anxiety was associated with anticipating more pain and tolerating pain for less time. CONCLUSIONS: This is the first study to examine children's attention to pain cues using eye-tracking technology in the context of a salient painful experience. Data suggest that attention control is an important moderator of anxiety on multiple outcomes relevant to young people's pain experiences. SIGNIFICANCE: This study uses eye tracking to study attention to pain cues in children. Attention control is an important moderator of anxiety on attention bias to pain and tolerance of cold pressor pain in youth.

Improving student nurses' aged care understandings through a supported placement.

AIM: The study aimed to identify the potential for aged care placements to deliver benefits for second year nursing students when conducted within a supportive framework with debriefing and critical reflection opportunities. BACKGROUND: Given the ageing population and complex care needs of aged care facility residents, exacerbated by the high prevalence of dementia, the healthcare workforce's ability to meet older people's care needs is paramount. Yet research shows that nursing students are disengaged from aged care. METHODS: Using a quasi-experimental mixed method design within an action research framework, 40 students were allocated a 3-week supported placement in 2011-2012 at one of the two intervention residential aged care facilities in Tasmania, Australia. Staff formed mentor action research groups in each facility and participated in a pre-placement capacity-building programme. Thirty-nine students were placed across 14 control facilities. Data were collected via meetings with students and pre-post placement questionnaires on placement experiences, attitudes and dementia knowledge. RESULTS: The intervention facility placement programme led to mentors and students being well prepared for the placement and to students experiencing enhanced teaching and learning derived from high levels of mentor support and increased autonomy. Students' knowledge, understanding and attitudes around aged care and dementia improved. DISCUSSION: Mentors working together within an action research framework can provide a supported residential aged care placement for nursing students that improves students' aged care attitudes and understandings. CONCLUSION AND IMPLICATIONS FOR NURSING AND HEALTH POLICY: Provision of quality, supported aged care student placements is vital to prepare a new generation of nurses who will have to deal with the complex chronic healthcare needs associated with an ageing population.

The role of pain-related anxiety in adolescents' disability and social impairment: ALSPAC data.

BACKGROUND: Anxiety, in particular pain-related anxiety, plays an important role in explaining the severity of pain complaints and pain-related disability in both adults and children with chronic pain. The fear-avoidance model (FAM) describes how pain-related anxiety plays a critical role in the maintenance of pain-avoidance behaviour, which in turn influences pain-related disability. However, the FAM does not take into account broader aspects of adolescence, such as social functioning, which could be negatively impacted by anxiety. In addition, most studies examining the role of anxiety in pain have used small convenience or clinical samples. By using a large UK epidemiological database, this study investigated the associations between pain-related anxiety, disability and judgements of social impairment. METHODS: Participants (n = 856) with recurrent pain were selected from a larger epidemiological study (Avon Longitudinal Study of Parents and Children) of adolescents attending a research clinic at the age of 17 (n = 5170). Adolescents completed a self-report questionnaire on pain-related anxiety, disability and perceived social impairment. RESULTS: High levels of pain-related anxiety were associated with more disability. In girls, higher levels of pain-related anxiety were also related to the self-perception of greater impairment in social functioning compared with their peers. CONCLUSIONS: Pain-related anxiety was associated with greater pain-related disability and impaired social functioning. Social functioning should be explored as an integral part of fear-avoidance models of adolescent chronic pain.

Why go online when you have pain? A qualitative analysis of teenagers' use of the Internet for pain management advice.

BACKGROUND: Adolescents are routinely recognized as native to online technologies. However, we know from previous research that this familiarity does not often translate into its use for help-seeking around health. We designed this study to examine the experience of adolescents in using the Internet to access pain management information, specifically why some adolescents may be reluctant to use these resources. METHODS: Twenty-six healthy, school attending, adolescents aged between 14 and 17 years old were recruited to a qualitative study of focus groups. Seventeen participants were female and nine were male. Participation was limited to those who self-selected as frequent users of the Internet, but who were loath to use it as a resource for health information as we wished to explore reasons for non-use. All data were thematically analysed. RESULTS: Most participants reported using the Internet to seek health information at least once. Experiences with online content were typically negative and drawn on only when all other sources of information and pain coping were exhausted. Three themes emerged, Drivers of Internet use, Barriers, and Anxiety around use. Adolescent health websites were reported to be confusing, anxiety provoking and hard to negotiate. The Internet was judged to be less accessible than other forms of pain and health coping information. Secondary themes related to topic embarrassment, the strive for independence and reassurance, preferred information source failure, curiosity, website design, availability of OTC analgesics, effort, fear-provoking narratives, mistrust of quality of online content and pain-related anxiety. CONCLUSIONS: Counter to many positive reports of the health benefits of Internet use during information seeking, its value is questionable to some adolescents. Typical experience was anxiety provoking, unlikely to yield helpful results, and wasteful comparative to off-line resources for pain.

Return to work with chronic pain: employers' and employees' views.

BACKGROUND: The sickness certification and return to work (RTW) of people with chronic pain are important health and economic issues for employees, employers, taxpayers and the UK government. The 'fit note' and a national educational programme promoting RTW were introduced in 2010 to curb rising rates of sickness absence. AIMS: To investigate employers' and employees' experiences of managing RTW when someone has taken sick leave for chronic pain and to explore the perceived efficacy of the fit note. METHODS: A qualitative study, comprising semi-structured interviews with employers who had managed sick leave cases and employees who had experienced sick leave for chronic pain. Interviews were recorded, transcribed and the data analysed using constructivist grounded theory principles. RESULTS: Five themes were elicited. Firstly, frequent enquiry after health status was seen as intrusive by some employees but part of good practice by employers and acknowledging this difference was useful. Secondly, being able to trust employees due to their performance track record was helpful for employers when dealing with complex chronic pain conditions. Thirdly, feeling valued increased employees' motivation to RTW. Fourthly, guidelines about maintaining contact with absent employees were useful if used flexibly. Finally, both parties valued the fit note for its positive language, interrogative format and biomedical authority. CONCLUSIONS: The fit note was perceived to be helpful if used in combination with other strategies for managing sick leave and RTW for people with chronic pain. These strategies may be applicable to other fluctuating, long-term conditions with medically unexplained elements.

Psychological approaches to chronic pain management: evidence and challenges.

Psychological interventions are a mainstay of modern pain management practice and a recommended feature of a modern pain treatment service. Systematic reviews for the evidence of psychological interventions are reviewed in this article. The evidence for effectiveness is strongest for cognitive behavioural therapy with a focus on cognitive coping strategies and behavioural rehearsal. Most evidence is available for treatments of adult pain, although adolescent chronic pain treatments are also reviewed. It is clear that treatment benefit can be achieved with cognitive behavioural methods. It is possible to effect change in pain, mood, and disability, changes not achieved by chance or by exposure to any other treatment. However, the overall effect sizes of treatments for adults, across all trials, are modest. Reasons for the relatively modest treatment effects are discussed within the context of all treatments for chronic pain being disappointing when measured by the average. Suggestions for improving both trials and evidence summaries are made. Finally, consideration is given to what can be achieved by the pain specialist without access to specialist psychology resource.

Keeping pain out of your mind: the role of attentional set in pain.

BACKGROUND: The involuntary capture of attention by pain may, to some extent, be controlled by psychological variables. In this paper, we investigated the effect of attentional set (i.e., the collection of task-related features that a person is monitoring in order to successfully pursue a goal) on pain. METHODS: Two experiments are reported in which the task relevance of the modality and spatial location of a target stimulus was manipulated. In both experiments, somatosensory and auditory stimuli were presented on each trial. In experiment 1, 29 participants were cued on each trial to localize either a somatosensory or an auditory target. In experiment 2, 37 participants were cued on each trial to identify either a somatosensory or an auditory target at a particular location. RESULTS: In experiment 1, self-reported pain intensity and unpleasantness were reduced when participants had to localize the auditory target. The location of the painful stimulus relative to the location of the auditory target did not affect pain. In experiment 2, again, pain intensity and unpleasantness ratings were reduced when participants identified the auditory target. Now, the location of the painful stimulus relative to the location of the auditory target moderated the effect. Pain intensity was less when the painful stimulus was at a different location than the auditory target. CONCLUSIONS: Results are discussed in terms of the attentional set hypothesis, and we argue that the effectiveness of distraction tasks depends on the degree to which the task-relevant features of the distraction task are distinct from pain-related features.

A normal psychology of everyday pain.

Proposed is a psychology of pain that focusses on normal psychological reactions to pain. A normal psychology of pain seeks to explain what normal people (those who would not meet any criteria for any psychological disorder) do when faced with pain. Herein, we focus on everyday pain defined as pain that is clinically unimportant that arises from normal everyday activity. Pain functions to interrupt current concerns and promote problem solving typically in the form of escape, pain management, or request for assistance. A model of analgesic problem solving is described. Focussing on pain as an interruption leads us to think about the purpose of analgesics in repairing attention and returning function. New endpoints for analgesic performance are offered. Similarly, a focus on pain as a motivation for analgesia demands that we understand how people self-medicate its relative success, and what influences patterns of self-medication. Finally, the problem of pain in children and adolescents, including self-medication in youth, is discussed. Although there is limited small-scale research on young people and their knowledge about analgesics, very little is known about their beliefs, attitudes to analgesics and their self-medication behaviour. Adolescents in most societies are left largely unguided. There is little child-specific communication about how to manage pain. Most children rely on parental knowledge, although increasingly the internet is becoming a source of advice for young people learning about analgesics.

Medical student bias and care recommendations for an obese versus non-obese virtual patient.

OBJECTIVE: This study examined the independent effect of a patient's weight on medical students' attitudes, beliefs and interpersonal behavior toward the patient, in addition to the clinical recommendations they make for her care. DESIGN: A total of 76 clinical-level medical students were randomly assigned to interact with a digital, virtual female patient who was visibly either obese or non-obese. METHODS: Interactions with the patient took place in an immersive virtual (virtual reality) clinical environment that allowed standardization of all patient behaviors and characteristics except for weight. Visual contact behavior was automatically recorded during the interaction. Afterward, participants filled out a battery of self-report questionnaires. RESULTS: Analyses revealed more negative stereotyping, less anticipated patient adherence, worse perceived health, more responsibility attributed for potentially weight-related presenting complaints and less visual contact directed toward the obese version of a virtual patient than the non-obese version of the patient. In contrast, there was no clear evidence of bias in clinical recommendations made for the patient's care. CONCLUSION: Biases in attitudes, beliefs and interpersonal behavior have important implications because they can influence the tone of clinical encounters and rapport in the patient-provider relationship, which can have important downstream consequences. Gaining a clear understanding of the nature and source of weight bias in the clinical encounter is an important first step toward the development of strategies to address it.

Parental catastrophizing about child's pain and its relationship with activity restriction: the mediating role of parental distress.

Recent research has demonstrated that parental behaviors have an important impact upon child and adolescent pain outcomes. At present, however, we do not know which parents engage in particular behaviors and why. In 2 studies, the impact of parental catastrophizing about their child's pain upon parental tendency to stop their child's pain-inducing activity was investigated. Further, the mediating role of parental distress was explored. In study 1, a sample of schoolchildren (n=62; M=12.48 years; SD=1.72) took part in a cold-pressor task. In study 2, a clinical sample of adolescents with chronic pain (n=36; M=15.68 years; SD=1.85) performed a 2-min walking task designed as a pain-inducing activity. In both studies, the accompanying parent was asked to watch their child performing the pain task. Findings revealed, for both studies, that parents with a high level of catastrophic thinking about their child's pain experienced more distress and a greater behavioral tendency of wanting to stop their child's pain-inducing activity. Further, parental feelings of distress mediated the relationship between parental catastrophic thinking and parents' tendency to restrict their child's activity. The findings are discussed in light of an affective-motivational conceptualization of pain and pain behavior. Parental catastrophizing was associated with parental tendency to restrict their child's engagement in a painful test, and this relationship was mediated by parental distress.

Children's catastrophic thinking about their pain predicts pain and disability 6 months later.

Catastrophic thinking about pain has been identified as an important determinant of adjustment to pain, in both adults and children. No study has investigated the prospective and unique role of catastrophizing in explaining later pain and disability in children. The aim of the present study was to investigate the prospective roles of catastrophic thinking about pain, pain intensity, and trait anxiety and their putative relationship with pain and disability tested 6 months later. Participants were 323 schoolchildren. Analyses revealed that the child's pain catastrophizing at baseline had a small but unique contribution to the prediction of pain and disability 6 months later, even when controlling for the initial pain and disability levels. In line with expectations, moderation analyses revealed that the effects of catastrophizing upon pain and disability at follow-up were only true for those children reporting low levels intensity of pain at baseline. The variability in disability and pain complaint could not be explained by trait anxiety. Instead anxious disposition might be best conceived of as a precursor of catastrophizing in children; i.e. children with higher levels of trait anxiety at baseline were more inclined to report higher levels of catastrophizing at follow-up. The findings are discussed in terms of potential mechanisms through which catastrophizing might exert its negative impact upon pain and disability outcomes in children.

Expressive dimensions of pain catastrophizing: An observational study in adolescents with chronic pain.

Investigated was the relationship between pain catastrophizing and pain intensity in adolescents suffering from chronic pain (n = 38) and the extent to which they expressed communicative pain and pain-related protective behaviours. Adolescents were observed on video performing a 2-Min Walk Test (2MWT). Behaviours were coded on videotape. The adolescents' verbalizations about the 2MWT were also rated by their parents. Analyses revealed that higher levels of catastrophic thinking about pain were associated with higher levels of facial pain expressions and verbalizations about their pain experience, beyond the effects of age, gender, pain duration and pain intensity. Pain-related protective behaviours did not vary with the adolescents' level of pain catastrophizing, but varied with pain intensity. The findings corroborate the functional distinctiveness of different types of pain behaviours. The results are discussed in terms of the processes linking (1) catastrophizing to communicative pain behaviours and (2) pain to pain-related protective behaviours.

The effects of parental presence upon the facial expression of pain: the moderating role of child pain catastrophizing.

This experiment investigated the effects of child catastrophic thinking and parental presence on the facial expressions of children when experiencing pain. School children experienced pressure pain in either one of two conditions: (1) when observed by a parent (n=53 children and their parent), or (2) when observed by an adult stranger (n=31 children). Analyses revealed that children showed more facial pain expression in the presence of their parent than in the presence of the stranger. This effect was, however, only found for children with infrequent catastrophic thoughts about pain. Children who have frequent catastrophic thoughts expressed high pain regardless of who they believed was observing them. Results are discussed in terms of the social consequences of pain catastrophizing, and the variables contributing to the expression or suppression of pain display in children and its impact upon others.

Controlled clinical trials in cancer pain. How controlled should they be? A qualitative systematic review.

This qualitative systematic review of the clinical methodology used in randomised, controlled trials of oral opioids (morphine, hydromorphone, oxycodone) for cancer pain underlines the difficulties of good pain research in palliative care. The current literature lacks placebo-controlled superiority trials. Recommendations for future research are discussed.