Standards for the diagnosis and management of complex regional pain syndrome: Results of a European Pain Federation task force.

BACKGROUND: Complex regional pain syndrome is a painful and disabling post-traumatic primary pain disorder. Acute and chronic complex regional pain syndrome (CRPS) are major clinical challenges. In Europe, progress is hampered by significant heterogeneity in clinical practice. We sought to establish standards for the diagnosis and management of CRPS. METHODS: The European Pain Federation established a pan-European task force of experts in CRPS who followed a four-stage consensus challenge process to produce mandatory quality standards worded as grammatically imperative (must-do) statements. RESULTS: We developed 17 standards in 8 areas of care. There are 2 standards in diagnosis, 1 in multidisciplinary care, 1 in assessment, 3 for care pathways, 1 in information and education, 4 in pain management, 3 in physical rehabilitation and 2 on distress management. The standards are presented and summarized, and their generation and consequences were discussed. Also presented are domains of practice for which no agreement on a standard could be reached. Areas of research needed to improve the validity and uptake of these standards are discussed. CONCLUSION: The European Pain Federation task force present 17 standards of the diagnosis and management of CRPS for use in Europe. These are considered achievable for most countries and aspirational for a minority of countries depending on their healthcare resource and structures. SIGNIFICANCE: This position statement summarizes expert opinion on acceptable standards for CRPS care in Europe.

Evidence-Based Pain Management: Building on the Foundations of Cochrane Systematic Reviews.

We discuss the history and current status of evidence-based medicine for the prevention and treatment of acute and chronic pain as it has developed in the Cochrane Collaboration's Pain, Palliative and Supportive Care Review Group.To date, the Pain, Palliative and Supportive Care Review Group has published 277 reviews and a further 11 reviews of systematic reviews summarizing the evidence for interventions. The Cochrane Library has readily available high-quality summaries of evidence of pharmacological interventions especially for postsurgical pain but also for chronic musculoskeletal and neuropathic pain. The library covers all forms of intervention, not only pharmacological.The world of evidence-based medicine is changing: most historical trials have been entered into reviews, but the evidence is still not well disseminated and needs to be better translated into decision support. Evidence should be at the heart of policymaking. Much has been achieved in the past 21 years, but there are no grounds for complacency.

Parental catastrophizing about their child's pain. The parent version of the Pain Catastrophizing Scale (PCS-P): a preliminary validation.

Numerous studies have found evidence for the role of catastrophizing about pain in adjustment to pain in both adults and children. However, the social context influencing pain and pain behaviour has been largely ignored. Especially in understanding the complexities of childhood pain, family processes may be of major importance. In line with the crucial role of pain catastrophizing in explaining adjustment and disability in adults and children, this study investigates the role of parental catastrophic thinking about their child's pain in explaining child disability and parental distress. To study parental catastrophizing, a parent version of the Pain Catastrophizing Scale (PCS-P) was developed. An oblique three-factor structure emerged to best fit the data in both a sample of parents of schoolchildren (N=205) and in a sample of parents of children with chronic pain (N=107). Moreover, this three-factor structure was found to be invariant across both parent samples. Further, in the clinical sample, parents' catastrophic thinking about their child's pain had a significant contribution in explaining (a) childhood illness-related parenting stress, parental depression and anxiety, and (b) the child's disability and school attendance, beyond the child's pain intensity.

Impaired disengagement from threatening cues of impending pain in a crossmodal cueing paradigm.

This paper reports an experimental investigation of attentional engagement to and disengagement from cues of impending pain. Pain-free volunteers performed a cueing task in which they were instructed to detect somatosensory and tone targets. Target stimuli were preceded by visual cues informing participants of the modality of the impending stimuli. Participants were randomly assigned to a pain group (n = 54) or to a control group (n = 53). Somatosensory targets consisted of painful electrocutaneous stimuli in the pain group and non-painful vibrotactile targets in the control group. Analyses revealed a similar amount of attentional engagement to both cues signalling somatosensory targets, irrespective of their threat value. However, participants had significantly more difficulty in disengaging attention from a threatening cue of impending pain compared to a cue signalling the non-painful vibrotactile target. Our findings provide further evidence that pain cues demand attention, particularly resulting in impaired disengagement.

Hypervigilance to pain in fibromyalgia: the mediating role of pain intensity and catastrophic thinking about pain.

OBJECTIVE: To investigate the mediating role of pain intensity, catastrophic thinking about pain, and negative affectivity in explaining enhanced attention for pain in patients with fibromyalgia. METHODS: Sixty-four patients with fibromyalgia and 46 patients with chronic low back pain completed self-report instruments of vigilance to pain, negative affectivity, and catastrophic thinking about pain. These measures, along with diagnostic group and pain intensity, were entered into a partial correlational analysis to investigate which variables mediate the relationship between diagnostic group (fibromyalgia vs. chronic low back pain) and vigilance to pain. RESULTS: Fibromyalgia patients reported significantly greater vigilance to pain than patients with chronic low back pain. They also reported higher pain intensity, more negative affectivity, and more catastrophic thinking about pain than patients with chronic low back pain. Vigilance to pain was correlated significantly with pain intensity, negative affectivity, and catastrophic thinking about pain. Further analyses revealed that pain intensity and catastrophic thinking about pain, but not negative affectivity, mediated the relationship between diagnostic group and vigilance to pain. CONCLUSION: Fibromyalgia patients report a heightened vigilance to pain. This vigilance is not a unique characteristic of fibromyalgia but is related to the intensity of pain and catastrophic thinking about pain.

Coping or acceptance: what to do about chronic pain?

Research and treatment of chronic pain over the past 20 or more years have tended to focus on patient coping as the primary behavioral contribution to adjustment. The purpose of the present study was to compare a coping approach to chronic pain with a different behavioral approach referred to as acceptance of chronic pain. These approaches were compared in terms of their ability to predict distress and disability in a sample of patients seeking treatment for chronic pain. Subjects were 230 adults assessed at a university pain management center. All patients completed the coping strategies questionnaire and the chronic pain acceptance questionnaire among other standard measures. Results showed that coping variables were relatively weakly related to acceptance of pain and relatively unreliably related to pain adjustment variables. On the other hand, acceptance of chronic pain was associated with less pain, disability, depression and pain-related anxiety, higher daily uptime, and better work status. Regression analyses examined the independent contributions of coping and acceptance to key adjustment indicators in relation to chronic pain. Results from these analyses demonstrated that acceptance of pain repeatedly accounted for more variance than coping variables.

The child version of the pain catastrophizing scale (PCS-C): a preliminary validation.

Catastrophizing about pain has emerged as a critical variable in how we understand adjustment to pain in both adults and children. In children, however, current methods of measuring catastrophizing about pain rely on brief subscales of larger coping inventories. Therefore, we adapted the Pain Catastrophizing Scale (Sullivan et al., 1995) for use in children, and investigated its construct and predictive validity in two studies. Study 1 revealed that in a community sample (400 boys, 414 girls; age range between 8 years 9 months and 16 years 5 months) the Pain Catastrophizing Scale for Children (PCS-C) assesses the independent but strongly related dimensions of rumination, magnification and helplessness that are subsumed under the higher-order construct of pain catastrophizing. This three factor structure is invariant across age groups and gender. Study 2 revealed in a clinical sample of children with chronic or recurrent pain (23 girls, 20 boys; age range between 8 years 3 months and 16 years 6 months) that catastrophizing about pain had a unique contribution in predicting pain intensity beyond gender and age, and in predicting disability, beyond gender, age and pain intensity. The function of pain catastrophizing is discussed in terms of the facilitation of escape from pain, and of the communication of distress to significant others.

How can we learn to live with pain? A Q-methodological analysis of the diverse understandings of acceptance of chronic pain.

An analysis is reported of the variety of understandings available in British culture to understand acceptance of chronic pain. Q-factor analysis is used within a critical framework as Q-methodology. Thirty participants completed the procedure. Eight factors or accounts of accepting chronic pain were derived. These are reported as taking control, living day to day, acknowledging limitations, empowerment, accepting loss of self, more to life than pain, don't fight battles that cannot be won, and spiritual strength. Common features of accepting chronic pain are (1) the acknowledgement that a cure for pain is unlikely, (2) a shift of focus away from pain to non-pain aspects of life, and (3) a resistance to any suggestion that pain is a sign of personal weakness. Where accounts of chronic pain differ is in the extent to which acceptance of pain means a change in core aspects of self. Implications of this study for the study of chronic pain are discussed. In particular, how identity is managed in the context of threatening chronic pain is suggested as a fruitful area of future investigation.

Exposure to physical movements in low back pain patients: restricted effects of generalization.

Whether the effects of exposure to 1 movement generalize to another dissimilar movement was investigated in 37 patients with low back pain (15 men, 22 women). Two movements were executed twice: bending forward while standing and lifting 1 leg while lying down. During each trial, baseline pain, expected pain, and experienced pain were recorded. Similar ratings for perceived harm were obtained. Analyses revealed an initial over prediction of pain, but after exposure the overprediction was readily corrected. This exposure effect did not generalize toward another dissimilar movement. These results were only characteristic for patients with catastrophic thinking about pain. Low pain catastrophizers did not overpredict pain. There were no effects of exposure on perceived harm. Exposure may profitably be conceived of as the learning of exceptions to a general rule.

Retarded disengagement from pain cues: the effects of pain catastrophizing and pain expectancy.

This paper reports an experimental investigation of engagement with and disengagement from a threatening cue of pain. As most paradigms in pain research only provide an overall index of attentional deployment by pain-related information, a new paradigm was developed that allowed an independent investigation of engagement with and disengagement from pain cues. Forty pain-free volunteers performed a cueing task in which they had to detect pain targets and tone targets as quickly and as accurately as possible. The target stimuli were preceded by pain cues (the word 'pain'), tone cues (the word 'tone'), or neutral cues (a series of the character 'X') at stimulus onset asynchrony (SOA: stimulus interval between cue onset and target onset) levels of 100, 500, or 900 ms. There was no contingency between the type of cue and the type of target. Catastrophic thinking about pain and the predictive value of the cues were assessed by self-reports. Results can be summarized as follows: When a cue correctly primed a target, attention was optimally engaged in the identification of the target irrespective of the threatening context of the cue or target. However, when pain was cued and did not occur, there was retardation in disengagement from the pain cue. This retardation was more pronounced and extended across time in those high in catastrophic thinking about pain. On examination it appeared that catastrophic thinking about pain may operate by a protection of the belief that the cue for pain is a valid one, despite experience to the contrary.

Attentional functioning in fibromyalgia, rheumatoid arthritis, and musculoskeletal pain patients.

OBJECTIVES: To investigate whether chronic pain patients have deficits in attentional functioning compared with pain-free controls, and whether fibromyalgia patients have larger deficits in attentional functioning compared with rheumatoid arthritis and musculoskeletal pain patients. METHODS: Sixty patients (20 in each of 3 patient groups) and 20 pain-free controls completed measures assessing pain intensity, mood, pain-related disability, somatic awareness, and catastrophic thinking about pain. Attentional functioning was assessed using an age-standardized, ecologically valid test battery. Analyses were made of between-group differences. RESULTS: Sixty percent of patients had at least one score in the clinical range of neuropsychological impairment, independent of demography and mood. Fibromyalgia patients were more anxious and somatically aware than rheumatoid arthritis or musculoskeletal pain patients, but did not show larger attentional deficits than other patient groups. CONCLUSION: All 3 groups of chronic pain patients, regardless of diagnosis, had impaired cognitive functioning on an ecologically sensitive neuropsychological test of everyday attention.

The attentional control of pain: methodological and theoretical concerns.

Although it is now well accepted that attention-based cognitive coping strategies are effective in altering pain perception and have potentially useful analgesic qualities, there exists contradiction and equivocation as to the role of various factors in the production of that analgesia. Cioffi (1991) has suggested that the response to this equivocation has been a 'collective ennui' on the part of researchers. This article seeks to explore methodological and theoretical reasons for this reigning equivocation and offers some suggestions for moving beyond it. In particular, critical attention is focussed upon four possible sources of variance in experimental pain procedures: the choice of the pain induction procedure, the instructions given, the measures taken and the content of the taught strategy.