Pre- and postoperative predictors of phantom limb pain.

Phantom limb (PLP) as well as residual limb pain (RLP) are still a very significant problem after amputation and their causes are only partially known. Here we tested whether the predisposition for the frequency, duration and intensity of PLP and RLP is shared with other prior chronic pains and/or the presence of postamputation subacute pain. A week preoperatively we collected data using validated questionnaires, a pain diary and interviews on past chronic pain conditions, acute pain, depression, anxiety, pain interference, life control, social support and affective distress and pain ratings one day before the amputation in 52 patients scheduled for limb amputation. In the week postamputation and again three and 12 months thereafter, we collected data on postoperative wound pain, PLP, RLP and non-painful phantom sensation (PLS). Phantom and residual limb pain indices were calculated per patient, integrating the intensity, frequency and duration of past chronic pain, PLP, RLP and PLS into a single value to index the overall burden of pain. We report that acute and chronic pain long before but not on the day before the amputation and subacute pain postamputation significantly predicted up to half of the variance in the incidence and severity of PLP, RLP and PLS 12 months postamputation. Moreover, the severity of these painful sensations at 12 months postamputation was partially predicted by preamputation scores of depression and anxiety. These findings corroborate the hypothesis that chronic pain and non-painful sensations following limb amputation are strongly related to longstanding preoperative chronic pain and to subacute postoperative pain as well as to psychological factors before the amputation that may be inherited and/or acquired (learning- and memory-related). Furthermore, we also confirm that subacute pain postamputation comprises an additional risk factor for long-term painful sensations postamputation. Our results suggest that timely interventions might prevent the development of chronic pain.

Online counseling via e-mail for breast cancer patients on the German internet: preliminary results of a psychoeducational intervention.

OBJECTIVES: The internet offers new possibilities in psychosocial patient care. However, empirical data are lacking for oncological patients. A field-experimental study was conducted to obtain initial data to enable evaluation of the effectiveness of online counseling via e-mail for breast cancer patients. A secondary objective was to explore how patients reached by the service can be characterized on psychosocial status and illness. METHODS: On a dedicated German-language website, 235 breast cancer patients registered for psychosocial counseling via e-mail. 133 registrants were randomly assigned to a treatment group to receive immediate counseling or to a waiting list control group. The two-month counseling session took the form of a psychoeducation, individually tailored to each patient. Psychosocial outcome measures including psychological distress (BSI) and quality of life (EORTC QLQ-C30) were assessed at registration and at a two-month follow-up. Descriptive data were recorded at registration. At the conclusion of the program, participants were asked to complete a patient satisfaction questionnaire (ZUF-8). RESULTS: BSI responses showed that 85% of all patients were initially diagnosable with comorbid psychopathology. Despite high severity of distress and attendant large reductions in quality of life, 72% of all patients were not obtaining conventional assistance. Among counseling participants (n=31), no significant improvements in distress or quality of life were found in comparison to the control group (n=34), but patient satisfaction was nonetheless high. CONCLUSION: The study demonstrates that online counseling via e-mail reaches patients with unmet therapeutic needs, but also indicated its limitations, suggesting that the online setting may be most useful for prompting and supporting a transition to conventional counseling services.

Distress in patients undergoing allogeneic haematopoietic stem cell transplantation is correlated with distress in nurses.

PURPOSE: To date, no studies have reported on the relationship between the emotional distress of patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT) and the distress of their nurses. METHODS: 113 patients rated their distress by means of a daily questionnaire during their inpatient hospitalisation for HSCT. At the same time, nurses were asked to assess their distress caused by the additional care needs and increased emotional demands placed on them by the patients. Surveys covered a treatment period from day -5 to day +29 post-HSCT. RESULTS: The correlation between the distress level of the patients and that of the nurses was r=0.40 (p<0.001). The partial coefficient of this correlation was r=0.43 (p<0.001) when an indicator of the physical state of the patients, as assessed by their treating physicians, was controlled. CONCLUSIONS: Distress, as experienced by patients and nurses, is positively correlated. We assume that such a relation holds beyond other individual, organisational, structural, and occupational influences that play decisive and limiting roles in the patient-nurse relationship. Reducing the distress of one of these parties could also positively affect the distress levels of the other party. Therefore, patient distress should be monitored since it may add to nurse distress. Types of patient interventions, as well as the people responsible for performing these interventions, must be discussed. On the other hand, interventions aimed at reducing nurse distress (regardless of the cause of the distress) could reduce patient distress and improve their satisfaction with the treatment, and their quality of life.

Physicians' prognostic estimates of survival for patients undergoing allogeneic hematopoietic stem cell transplantation.

OBJECTIVE: Patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) often demand a single estimate of their prognosis from their treating physician. Little is known about the validity of and the factors influencing these estimates. PATIENTS AND METHODS: We explored physicians' prognostic estimates (six-point scale from very good to very poor) in a sample of 136 patients participating in a psycho-oncology study. Patients (mean age, 41 years) were followed-up for at least 2 years, and 72 patients died during the follow-up period. RESULTS: Physicians' estimates were clearly associated with overall survival (univariate Cox regression: hazard ratio=1.51, 95% confidence interval=1.24-1.82). In a multivariate Cox regression model, these estimates were independent predictors for survival in addition to previous treatment (former HSCT) and donor type (related vs. unrelated). DISCUSSION: Physicians on transplant units are able to give a concise prognostic estimate that corresponds to real outcomes. Patients often do not have a sufficient understanding of the risks of their treatment. Obtaining such condensed information instead of a complex prognostic estimate might be easier to understand. For the physician, it might be helpful to reflect his/her individual method of condensing information to be able to give a concise prognosis and to achieve informed consent with the patient. A systematic description of the extensive implicit and explicit experiences regarding objective and subjective data and its respective weight could help to improve the training of future hematologists and should be explored in further studies.

Pre-transplant depression as risk factor for survival of patients undergoing allogeneic haematopoietic stem cell transplantation.

INTRODUCTION: Depression is discussed as a possible risk factor for survival in cancer patients. We explored this relationship for patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT). PATIENTS AND METHODS: The depression subscale of the Hospital Anxiety and Depression Scale (HADS) served as a measure for depression. One hundred and thirty-eight patients (mean age 41 years; different diagnoses) participating in a psycho-oncology study filled in the HADS after admission for allogeneic HSCT. They were followed-up for at least two years; 72 patients died during follow-up. RESULTS: Depression scores were not correlated with medical and psychosocial objective factors with the exception of having under-aged children. Controlling for medical factors that showed up as predictors for survival in our sample (patient's age at HSCT, having had a transplant before, risk for treatment failure) the HADS depression score (range 0-21) emerged as an independent predictor (Cox regression): hazard ratio = 1.087, 95% CI = 1.018-1.161. CONCLUSION: Depression is probably not a simple indicator of a worse health status. Further research is needed to decide if depression must be considered as an independent risk factor for survival when diagnosed in the pre-transplant period.

Abnormal reactivity of the primary somatosensory cortex during the experience of pain in complex regional pain syndrome: a magnetoencephalograhic case study.

A 49-year-old male worker developed persistent pain in his left wrist after work strain injuries. Clinical symptoms met with criteria for Complex Regional Pain Syndrome (CRPS) type I. In the present study, the effect of the experience of pain on the somatotopy of the primary cortical hand representation was investigated. Somatosensory evoked magnetic fields (SEF) elicited by non-painful tactile stimulation at the index finger of the affected and the unaffected hand were recorded when experiencing pain elicited by a moderate physical load condition (holding a 1.6 kg object in the hand). It was shown that MEG and subjective responses to innocuous tactile stimuli were reduced when simultaneous nociceptive stimulation was applied. These findings suggest a gating effect in the central nervous system elicited by concurrent simultaneous information from two different somatosensory modalities (pain and tactile). The results revealed the existence of nociceptive-induced plastic changes in the central nervous system associated with CRPS type I.

Mental adjustment to cancer and survival of patients admitted for allogenic hemopoietic stem cell transplantation - a prospective cohort study.

OBJECTIVE: The Mental Adjustment to Cancer Scale (MAC scale) has evolved to a standard measure in the field of psycho-oncology. In this context an attitude called "fighting spirit" gained much attention as a coping style. Some reports suggest that coping efforts as measured by the MAC scale are predictive for survival of breast cancer patients. We explored the predictive power of the MAC scale by using a sample of patients with haematological malignancies undergoing allogenic hemopoietic stem cell transplantation (HSCT). METHODS: Between 9/1999 and 12/2001 127 patients were administered the MAC scale prior to HSCT. Follow-up data of overall survival and event-free survival were obtained in December 2003 and analyzed using Cox-regression models. RESULTS: At the time of the follow-up, 68 patients had died (overall survival), 75 patients had experienced a relapse or had died (event-free survival). We failed to find significant results for the MAC subscales with and without adjustment for prognostic factors. CONCLUSION: In the special situation of patients facing HSCT the MAC scale seems not to be of predictive value. In general, with respect to survival the empirical evidence is not very convincing.

Influence of social support and emotional context on pain processing and magnetic brain responses in fibromyalgia.

OBJECTIVE: To examine the effects of social support provided by the presence of patient's significant other on pain ratings, pain thresholds, and brain activity associated with tactile stimulation in 18 fibromyalgia (FM) patients and 18 migraine patients (controls), and to assess the influence of emotional context on thermal pain perception and processing of non-pain-related information. METHODS: Thermal pain thresholds and somatosensory brain magnetic responses elicited by tactile stimulation at the elbow (a painful tender point in the FM group) and at the finger (nonpainful site) were evaluated under 2 experimental conditions of social support: patient alone and patient's significant other present. Brain activity was recorded using a 151-channel whole-head magnetoencephalography system. Additionally, the emotional context during presentation of tactile stimuli was manipulated by presenting aversive, pain-related pictures and neutral pictures and asking the patients to imagine that they were experiencing the situations depicted. RESULTS: Thermal pain thresholds indicated greater sensitivity in FM patients than in migraine patients, as well as enhanced sensitivity at the elbow than at the fingers. Specifically, in FM patients, there were significant reductions in pain sensitivity and subjective pain ratings when patients were stimulated at the painful tender point in the presence of their significant others as compared with the ratings when the patients were alone. Brain activity elicited by elbow stimulation was also significantly reduced in FM patients when a significant other was present as compared with the activity when the patient was alone. These effects were not observed in the migraine patients. CONCLUSION: When the significant other was present, FM patients reported less pain and thermal pain sensitivity and showed diminished brain activity elicited upon tactile stimulation of a tender point compared with these levels when the patients were alone. These findings are consistent with the hypothesis that social support through the presence of a significant other can influence pain processing at the subjective-behavioral level as well as the central nervous system level.

Somatosensory event-related potentials to painful and non-painful stimuli: effects of attention.

In order to determine the effects of attention and distraction on painful and non-painful stimuli, the amplitude changes of 3 components (N150, P200, P300) of the somatosensory event-related potential (SERP) elicited by painful and non-painful electrical stimuli were investigated. Painful and non-painful stimuli were determined using a visual analog scale. SERPs were recorded from 16 healthy volunteers at 5 midline and 4 left and 4 right hemispheric sites. The differences between the amplitudes of attended and ignored stimuli were quantified with a baseline-to-peak measure. ANOVA results revealed no significant attention or stimulus intensity effects for N150 but highly significant differences in P200 and P300 amplitudes between attended and ignored stimuli. In addition, P200 and P300 amplitudes were larger for strong stimuli than for weak stimuli, with no significant differences between non-painful and painful stimuli. These findings are consistent with the existence of a relative, rather than an absolute, relationship between SERP component amplitudes and subjective pain reports. Furthermore, the data give evidence that attentional manipulations represent a powerful method to decrease the perception of pain and that, when used with subjective and behavioral measures, the SERP represents a valuable asset in the multidimensional approach to pain measurement and assessment.

Biofeedback of somatosensory event-related potentials: can individual pain sensations be modified by biofeedback-induced self-control of event-related potentials?

This study investigates the effects of biofeedback based upon event-related brain potentials evoked by nociceptive electrical stimuli. In a visual and monetary feedback paradigm, 10 subjects received positive feedback within one training session when systematically showing two different behavior patterns: one pattern correlated with a decrease (down-training) and one with an increase (up-training) of the peak-to-peak size of the N150-P260 complex, respectively. Training conditions were changed randomly from trial to trial over 300 trials. All subjects achieved control on both behavior patterns resulting in a simultaneous modification of the size of this complex according to the training conditions. Furthermore, the individual pain report measured with a visual analogue scale was altered in accordance with the biofeedback-induced behavioral modifications. A decrease in subjective pain report was achieved after down-training while an increase was observed after the up-training.