Persistent Pain After Breast Cancer Treatment, an Underreported Burden for Breast Cancer Survivors.

BACKGROUND: Many patients who have undergone surgery experience persistent pain after breast cancer treatment (PPBCT). These symptoms often remain unnoticed by treating physician(s), and the pathophysiology of PPBCT remains poorly understood. The purpose of this study was to determine prevalence of PPBCT and examine the association between PPBCT and various patient, tumor, and treatment characteristics. PATIENTS AND METHODS: We conducted a questionnaire-based cross-sectional study enrolling patients with breast cancer treated at Máxima Medical Center between 2005 and 2016. PPBCT was defined as pain in the breast, anterior thorax, axilla, and/or medial upper arm that persists for at least 3 months after surgery. Tumor and treatment characteristics were derived from the Dutch Cancer Registry and electronic patient files. RESULTS: Between February and March 2019, a questionnaire was sent to 2022 women, of whom 56.5% responded. Prevalence of PPBCT among the responders was 37.9%, with 50.8% reporting moderate to severe pain. Multivariable analyses showed that women with signs of anxiety, depression or a history of smoking had a higher risk of experiencing PPBCT. Women aged 70 years or older at diagnosis were significantly less likely to report PPBCT compared with younger women. No significant association was found between PPBCT and treatment characteristics, including type of axillary surgery and radiotherapy. CONCLUSIONS: A considerable percentage of patients with breast cancer experience PPBCT. Women with signs of anxiety or depression and women with a history of smoking are more likely to report PPBCT. Further research is required to understand the underlying etiology and to improve prevention and treatment strategies for PPBCT.

Pain trajectories and their associations with cognition among older adults: a 10-year cohort study from network perspective.

BACKGROUND: Few studies have examined the associations between pain trajectories and cognitive function in older adults. This study explored the associations between pain trajectories and different cognitive domains in older adults from a network perspective. METHODS: Data on pain trajectories were derived from the Health and Retirement Study between 2010 and 2020 using latent class growth analyses. Measurements of key cognition domains, including memory, attention, calculation, orientation and language, were included. Linear regression and network analysis were performed to evaluate the associations between different pain trajectories and cognition. RESULTS: A total of 9,551 older adults were included in this study and three trajectories of pain were identified. After controlling for the covariates, persistent severe pain trajectory was associated with poorer overall cognition, memory and calculation ability when compared to mild or non-persistent pain trajectory. In the pain and cognition network model, memory (expected influence (EI) = 0.62), language (EI = 0.58) and calculation (EI = 0.41) were the most central domains. CONCLUSIONS: Pain trajectories appeared stable over time among older adults in this study. Severity of persistent pain was an important risk factor for poor cognition, especially in relation to memory and calculation domains. Interventions targeting memory, language and calculation domains might be useful in addressing cognitive decline in older adults with persistent pain.

Telehealth and Virtual Reality Technologies in Chronic Pain Management: A Narrative Review.

PURPOSE OF REVIEW: This review provides medical practitioners with an overview of the present and emergent roles of telehealth and associated virtual reality (VR) applications in chronic pain (CP) management, particularly in the post-COVID-19 healthcare landscape. RECENT FINDINGS: Accumulated evidence points to the efficacy of now well-established telehealth modalities, such as videoconferencing, short messaging service (SMS), and mobile health (mHealth) applications in complementing remote CP care. More recently, and although still in early phases of clinical implementation, a wide range of VR-based interventions have demonstrated potential for improving the asynchronous remote management of CP. Additionally, VR-associated technologies at the leading edge of science and engineering, such as VR-assisted biofeedback, haptic technology, high-definition three-dimensional (HD3D) conferencing, VR-enabled interactions in a Metaverse, and the use of wearable monitoring devices, herald a new era for remote, synchronous patient-physician interactions. These advancements hold the potential to facilitate remote physical examinations, personalized remote care, and innovative interventions such as ultra-realistic biofeedback. Despite the promise of VR-associated technologies, several limitations remain, including the paucity of robust long-term effectiveness data, heterogeneity of reported pain-related outcomes, challenges with scalability and insurance coverage, and demographic-specific barriers to patient acceptability. Future research efforts should be directed toward mitigating these limitations to facilitate the integration of telehealth-associated VR into the conventional management of CP. Despite ongoing barriers to widespread adoption, recent evidence suggests that VR-based interventions hold an increasing potential to complement and enhance the remote delivery of CP care.

The contribution of pain catastrophizing, depression and anxiety symptoms among patients with persistent pain and opioid misuse behaviours.

BACKGROUND: Anxiety, depression and pain catastrophizing are independently associated with risk of opioid misuse in patients with persistent pain but their relationship to current opioid misuse, when considered together, is poorly understood. This study will assess the relative contribution of these modifiable, and distinct psychological constructs to current opioid misuse in patients with persistent pain. METHODS: One hundred and twenty-seven patients referred to a specialized opioid management clinic for prescription opioid misuse within a tertiary pain service were recruited for this study. The Pain Catastrophizing Scale, Depression, Anxiety and Stress Scales and the Current Opioid Misuse Measure were administered pre-treatment. Pain severity and morphine equivalent dose based on independent registry data were also recorded. RESULTS: Higher levels of pain catastrophizing, depression, and anxiety were significantly associated with higher current opioid misuse (r = .475, 0.599, and 0.516 respectively, p < .01). Pain severity was significantly associated with pain catastrophizing (r = .301, p < .01). Catastrophizing, depression, and anxiety explained an additional 11.56% of the variance (R2 change = 0.34, p < .01) over and above age, gender, pain severity and morphine equivalent dose. Depression was the only significant variable at Step 2 (ß = 0.62, p < .01). CONCLUSION: Findings show that in a sample of people with persistent pain referred for treatment for opioid misuse, depression contributes over and above that of anxiety and pain catastrophizing. Theoretical and clinical practice implications are presented.

Development of an interdisciplinary training program about chronic pain management with a cognitive behavioural approach for healthcare professionals: part of a hybrid effectiveness-implementation study.

BACKGROUND: Many applied postgraduate pain training programs are monodisciplinary, whereas interdisciplinary training programs potentially improve interdisciplinary collaboration, which is favourable for managing patients with chronic pain. However, limited research exists on the development and impact of interdisciplinary training programs, particularly in the context of chronic pain. METHODS: This study aimed to describe the development and implementation of an interdisciplinary training program regarding the management of patients with chronic pain, which is part of a type 1 hybrid effectiveness-implementation study. The targeted groups included medical doctors, nurses, psychologists, physiotherapists, occupational therapists, dentists and pharmacists. An interdisciplinary expert panel was organised to provide its perception of the importance of formulated competencies for integrating biopsychosocial pain management with a cognitive behavioural approach into clinical practice. They were also asked to provide their perception of the extent to which healthcare professionals already possess the competencies in their clinical practice. Additionally, the expert panel was asked to formulate the barriers and needs relating to training content and the implementation of biopsychosocial chronic pain management with a cognitive behavioural approach in clinical practice, which was complemented with a literature search. This was used to develop and adapt the training program to the barriers and needs of stakeholders. RESULTS: The interdisciplinary expert panel considered the competencies as very important. Additionally, they perceived a relatively low level of healthcare professionals' possession of the competencies in their clinical practice. A wide variety of barriers and needs for stakeholders were formulated and organized within the Theoretical Domain Framework linked to the COM-B domains; 'capability', 'opportunity', and 'motivation'. The developed interdisciplinary training program, including two workshops of seven hours each and two e-learning modules, aimed to improve HCP's competencies for integrating biopsychosocial chronic pain management with a cognitive behavioural approach into clinical practice. CONCLUSION: We designed an interdisciplinary training program, based on formulated barriers regarding the management of patients with chronic pain that can be used as a foundation for developing and enhancing the quality of future training programs.

[Tumor-associated pain]. / Tumorassoziierter Schmerz.

Tumor-associated pain has a high prevalence and is still a challenging aspect of pain medicine. Treatment-related etiologies often coexist with pain caused by the oncological disease itself. For cancer pain as well, a pathophysiologically oriented analysis of nociceptive, nociplastic and neuropathic pain is advisable for planning a tailored treatment. The analgesic three-step ladder of the World Health Organization (WHO) should be customized in this context, incorporating antineuropathic or antihypersensitizing pharmacological approaches as well as minimally invasive techniques. Psycho-oncological and exercise therapy interventions should be considered. In cases of long-term courses of treatment or following curative oncological treatment, chronically persistent or chronic tumor-associated pain can occur, necessitating multimodal therapeutic approaches analogue to noncancer pain conditions. Close integration with palliative medicine enhances the therapeutic effectiveness during the transition from nonpalliative to palliative treatment phases.

Partners' Experiences of Chronic Pain: A Qualitative Evidence Synthesis.

This systematic review of qualitative studies synthesised evidence on the experience chronic pain from the perspective of romantic partners. Medline via Ovid, Embase via Ovid, CINAHL via EBSCO, APA PsycInfo via Ovid, Scopus, and Web of Science databases were searched. Studies exploring the impact of chronic pain from partners' perspectives using qualitative data collection methods were eligible for inclusion. Thematic synthesis was conducted, and confidence in the review findings was assessed using GRADE CERQual criteria. A total of 198 participants were represented from 15 primary studies. Four interconnected analytical themes were developed: 'life is different', 'internal conflict between two worlds', 'togetherness vs separateness', and 'coping in the longer term'. Out of 27 review findings, 9 were assessed as high confidence, 12 as moderate confidence, 4 as low confidence, and 2 as very low confidence. Socially isolated partners, those in strained relationships, and partners who continually sacrificed their own needs were more likely to experience distressing emotions. Greater recognition of partners' needs is needed within pain management services.

Health-related quality of life, work ability and disability among individuals with persistent post-dural puncture headache.

BACKGROUND AND OBJECTIVES: Postdural puncture headache (PDPH) is an acknowledged consequence of procedures like lumbar punctures, epidural analgesia, and neurosurgical interventions. Persistence over more than three months, however has been poorly studied. In particular, little is known about the impact of persistent PDPH (pPDPH) on health related quality of life (HRQoL), disability and ability to work. The study aimed to provide a holistic understanding of pPDPH, encompassing medical, physical and psychological aspects. METHODS: We conducted a cross-sectional anonymous online survey in individuals aged 18 or older, diagnosed with, or suspected to have pPDPH via self-help groups on Facebook. Participants completed a structured questionnaire covering diagnosis, symptoms, and the ability to work. For assessing headache related disability, and mental health, they filled in the Henry Ford Hospital Headache Disability Inventory (HDI) and the Depression Anxiety Stress Scale-21 (DASS-21). RESULTS: A total of 179 participants (83.2% female, mean age 39.7 years) completed the survey. PPDPH had been present for one year or more in 74.3%, and 44.1% were unable to be in an upright position for more than one hour per day without having to lie down or sit down. Headaches were extremely severe or severe in 18% and 34%, respectively. According to the HDI, 31.8% of participants had mild, 25.7% moderate, and 42.5% severe disability. DASS-21 revealed substantial mental health challenges with depression, anxiety and stress experienced by 83%, 98%, and 88% of the respondents. The ability to work was limited considerably: 27.9% were unable to work, 59.8% worked part-time, 1.1% changed their job because of pPDPH, and only 11.2% were able to work full-time in their previous job. Despite treatment, the patients' condition had deteriorated in 32.4% and remained unchanged in 27.9%. CONCLUSION: This study stresses the burden of pPDPH in terms of substantial disability, limited quality of life, mental health concerns, and significant impact on the ability to work. The study highlights the long-term impact of pPDPH on individuals, emphasizing the need for timely diagnosis and effective treatment. It underscores the complexity of managing pPDPH and calls for further research into its long-term effects on patient health and HRQoL.

Ocular Pain after Refractive Surgery: Interim Analysis of Frequency and Risk Factors.

PURPOSE: To examine the frequency and risk factors for ocular pain after laser assisted in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK). DESIGN: Prospective study of individuals undergoing refractive surgery at 2 different centers. PARTICIPANTS: One hundred nine individuals undergoing refractive surgery: 87% LASIK and 13% PRK. METHODS: Participants rated ocular pain on a numerical rating scale (NRS) of 0 to 10 before surgery and 1 day, 3 months, and 6 months after surgery. A clinical examination focused on ocular surface health was performed 3 and 6 months after surgery. Persistent ocular pain was defined as an NRS score of 3 or more at both 3 and 6 months after surgery (patients), and this group was compared with individuals with NRS scores of < 3 at both time points (control participants). MAIN OUTCOME MEASURES: Individuals with persistent ocular pain after refractive surgery. RESULTS: The 109 patients who underwent refractive surgery were followed up for 6 months after surgery. Mean age was 34 ± 8 years (range, 23-57 years); 62% self-identified as female, 81% as White, and 33% as Hispanic. Eight patients (7%) reported ocular pain (NRS score ≥ 3) before surgery, with the frequency of ocular pain increasing after surgery to 23% (n = 25) at 3 months and 24% (n = 26) at 6 months. Twelve patients (11%) reported an NRS score of 3 or more at both time points and constituted the persistent pain group. Factors that predicted persistent pain after surgery in a multivariable analysis were (1) ocular pain before surgery predicated persistent pain after surgery (odds ratio [OR], 1.87; 95% confidence interval [CI], 1.06-3.31), (2) symptom report of depression before surgery (Patient Health Questionnaire-9: OR, 1.3; 95% CI, 1.1-1.6; P = 0.01), (3) use of an oral antiallergy medication before surgery (OR, 13.6; 95% CI, 2.1-89.3; P = 0.007), and (4) pain intensity day 1 after surgery (OR, 1.6; 95% CI, 1.2-2.2; P = 0.005). There were no significant associations between ocular surface signs of tear dysfunction and ocular pain, P > 0.05 for all ocular surface signs. Most individuals (> 90%) were completely or somewhat satisfied with their vision at 3 and 6 months. CONCLUSIONS: Eleven percent of individuals reported persistent ocular pain after refractive surgery, with several preoperative and perioperative factors predicting pain after surgery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

The incidence, impact, and risk factors for moderate to severe persistent pain after breast cancer surgery: a prospective cohort study.

BACKGROUND: Few Australasian studies have evaluated persistent pain after breast cancer surgery. OBJECTIVE: To evaluate the incidence, impact, and risk factors of moderate to severe persistent pain after breast cancer surgery in a New Zealand cohort. DESIGN: Prospective cohort study. METHODS: Consented patients were reviewed at 3 timepoints (preoperative, 2 weeks and 6 months postoperative). Pain incidence and interference, psychological distress and upper limb disability were assessed perioperatively. Clinical, demographic, psychological, cancer treatment-related variables, quantitative sensory testing, and patient genotype (COMT, OPRM1, GCH1, ESR1, and KCNJ6) were assessed as risk factors using multiple logistic regression. RESULTS: Of the 173 patients recruited, 140 completed the 6-month follow-up. Overall, 15.0% (n = 21, 95% CI: 9.5%-22.0%) of patients reported moderate to severe persistent pain after breast cancer surgery with 42.9% (n = 9, 95% CI: 21.9%-66.0%) reporting likely neuropathic pain. Pain interference, upper limb dysfunction and psychological distress were significantly higher in patients with moderate to severe pain (P < .004). Moderate to severe preoperative pain (OR= 3.60, 95% CI: 1.13-11.44, P = .03), COMT rs6269 GA genotype (OR = 5.03, 95% CI: 1.49-17.04, P = .009) and psychological distress at postoperative day 14 (OR= 1.08, 95% CI: 1.02-1.16, P = .02) were identified as risk factors. Total intravenous anesthesia (OR= 0.31, 95% CI: 0.10 - 0.99, P = .048) was identified as protective. CONCLUSION: The incidence of moderate to severe persistent pain after breast cancer surgery is high with associated pain interference, physical disability, and psychological distress. Important modifiable risk factors were identified to reduce this important condition.

A systematic review of prevalence of pain in nursing home residents with dementia.

BACKGROUND: The prevalence of dementia in nursing home (NH) residents is high, and pain is a troublesome symptom for them. Several studies since 2010 have focused on pain in NH residents with dementia, but there is a lack of systematic reviews on the prevalence of pain in NH residents with dementia. AIM: To systematically review observational studies published from 2010 to 2023 on how pain is assessed and prevalence of pain found in NH residents with dementia. METHODS: A systematic search was conducted in the MEDLINE, PubMed, PsycINFO, Embase, CINAHL, AgeLine, and Cochrane databases for studies published from January 2010 to August 2023. Studies were included if they were observational studies with a quantitative design where self-report, staff assessment, and/or chart review were used to define the prevalence of pain in samples or subsamples of NH residents with dementia. RESULTS: Of 184 studies considered, 25 were included. The studies assessed pain as daily, present, clinically relevant, chronic, intermittent, persistent pain and/or if pain affected quality of life. The prevalence of pain was high in most studies of NH residents with dementia independent of whether pain was reported as presence of pain or clinically relevant pain, but the prevalence varied from 8.6% to 79.6%. This prevalence was quite stable across the NH stay, but higher towards the end of life (up to 80.4%). Study designs and methodologies differed considerably. About half relied on an observational assessment inventory. CONCLUSION: The number of studies focusing on pain in NH residents with dementia was restricted and methodologies differed considerably. Relatively few studies used an observational assessment inventory. In view of the fact that residents with dementia may have difficulties communicating pain, clinicians should pay attention to pain in these residents, systematically and reliably uncover pain by use of observational inventories, and subsequently treat pain to secure high quality care.

Inflammatory changes in the plasma and cerebrospinal fluid of patients with persistent pain and postpartum depression after elective Cesarean delivery: an exploratory prospective cohort study.

PURPOSE: Severe acute pain after Cesarean delivery increases the risk of developing persistent pain (~20% incidence) and postpartum depression (PPD) (~15% incidence). Both conditions contribute to maternal morbidity and mortality, yet early risk stratification remains challenging. Neuroinflammation has emerged as a key mechanism of persistent pain and depression in nonobstetric populations. Nevertheless, most studies focus on plasma cytokines, and the relationship between plasma and cerebrospinal fluid (CSF) cytokine levels is unclear. Our primary aim was to compare inflammatory marker levels between patients who developed the composite outcome of persistent pain and/or PPD vs those who did not. METHODS: We recruited term patients with singleton pregnancies undergoing elective Cesarean delivery under neuraxial anesthesia into an exploratory prospective cohort study. We collected baseline demographic, obstetric, and Edinburgh Postnatal Depression Scale information, and performed quantitative sensory tests. Plasma was collected preoperatively and 48 hr postoperatively. In the operating room, 10 mL of CSF was collected, followed by a standardized anesthetic. Intra- and postoperative management were according to standard practice. We obtained Edinburgh Postnatal Depression Scale and pain scores at six weeks and three months after delivery. The primary outcome was persistent pain and/or PPD at three months. We analyzed the difference in inflammatory marker levels between the groups (primary aim) using two-sided Mann-Whitney tests. RESULTS: Eighty participants were enrolled, and 63 patients completed the study; 23 (37%) experienced the primary outcome at three months. Preoperative plasma transforming growth factor beta 1 (TGF-ß1) concentration was higher in patients who developed the primary outcome compared with those who did not (median [interquartile range (IQR)], 2,879 [2,241-5,494] vs 2,292 [1,676-2,960] pg·mL-1; P = 0.04), while CSF IL-1ß concentration was higher in patients who developed the primary outcome than in those who did not (median [IQR], 0.36 [0.29-0.39] vs 0.30 [0.25-0.35] pg·mL-1; P = 0.03). CONCLUSIONS: We observed differential levels of plasma and CSF inflammatory biomarkers in patients who developed persistent pain and PPD compared with those who did not. We showed the feasibility of collecting plasma and CSF samples at Cesarean delivery, which may prove useful for future risk-stratification. STUDY REGISTRATION: ClinicalTrials.gov (NCT04271072); registered 17 February 2020.

RéSUMé: OBJECTIF: La douleur aiguë sévère après un accouchement par césarienne augmente le risque de douleur persistante (~20 % d'incidence) et de dépression post-partum (DPP) (~15 % d'incidence). Ces deux conditions contribuent à la morbidité et à la mortalité maternelles, mais la stratification précoce des risques demeure difficile. La neuroinflammation est apparue comme un mécanisme clé de la douleur persistante et de la dépression dans les populations non obstétricales. Néanmoins, la plupart des études se concentrent sur les cytokines plasmatiques, et la relation entre les taux de cytokines plasmatiques et de liquide céphalorachidien (LCR) n'est pas claire. Notre objectif principal était de comparer les taux de marqueurs inflammatoires entre les patient·es qui ont eu un résultat composite de douleur persistante et/ou de DPP vs les personnes qui n'en ont pas eu. MéTHODE: Nous avons recruté des patient·es à terme avec des grossesses uniques bénéficiant d'une césarienne programmée sous anesthésie neuraxiale dans une étude de cohorte prospective exploratoire. Nous avons recueilli des informations démographiques de base, obstétricales et tirées de l'Échelle de dépression postnatale d'Édimbourg, et effectué des tests sensoriels quantitatifs. Le plasma a été prélevé avant l'opération et 48 heures après l'opération. En salle d'opération, 10 mL de LCR ont été recueillis, suivis d'un anesthésie standardisée. La prise en charge per- et postopératoire était conforme à la pratique courante. Nous avons obtenu les scores sur l'Échelle de dépression postnatale d'Édimbourg et les scores de douleur six semaines et trois mois après l'accouchement. Le critère d'évaluation principal était la douleur persistante et/ou la DPP à trois mois. Nous avons analysé la différence dans les niveaux de marqueurs inflammatoires entre les groupes (objectif principal) en utilisant des tests bilatéraux de Mann-Whitney. RéSULTATS: Quatre-vingts personnes ont été recrutées et 63 patient·es ont terminé l'étude; 23 (37 %) ont rapporté le critère d'évaluation principal à trois mois. Le facteur TGF-ß1 (transforming growth factor beta 1) plasmatique préopératoire était plus élevé chez les patient·es qui ont manifesté le critère d'évaluation principal par rapport aux personnes qui ne l'ont pas manifesté (médiane [écart interquartile (ÉIQ)], 2879 [2241-5494] vs 2292 [1676­2960] pg·mL−1; P = 0,04), tandis que le IL-1ß dans le LCR était plus élevé chez les patient·es qui ont manifesté le critère d'évaluation principal que chez les personnes qui ne l'ont pas manifesté (médiane [ÉIQ], 0,36 [0,29-0,39] vs 0,30 [0,25­0,35] pg·mL−1; P = 0,03). CONCLUSION: Nous avons observé des taux différentiels de biomarqueurs inflammatoires plasmatiques et de LCR chez les patient·es qui ont manifesté une douleur persistante et une DPP par rapport aux personnes qui n'en ont pas manifesté. Nous avons montré la faisabilité de la collecte d'échantillons de plasma et de LCR lors de l'accouchement par césarienne, ce qui pourrait s'avérer utile pour la stratification future des risques. ENREGISTREMENT DE L'éTUDE: clinicaltrials.gov (NCT04271072); enregistrée le 17 février 2020.

'I Will Fight for People to Not Have the Experience I've Had': A Thematic Analysis of the Experiences and Perspectives of Chronic Pain Lived Experience Advocates.

Navigating the healthcare system with chronic pain, alongside navigating the experience of the chronic pain itself, is recognised to be highly challenging. Frequently available interventions do not fully meet the needs of people with chronic pain. This study aimed to explore the perspectives of people who have been through these experiences and now support and campaign for improved approaches to chronic pain management. Semi-structured interviews of 10 participants who independently support others through some form of chronic pain advocacy or support were conducted online. Data were digitally recorded, transcribed, and analysed using reflexive thematic analysis, through a critical realist and constructivist lens. Data were interpreted to represent a journey into chronic pain advocacy, represented by three overarching themes. Advocacy as healing incorporates sub-themes of pain trauma, gaining knowledge, and using my experience for good. Unequal partnership includes respect and unmet needs from institutions. The final theme, evolution, relates to two sub-themes of pushing boundaries and personal growth. Participants talked about the dual benefit of their contribution to pain advocacy, both in terms of helping others and also their own personal benefit. Overall findings indicated that pain advocacy can take multiple and various forms. Commonly, our participants who took on the role of pain advocacy were motivated by their own early difficult experiences, both navigating their pain and healthcare systems, and by a wish for others to not have similar difficult experiences. Having taken on the role, despite its challenges, rewards can include recognition and personal growth.

Pre-Trauma Pain Is the Strongest Predictor of Persistent Enhanced Pain Patterns after Severe Trauma: Results of a Single-Centre Retrospective Study.

Background and Objectives: Traumatic injuries are a significant public health issue worldwide, with persistent enhanced pain being a common complication following severe trauma. Persistent and chronic pain can have a profound impact on patients' quality of life, affecting physical, emotional, and social functioning. This study aimed to investigate the pain patterns of trauma patients before and after severe trauma, and identify the predictors of persisting pain after injury. Materials and Methods: A total of 596 patients of a level-one trauma centre with severe trauma were included in this study. The Trauma Outcome Profile Scale was used to assess pain severity before and after trauma, and a logistic regression analysis was performed to determine the most significant predictors of relevant pain after severe trauma. Results: The mean age of the included patients was 48.2 years, and 72% were males. The most frequent cause of injury was traffic accidents, and the mean Injury Severity Score was 17.6. Nearly half of the patients experienced reduced pain-related quality of life after trauma, with persisting pain predominantly occurring in the neck, spine, shoulder, pelvis, hip, knee, and feet. Even minor injuries led to increased pain scores. Preexisting pain before injury (OR: 5.43; CI: 2.60-11.34), older age (OR: 2.09, CI: 1.22-3.27), female gender (OR: 1.08, CI: 0.73-1.59), and high injury severity (OR: 1.80, CI: 1.20-2.69) were identified as significant predictors of enhanced pain. Conclusions: These findings highlight the importance of considering pre-existing pain, body area, and injury severity in assessing the risk of persistent pain in trauma patients.

Biopsychosocial risk factors for pain and pain-related disability 1 year after surgery for breast cancer.

PURPOSE: Knowledge regarding risk factors for pain in the long term after surgery for breast cancer may be of great value in preventing this prevalent and debilitating side effect. Despite the biopsychosocial nature of pain, the predictive value of both pre- and postoperative biopsychosocial functioning for long-term pain intensity and pain-related disability has not yet been studied. METHODS: One hundred sixty-six women planned for unilateral breast cancer surgery were included in this prospective cohort study. Pre- and postoperative outcomes related to pain, psychosocial, and somatosensory functioning (questionnaires and quantitative sensory testing) were evaluated as risk factors for pain intensity (visual analog scale) and pain-related disability (pain disability index) 1 year after surgery for breast cancer. Both bivariable and stepwise linear regression analyses were performed. RESULTS: The most consistent biopsychosocial risk factors were symptoms related to altered central somatosensory functioning (central sensitization inventory), psychological symptoms, and social support (psychological symptoms and support subscale of McGill Quality of Life Questionnaire). Results also showed that a pre- and postoperative disturbed functioning of the somatosensory nervous system in the surgical area could provide additional information regarding pain intensity or pain-related disability in the long term after surgery for breast cancer. CONCLUSION: This study revealed several biopsychosocial characteristics that might be used to identify women more vulnerable to have pain and pain-related disability in the long term after surgery for breast cancer, allowing for more effective pain management and prevention.

Psychosocial predictors of persistent low back pain in patients presenting to the emergency department.

OBJECTIVES: Chronic low back pain is an important public health problem, generating high financial and social costs. While most clinical guidelines stress the importance of managing low back pain in primary care, in practice a disproportionate amount of patients with low back pain present to emergency departments. Patients presenting to emergency departments may form a specific group with different factors leading to chronicity. This prospective cohort study aimed to determine the sociodemographic and psychological predictors of persistent low back pain and the length of sick leave due to pain in patients with acute symptoms visiting an emergency department. METHODS: Patients with a first episode of non-specific acute low back pain in at least three months were qualified for this study. The participants filled a battery of questionnaires, including measures of pain, pain-related disability, depression, anxiety and pain coping strategies. A structured telephone interview was performed after three months with questions regarding pain and the length of sick leave. RESULTS: 110 patients participated in the study. 97 patients completed the follow-up, with 70.1% suffering from pain after three months. Lower self-rated health predicted pain after three months. Longer length of sick leave was predicted by lower self-rated health, distraction as a coping strategy and decreased behavioral activity. CONCLUSION: Because of its simplicity, a measurement of self-rated health may be included in future clinical practice for assessing the risk of persistent pain.

Pain self-management intervention supports successful attainment of self-selected rehabilitation goals-secondary analysis of a randomized controlled trial.

OBJECTIVES: (i) Describe patients' self-selected activity-related rehabilitation goals, and (ii) compare attainment of these rehabilitation goals among people with persistent tension-type neck pain receiving a group-based pain and stress self-management intervention (PASS) or individual physiotherapy (IPT). METHODS: Before intervention and random allocation to PASS or IPT, 156 people (PASS n = 77, IPT n = 79), listed three self-selected activity-related rehabilitation goals by use of the Patient Goal Priority Questionnaire (PGPQ). For each activity goal, participants rated limitations in activity performance, self-efficacy and fear of activity performance, readiness to change to improve performance, and expectations of future activity performance. At follow-ups (10 weeks, 20 weeks, 1 year and 2 years after inclusion), participants also responded to a question on changes made to improve activity performance. Mann-Whitney U test was used to evaluate between-group differences. RESULTS: There were between-group differences in favour of PASS in the attainment of self-selected rehabilitation goals with regard to activity limitations and satisfaction with activity performance at all follow-ups. CONCLUSIONS: PASS was more successful than IPT for the attainment of self-selected rehabilitation goals, improvements in activity limitations and satisfaction with activity performance as measured by PGPQ. The PASS programme emphasized the importance of applying active pain- and stress-coping techniques in personal 'risk situations' for pain flare-ups, which appear to support people with persistent tension-type neck pain to make changes in their lives to improve activity performance. PATIENT OR PUBLIC CONTRIBUTION: Patient engagement in rehabilitation by self-selected goals was investigated, but patients were not involved in the design or conduct of the study.

A scoping review of outpatient interventions to support the reduction of prescription opioid medication for chronic non cancer pain.

BACKGROUND: Prescription opioid use is a global health issue. Previous systematic reviews have not identified that any specific intervention supports prescription opioid reduction effectively. In keeping with the nature of a scoping review, this review details an overview of the existing literature on this topic, with quality of evidence being discussed rather than formally analysed. AIM: This review aimed to examine and describe outpatient interventions that support the reduction of prescription opioid medication for chronic non cancer pain. ELIGIBILITY CRITERIA: Abstracts were reviewed against the inclusion criteria of outpatient clinical interventions, for the purpose of prescription opioid dose reduction, offered to adults with CNCP. SOURCES OF EVIDENCE: Following a structured review approach an electronic database search, of Medline, Embase, Cochrane, Cinahl, and Proquest and grey literature was undertaken. Search results were screened by title for relevance. CHARTING METHODS: Two reviewers adhering to the PRISMA-ScR checklist charted and assessed studies for quality using Critical Appraisal Skills Programme checklist assessment tools. Extracted data were collated and synthesised for presentation as a tabular and narrative review. RESULTS: From the initial search of 5089 papers, 19 underwent full-text review and quality appraisal. A variety of interventions were described to support reduction in prescription opioid use, however only one study of at least fair quality was able to demonstrate a demonstrated a statistically significant benefit in reducing measured opioid dose compared with a control group. Interventions were implemented in both specialist pain services and in primary care with multidisciplinary and interdisciplinary clinician care. Barriers and facilitators were observed in both settings. CONCLUSION AND IMPLICATIONS FOR CLINICAL PRACTICE: Further rigorous research needs to be conducted to conclusively answer the question of what outpatient interventions support opioid reduction in chronic non cancer pain. This scoping review is the first step of inquiry in the development of a nursing intervention to support reduction of prescription opioids.

Inhibition of fibrotic changes in infrapatellar fat pad alleviates persistent pain and articular cartilage degeneration in monoiodoacetic acid-induced rat arthritis model.

OBJECTIVE: We have reported that fibrotic changes in infrapatellar fat pad (IFP) after acute joint inflammation are closely associated with persistent pain in rats. In this study, to examine the effects of anti-fibrotic treatment on persistent pain, we used C-type natriuretic peptides (CNP) at the recovery phase after acute joint inflammation. DESIGN: Thirty-two male Wistar rats were used in this study. Monoiodoacetic acid (MIA) was injected intra-articularly to induce IFP fibrosis and persistent pain. CNP was injected after acute inflammatory phase in the same knee joint. Time-course pain-avoidance behavior tests and histological analyses were performed to examine the effects of CNP. RESULTS: Histological evaluations indicated that intra-articular injection of CNP inhibited fibrotic changes in IFP after acute inflammation. Incapacitance tests indicated that MIA injection into rat knee joint quickly decreased the percent weight on ipsilateral limb. In the vehicle group, the decrease was maintained up to day 28, suggesting that pain persistence occurred after acute inflammation (Day 0/Day 28, Est Dif -8.15, CI -10.78∼-5.53, Linear mixed-effect model). In contrast, the pain was alleviated in the CNP group after day 14 (Day0/Day 14, -0.51, -2.62-1.59). In addition, we observed significant improvement in the degree of articular cartilage degeneration at day 14 in the CNP group (OARSI score: vehicle 16.14 ± 4.37 vs CNP 6.87 ± 3.44, P < 0.01; Wilcoxon rank sum test). CONCLUSION: Fibrotic changes in IFP may play important roles in both persistent pain and articular cartilage degeneration.

Incidence and predictors of persistent pelvic pain following hysterectomy in women with chronic pelvic pain.

BACKGROUND: Chronic pelvic pain is a debilitating problem that afflicts 15% to 20% of women in the United States. Although more than 200,000 hysterectomies are performed annually for the treatment of chronic pelvic pain, previous studies indicate that 1 in 4 women undergo the discomfort and morbidity of hysterectomy without the relief of pain. The factors that predict treatment failure remain poorly characterized. OBJECTIVE: To describe the incidence of persistent pelvic pain 6 months following hysterectomy in women with chronic pelvic pain and determine whether a simple, self-reported measure of central sensitization is associated with a greater risk of persistent pelvic pain following hysterectomy. STUDY DESIGN: We conducted a prospective, observational cohort study of women undergoing hysterectomy at an academic tertiary care center for a benign indication. Patients with preoperative chronic pelvic pain, defined as average pelvic pain ≥3 on a 0 to 10 numeric rating scale for >3 months before hysterectomy, were included in this analysis. The patients completed validated assessments of pain, anxiety, depression, and centralized pain (using the 2011 Fibromyalgia Survey Criteria, 0-31 points) preoperatively and 6 months after hysterectomy. The demographic information, surgical history, intraoperative findings, and surgical pathology were abstracted from the electronic medical records. Multivariate logistic regression was used to identify the independent predictors of persistent pelvic pain 6 months following hysterectomy, defined as <50% improvement in pelvic pain severity. RESULTS: Among 176 participants with pelvic pain before hysterectomy, 126 (71.6%) were retained at 6 months, and 15 (11.9%) reported persistent pelvic pain. There was no difference in age (P=.46), race (P=.55), average pain severity during menses (P=.68), average overall pelvic pain (P=.10), or pain duration (P=.80) in those with and without persistent pelvic pain. Whereas intraoperative findings of endometriosis (P=.05) and uterine fibroids (P=.03) were associated with a higher incidence of persistent pain on univariate analysis, the surgical route (P=.46), pelvic adhesions (0.51), uterine weight (P=.66), and adenomyosis on histopathology (P=.27) were not related to the risk of persistent pain. Higher preoperative centralized pain scores (P=.01) but not depression (P=.64) or anxiety (P=.45) were more common in women with persistent pelvic pain. Multivariate logistic regression adjusting for age, preoperative pain severity, anxiety, depression, and operative findings of endometriosis and fibroids indicated that every 1-point increase in centralized pain before hysterectomy was associated with a 27% increase in the odds of persistent pelvic pain (odds ratio, 1.27; 95% confidence interval, 1.03-1.57) 6 months after surgery. CONCLUSION: Although the majority of women with chronic pelvic pain report considerable improvement in pain following hysterectomy, higher degrees of centralized pain before hysterectomy is a robust predictor of persistent pelvic pain.