Higher Levels Of Pain Intensity Research Articles

Preliminary Evaluation of a Modified STarT Back Screening Tool Across Different Musculoskeletal Pain Conditions.

The STarT Back Screening Tool is a validated multidimensional screening measure and risk stratification tool for people with low back pain. The study objective was to compare relationships between a modified STarT Back Screening Tool (mSBT) and clinical and psychological measures in people with low back, neck, shoulder, and knee pain. The hypothesis was that the relationships between mSBT scores and clinical and psychological measure scores would be similar across the included musculoskeletal pain conditions. A cross-sectional, secondary analysis was done in this study. Participants with low back (n=118), neck (n=92), shoulder (n=106), or knee (n=111) pain were recruited, and an mSBT was developed for use across the pain conditions. Separate hierarchical linear regression models were developed, with clinical (health status, pain intensity, and disability) and psychological (kinesiophobia, catastrophizing, fear avoidance, anxiety, depressive symptoms, and self-efficacy) measures as dependent variables. Demographic and pain region variables were entered in the first step, mSBT scores were entered in the second step, and pain region × mSBT interactions were entered in the last step. In the final models, no interactions were identified, suggesting that dependent measure scores did not differ by pain region. The strongest contributor for all dependent variables was mSBT scores (β=|0.32|-|0.68|); higher mSBT scores were associated with poorer health status and self-efficacy and with higher levels of pain intensity, disability, kinesiophobia, catastrophizing, fear avoidance, anxiety, and depressive symptoms. Generalizability was restricted to physical therapy outpatients with the included pain conditions. The mSBT used in this study is not ready for clinical implementation. The results of this study support the feasibility of using a single measure for concise risk assessment across different musculoskeletal pain conditions. Further longitudinal studies are needed to better direct the clinical use of an mSBT in people with low back, neck, shoulder, and knee pain.

Pain Intensity Moderates the Relationship Between Age and Pain Interference in Chronic Orofacial Pain Patients

Background/Study Context: Chronic pain is associated with increased interference in daily functioning that becomes more pronounced as pain intensity increases. Based on previous research showing that older adults maintain well-being in the face of pain as well as or better than their younger counterparts, the current study examined the interaction of age and pain intensity on interference in a sample of chronic orofacial pain patients.Methods: Data were obtained from the records of 508 chronic orofacial pain patients being seen for an initial evaluation from 2008 to 2012. Collected data included age (range: 18–78) and self-reported measures of pain intensity and pain interference. Bivariate correlations and regression models were used to assess for statistical interactions.Results: Regression analyses revealed that pain intensity positively predicted pain interference (R2 = .35, B = 10.40, SE = 0.62, t(507) = 16.70, p < .001). A significant interaction supported the primary hypothesis that aging was associated with reduced interference at high levels of pain intensity (ΔR2 = .01, B = −1.31, SE = 0.63, t(505) = −2.90, p = .04).Conclusion: At high levels of pain intensity, interference decreased with age, although the age by pain intensity interaction effect was small. This evidence converges with aging theories, including socioemotional selectivity theory, which posits that as people age, they become more motivated to maximize positive emotions and minimize negative ones. The results highlight the importance of studying the mechanisms older adults use to successfully cope with pain.

Attrition with spinal cord stimulation

The aim of this prospective study was to investigate whether spinal cord stimulation (SCS) significantly reduces pain intensity for up to 18-month follow-up in patients with chronic neuropathic pain. Forty-eight patients were recruited. Patients rated their pain using a Visual analog scale (VAS) and pain-related disability using the Oswestry Disability Index (ODI) at baseline (1 week prior to SCS surgery) and at 6-, 12-, and 18-month follow-up. Pain intensity significantly decreased from baseline to all 3 time points [F (3,135) = 16.264, p < 0.001]. The greatest difference in the reduction of pain intensity was observed between baseline (M = 7.20, SD = 1.34) and 6-month follow-up (M = 4.60, SD = 2.20), [t(47) = 6.741, p < 0.001]. However, when looking at differences between the 6-month follow-up and subsequent assessments, statistically significant increases in pain intensity from the 6-month to the 12-month follow-up [t(47) = −2.788, p = 0.008], and from the 6-month to the 18-month follow-up [t(47) = −3.339, p = 0.002] could be observed. Statistically significant changes were also observed for clinical changes in pain scores [F (2,94) = 4.972, p = 0.009. There was a significant decrease in the percentage of clinical change obtained from the 6-month (M = 33.19, SD = 35.63) to the 12-month follow-up (M = 23.76, SD = 33.62), [t(47) = 2.347, p = 0.025], and from the 6-month to the 18-month follow-up (M = 18.34, SD = 33.51), [t(47) = 3.072, p = 0.004]. A number of patients also reported higher levels of pain intensity at the 12-and 18-month follow-up than at baseline.Pain-related disability scores significantly decreased from baseline (M = 55.04, SD = 16.43) to the 6-month follow up (M = 46.98, SD = 19.05), [t(47) = 3.464, p = 0.001] and from baseline to the 12-month follow up (M = 48.49, SD = 20.94), [t(47) = 2.918, p = 0.005], but not during the 18-month follow up (M = 51.75, SD = 20.92), [t(47) = 1.330, p = .190]. There was a significant increase in pain-related disability between the 6- and the 18-month follow up [t(47) = −2.188. p = 0.034]. These findings suggest that the beneficial effect of SCS on pain intensity may diminish over time, and that the 6-month follow-up scores may reflect a placebo effect.

Correlation between pressure pain threshold and pain intensity in patients with temporomandibular disorders who are compliant or non-compliant with conservative treatment

To investigate the correlation between pain measurements performed using a visual analogue scale (VAS) and pressure pain threshold (PPT) in individuals with temporomandibular disorders who underwent conservative treatment. This prospective study assessed 78 individuals diagnosed with myofascial pain, and the treatment consisted of counseling and self-care therapy sessions. Pain was assessed by means of a VAS and PPT at baseline (T0), after 15 to 30 days (T1), and after 75 to 90 days (T2). The participants were divided into two groups: "Compliant Group" and "Non-Compliant Group." The data were analyzed by means of Spearman's correlation test and Friedman's analysis of variance by ranks. Correlations were not identified between the VAS and PPT values at time points-T0, T1, or T2-in any group. Although, VAS and PPT represent subjective features, such as the perception of pain, the hypothesis that high pain intensity levels are equivalent to high pain sensitivity levels was not demonstrated.

Understanding the biomechanical “spread” of joint pain: knee pain predicts subsequent shoulder pain and this is mediated by leg weakness. Data from the osteoarthritis initiative

Joint pain is common in older adults; typically multiple joints are involved. A greater number of painful sites is associated with higher levels of pain intensity in affected joints, more functional impairment and poorer quality of life. However, little is known about the pattern of multi-site joint pain development. We aimed to assess whether the number of painful joints increases over time, whether pain in certain joints precedes pain in others, and to assess whether the association is mediated by weakness in a cohort of older adults with painful knee osteoarthritis or at risk of knee osteoarthritis in the NIH Osteoarthritis Initiative (OAI).

Pain experience and satisfaction with postoperative pain control among surgical patients.

Alleviating acute pain and providing pain relief are central to caring for surgical patients as pain can lead to many adverse medical consequences. This study aimed to explore patients' experience of pain and satisfaction with postoperative pain control. A cross-sectional survey was carried out among 107 respondents who had undergone abdominal surgery in the surgical ward of an urban hospital using the Revised American Pain Society's Patient Outcome and Satisfaction Survey Questionnaires (APS-POQ-R). Data were analysed using descriptive statistics and chi-square test. Chi-square test showed significant association between race (P = 0.038), education level (P ≤ 0.001), previous operation status (P = 0.032) and operation status (P ≤ 0.001). Further analysis on nominal regression, association between dissatisfaction with factors of operation status (46.09 (95% CI 7.456, 284.947)) and previous operation status (13.38 (95% CI 1.39, 128.74)) was found to be significant. Moderate to high levels of pain intensity in the last 24 h after surgery, as well as moderate to high rates of pain-related interference with care activities were most reported. Pain still remains an issue among surgical patients, and effective pain management and health education are needed to manage pain more effectively after surgery.

Neuropathic sensory symptoms: association with pain and psychological factors.

BackgroundA large number of population-based studies of chronic pain have considered neuropathic sensory symptoms to be associated with a high level of pain intensity and negative affectivity. The present study examines the question of whether this association previously found in non-selected samples of chronic pain patients can also be found in chronic pain patients with underlying pathology of neuropathic sensory symptoms.MethodsNeuropathic sensory symptoms in 306 patients with chronic pain diagnosed as typical neuropathic pain, radiculopathy, fibromyalgia, or nociceptive back pain were assessed using the Pain DETECT Questionnaire. Two separate cluster analyses were performed to identify subgroups of patients with different levels of self-reported neuropathic sensory symptoms and, furthermore, to identify subgroups of patients with distinct patterns of neuropathic sensory symptoms (adjusted for individual response bias regarding specific symptoms).ResultsANOVA (analysis of variance) results in typical neuropathic pain, radiculopathy, and fibromyalgia showed no significant differences between the three levels of neuropathic sensory symptoms regarding pain intensity, pain chronicity, pain catastrophizing, pain acceptance, and depressive symptoms. However, in nociceptive back pain patients, significant differences were found for all variables except pain chronicity. When controlling for the response bias of patients in ratings of symptoms, none of the patterns of neuropathic sensory symptoms were associated with pain and psychological factors.ConclusionNeuropathic sensory symptoms are not closely associated with higher levels of pain intensity and cognitive-emotional evaluations in chronic pain patients with underlying pathology of neuropathic sensory symptoms. The findings are discussed in term of differential response bias in patients with versus without verified neuropathic sensory symptoms by clinical examination, medical tests, or underlying pathology of disease. Our results lend support to the importance of using adjusted scores, thereby eliminating the response bias, when investigating self-reported neuropathic symptoms by patients.

Cancer pain management in an oncological ward in a comprehensive cancer center with an established palliative care unit

This survey was performed to draw information on pain prevalence, intensity, and management from a sample of patients who were admitted to an oncologic center where a palliative care unit (PCU) has been established for 13years. Cross-sectional survey in an oncological department performed 1day per month for six consecutive months. Of the 385 patients, 69.1, 19.2, 8.6, and 3.1% had no pain, mild, moderate, and severe pain, respectively. Inpatients and patients with a low Karnofsky score showed higher levels of pain intensity (p < 0.0005). One hundred twenty-eight patients with pain or receiving analgesics were analyzed for pain management index (PMI). Only a minority of patients had negative PMI score, which was statistically associated with inpatient admission (p = 0.011). Fifty of these 128 patients had breakthrough pain (BTP), and all of them were receiving some medication for BTP. It is likely that the presence of PCU team providing consultation, advices, and cultural pressure, other than offering admissions for difficult cases had a positive impact on the use of analgesics, as compared with previous similar surveys performed in oncological setting, where a PCU was unavailable. This information confirms the need of the presence of a PCU in a high volume oncological department.

Prevalence and Characteristics of Flare-ups of Chronic Nonspecific Back Pain in Primary Care

To describe the prevalence and characteristics of flare-ups of chronic nonspecific back pain (CNSBP) among primary care patients, and to examine associations with measures of pain severity and psychosocial factors. Six hundred thirty-four participants with nonspecific back pain were interviewed by telephone 2 years after an initial primary care visit for back pain. Participants experiencing flare-ups in the last 6 months reported on frequency, duration, and other characteristics of flare-ups. Using bivariate and multivariate analyses, we compared individuals with and without CNSBP flare-ups with respect to demographic characteristics, measures of pain severity, and psychosocial factors. Approximately 51% of the participants reported flare-ups. Physical activities, including lifting and bending, were the most common perceived triggers of flare-ups. Participants with flare-ups experienced greater levels of pain intensity, disability, opioid medication use, and psychosocial comorbidities. After adjustment for demographic factors, pain intensity, and pain frequency, participants with flare-ups were more disabled than those without [mean (95% confidence interval) disability score 4.2 (3.9-4.4) vs. 3.3 (2.9-3.6); P<0.0001] and demonstrated higher levels of passive coping [mean passive coping score 4.1(3.8-4.3) vs. 3.4 (3.1-3.7); P=0.0008]. Flare-ups of CNSBP are common among primary care patients, and are independently associated with higher levels of pain intensity, disability, and passive coping. The presence of flare-ups and the perception of activity as a trigger may predispose patients with flare-ups to experience disability not explained by pain intensity alone. Further longitudinal studies are required to better characterize CNSBP flare-ups and determine their clinical implications.

Comparing the effects of ice massage and acupressure on labor pain reduction

BackgroundChildbirth is arguably one of the most painful experiences women undergo during their lives. This study aimed to compare the effects of ice massage, acupressure and placebo in reducing the intensity of labor pain in pregnant women from selected hospitals in Tehran, Iran. MethodsA quasi-experimental study was conducted on 90 pregnant women referred from selected hospitals in Tehran. Mean age of the participants was 27.82 ± 6.20 years. Subjects were randomly divided into three groups (n = 30) to receive ice massage, acupressure or placebo. The intervention was applied at the Hegu point and pain intensity assessed using a visual analogue scale (VAS) before the intervention, immediately 30 min and 1 h after the intervention. ResultsComparing pain intensity immediately, 30 min and 1 h post-intervention across the three groups showed a significant difference between the groups. At 30 min post-intervention (p < 0.05). A Tukey test showed this difference was related to ice massage. ConclusionIce massage and acupressure techniques reduced pain during labor. However, ice massage provided more persistent pain relief. Due to high levels of pain intensity and increased pain experienced by the women during the active phase of labor, it is suggested that repeating these techniques during the first stage of labor could be an effective, accessible, cost-effective and non-invasive technique to help reduce the intensity of labor pain.

The Influence of Pain Distribution on Walking Velocity and Horizontal Ground Reaction Forces in Patients with Low Back Pain

Objective. The primary purpose of this paper was to evaluate the influence of pain distribution on gait characteristics in subjects with low back problems (LBP) during walking at preferred and fastest speeds. Design. Cross-sectional, observational study. Setting. Gait analysis laboratory in a health professions university. Participants. A convenience age- and gender-matched sample of 20 subjects with back pain only (BPO), 20 with referred leg pain due to back problems (LGP), and 20 pain-free individuals (CON). Methods and Measures. Subjects completed standardized self-reports on pain and disability and were videotaped as they walked at their preferred and fastest speeds along a walkway embedded with a force plate. Temporal and spatial gait characteristics were measured at the midsection of the walkway, and peak medial, lateral, anterior, and posterior components of horizontal ground reaction forces (hGRFs) were measured during the stance phase. Results. Patients with leg pain had higher levels of pain intensity and affect compared to those with back pain only (t = 4.91, P < .001 and t = 5.80, P < 0.001, resp.) and walking had an analgesic effect in the BPO group. Gait velocity was highest in the control group followed by the BPO and LGP group and differed between groups at both walking speeds (F 2.57 = 13.62, P < .001 and F 2.57 = 9.09, P < .001, for preferred and fastest speed condition, resp.). When normalized against gait velocity, the LGP group generated significantly less lateral force at the fastest walking speed (P = .005) and significantly less posterior force at both walking speeds (P ≤ .01) compared to the control group. Conclusions. Pain intensity and distribution differentially influence gait velocity and hGRFs during gait. Those with referred leg pain tend to utilize significantly altered gait strategies that are more apparent at faster walking speeds.

Pain‐related catastrophizing in pain patients and people with pain in the general population

Catastrophizing is a defining factor in the pain experience and strongly contributes to the prediction of various aspects of health. Catastrophizing is not just present in pain patients, but may also be present in people with non-clinical pain. The aim of the present study is to investigate levels of catastrophizing in pain patients and people with pain from the general population. Also, the relationship between catastrophizing and pain intensity, specialist consultation and use of pain medication is studied. A cross-sectional survey design was used, including 150 pain patients and 376 respondents from the general population. The results show that pain is highly prevalent in the general population. The pain patients reported significantly higher levels of pain intensity and catastrophizing than the community pain sample. In both samples, significant positive correlations between catastrophizing and pain intensity were found. The data show a linear relationship between catastrophizing and pain intensity, which can be interpreted as evidence for a dose-response pattern in pain-related catastrophizing. Furthermore, catastrophizing predicted specialist consultation and medication use in the community pain sample. It can be concluded that pain-related catastrophizing is present in pain patients as well as people with pain from the general population in a dose-response pattern. Catastrophizing seems to be an important factor determining certain aspects of pain-related medical consumption, even in non-clinical pain, and should therefore be a target of the screening procedure and early intervention.

Does attachment insecurity affect the outcomes of a multidisciplinary pain management program? The association between attachment insecurity, pain, disability, distress, and the use of opioids

Cognitive and behavioural treatments have been shown to be effective for the management of chronic pain. However, not all patients succeed at such a treatment. Attachment insecurity has recently been proposed as an individual vulnerability factor that may have a negative impact on pain, disability, psychological distress, and compliance with treatment, resulting in a poorer outcome. Furthermore, attachment avoidance has been associated with opioid abuse. We hypothesised that attachment anxiety would be associated with higher levels of pain intensity and disability, and that both attachment dimensions would be associated with anxiety and depression. Moreover, we hypothesised that attachment avoidance would be positively associated with the use of opioids. Finally, we predicted that patients with an insecure attachment orientation would profit less from a routine pain management program. Data were collected from 72 patients referred consecutively from December 2008 to August 2009 to a 13-week pain management program at a Danish multidisciplinary pain centre. Both attachment dimensions were positively associated with anxiety and depression. Moreover, the insecurely attached patients used significantly more opioids compared to the securely attached. None of the attachment dimensions was associated with pain and disability, and the pain management program was equally effective for both the secure and insecure groups. However, the level of anxiety and depression for insecurely attached patients did not decline below a clinical level post-treatment. The present study suggests that attachment insecurity plays an important role in the context of chronic pain management. With regards to the management of pain related anxiety, depression, and the use of opioids, the current results suggests that practitioners should keep attachment insecurity in mind.

2011 Young Investigator Award Winner

A cross-sectional study. To determine whether body composition is associated with low back pain intensity and/or disability. The relationship between obesity and low back pain and disability is unclear. No study has examined the role of body composition in low back pain and disability. A total of 135 participants (25-62 years), with a range of body mass indices (18-55 kg/m), were recruited for a study examining the relationship between obesity and musculoskeletal disease. Participants completed the Chronic Back Pain Grade Questionnaire, which examines individuals' levels of low back pain intensity and disability. Body composition was assessed using dual radiograph absorptiometry. Body mass index was associated with higher levels of back pain intensity (Odds ratio [OR] = 1.35; 95% confidence interval [CI] = 1.09, 1.67) and disability (OR = 1.66; 95% CI = 1.31, 2.09). Higher levels of pain intensity were positively associated with total body (OR = 1.19; 95% CI = 1.04, 1.38) and lower limb fat mass (OR = 1.51; 95% CI = 1.04, 2.20), independent of lean tissue mass. There were also positive associations between higher levels of low back disability and total body (OR = 1.41; 95% CI = 1.20, 1.67) and upper (OR = 1.67; 95% CI = 1.27, 2.19) and lower (OR = 2.29; 95% CI = 1.51, 3.49) limbs fat mass. Similar relationships were observed with trunk, android, and gynoid fat mass. After adjusting for confounders, no measures of lean tissue mass were associated with higher pain intensity or disability (P > 0.10). Greater fat, but not lean tissue mass, was associated with high levels of low back pain intensity and disability. Longitudinal investigation is needed to determine whether fat mass is predictive of low back pain and disability, as this may have important implications for further prevention strategies. Understanding the mechanism for these relationships may provide novel approaches to managing low back pain.

Assessing Pain Behaviors in Healthy Subjects Using the Critical-Care Pain Observation Tool (CPOT): A Pilot Study

The Critical-Care Pain Observation Tool (CPOT) is a behavioral scale recommended by experts for pain assessment in critically ill patients unable to verbally communicate. The main goal of this study was to determine the relationship between self-reports of pain intensity and the CPOT score, and establish the sensibility and the specificity of the CPOT to different levels of pain intensity in healthy subjects. A total of 18 healthy subjects participated in the study (mean age = 37.8 years). All subjects underwent a 2 minutes noxious cold pressor test (CPT) at 7°C. Verbal pain ratings were obtained with a visual analog scale (0-100) while pain behaviors were videotaped. Afterwards, 2 independent evaluators quantified pain behaviors using the CPOT. Interrater reliability was supported with an ICC of 0.963 (95%CI [0.904-0.986]). A moderate positive correlation between the CPOT scores and self-reports of pain intensity during the CPT was found (r = 0.52, p = 0.028). Such result indicates that subjects reporting high level of pain showed a higher number or more intense pain behaviors. A cut-off score >2.5/8 on the CPOT led to a sensibility of 64% and a specificity of 86%. Results from this pilot study support that an increase of CPOT score is correlated with moderate to high levels of pain intensity and further support the clinical use of the CPOT. This article presents the psychometric properties of a behavioral pain scale called the CPOT which was developed to assess pain in critically ill adults unable to self-report. Our results inhealthy subjects showed that the CPOT behavioral score is significantly correlated with the self-report of pain intensity and supports its clinical use.

Do Pain Patients at High Risk for Substance Misuse Experience More Pain?: A Longitudinal Outcomes Study

The Screener and Opioid Assessment of Pain Patients (SOAPP v.1) has been shown to be a reliable measure of risk potential for substance misuse and to correlate with a history of substance abuse, legal problems, craving, smoking, and mood disorders among chronic pain patients. The aim of this study was to examine differences over time on a number of measures among chronic pain patients who were classified as high or low risk for opioid misuse based on scores on the SOAPP. From an initial sample of one hundred thirty-four participants (N = 134), one hundred and ten (N = 110) completed the SOAPP and were grouped as high or low risk for misuse of medication based on SOAPP scores of > or =7. All subjects were asked to complete baseline measures and in-clinic monthly diaries of their pain, mood, activity interference, medication, and side effects over a 10-month study period. The results showed that although those who were classified as high-risk for opioid misuse reported significantly higher levels of pain intensity, activity interference, pain catastrophizing, disability, and depressed mood at baseline (P < 0.05), only pain intensity ratings were found to differentiate groups over time (P < 0.01). These results were unrelated to perceived helpfulness of pain treatment. Differences in subjective pain intensity were found between those who are high risk for opioid misuse compared with those at low risk for medication misuse, implying that higher-risk patients may experience more subjective pain. Consequently, these patients may be more challenging to treat.

Assessing pain behaviors in healthy subjects using the Critical-Care Pain Observation Tool (CPOT): a pilot study

The critical care pain observation tool (CPOT) is the only valid pain assessment tool used in critical care with patients who cannot communicate verbally. However, the predictive value of the CPOT has not been studied in controlled experimental settings. The goal of this study was to determine the strength of the relationship between verbal pain ratings and the pain behaviour (score obtained via the CPOT) in healthy subjects. 18 subjects participated in the study (mean age = 37.8 years). All subjects underwent a two minutes noxious cold pressor test (CPT) at 7°C. Verbal pain ratings were obtained with a numerical pain scale (0-100) while pain behaviours were recorded by video camera. Afterwards, two independent evaluators quantified pain behaviours using the CPOT. Simple regression analysis between pain intensity and the CPOT score enabled us to obtain the predictive value of the CPOT. We found an excellent interrater reliability (ICC = 0.963, 95%CI [0.904-0.986]). We observed a significant relationship between the total CPOT score and pain intensity during the CPT (r = 0.52, p = 0.028). Although this relationship is moderate, it still indicates that subjects reporting greatest pain intensity showed more pain behaviour. Furthermore, no sex differences were observed, suggesting that men and women tend to have similar pain behaviours. This pilot study confirms the relationship between pain behaviours and pain intensity ratings in healthy subjects. Furthermore, this study supports the use of the CPOT in clinical settings and confirms that a high CPOT score is correlated with moderate to high levels of pain intensity.

Non-consultation among community-dwelling older adults with knee pain: completing the picture

AimTo investigate knee-related and comorbid consultations in a sample of community-dwelling older adults with knee pain.BackgroundKnee pain affects 25–37% of people aged over 50 years. Previous studies suggest a minority will consult their general practitioner (GP) about it. One reason might be the relatively low priority given to this problem in the context of multi-morbidity.MethodsAdults aged over 50 years, registered with three local general practices reporting knee pain within the last 12 months, were recruited to an observational cohort. Consultation data were reviewed for the three-year period following study entry. All knee-related consultations, including those for knee osteoarthritis (OA), were identified. Contacts for non-knee-related morbidity were also identified. Consultation patterns were summarized as incidence rates using exact person–time and cumulative incidences.FindingsSeven hundred and forty-two people (mean age 65.5 years (SD 8.6); 54% female) were included and provided 1917 person–years of observation. The rate of knee-related consultations was 38.5 per 100 person–years (95% CI 35.8, 41.3), of knee OA consultations 10.6 (9.2, 12.1), and of comorbid contacts 790.6 (778.0, 803.3). The cumulative incidence of knee-related consultation at three years was 41.0%. Knee-related consultation was related to severity of knee pain but almost 50% with high levels of pain intensity did not visit the GP about their knee problem. Contrastingly, within six months of study entry 85.6% of participants had contacted the practice about other comorbid illness (predominately circulatory disease or other musculoskeletal complaints). By three years, 99.6% participants had consulted about comorbid illness. Incidence rates for knee-related consultations and comorbid contacts were associated with the relative importance the patient gave to their knee problem. For every knee-related consultation there were 20 comorbid contacts. There is considerable scope for opportunistic care of knee pain and for further research on how patients and GPs prioritize health conditions in the context of multi-morbidity.

Cognitive appraisal and coping in chronic pain patients

Objectives This study analyses the relationships between patients’ cognitive appraisals concerning their pain and the coping strategies they use. In addition, the way the coping strategy influences the intensity of perceived pain and impairment in these patients was studied. Methods One hundred and twenty two patients with musculoskeletal chronic pain participated. The assessment tools were as follows: The Cognitive Appraisal Inventory for Chronic Pain Patients (CAI), the Vanderbilt Pain Management Inventory (VPMI), the McGill Pain Questionnaire (MPQ) and the Impairment and Functioning Inventory for Chronic Pain Patients (IFI). The hypothetical model was empirically tested using the LISREL 8.20 software package and the unweighted least squares method. Results High levels of challenge appraisal were associated with low levels of passive coping and high levels of active coping strategies, whereas the harm, loss or threat appraisal predicted high use of passive coping strategies. Passive coping had three statistically significant path coefficients: high levels of passive coping were associated with low levels of functioning and high levels of pain intensity and impairment. However, high levels of active coping reported high levels of daily functioning. Discussion By analysing the cognitive appraisals made by chronic pain patients, clinicians could make better predictions regarding the way they cope and adjust.

Applying Centrality of Event to Persistent Pain: A Preliminary View

Living with persistent pain is a complex experience. Based on clinical observations, persistent pain is often described as a stressful life event that has significantly altered how patients view themselves and the world around them. The Centrality of Event Scale (CES) assesses how much a stressful life event serves as a turning point in the individual's life, forms a reference point for personal identity, and affects the attribution of meaning to other life experiences. In this study, 47 patients with persistent pain were asked to complete the CES using "the experience of persistent pain" as the designated stressful life event. Data analyses revealed patients scoring high on the CES (ie, those who viewed persistent pain as a central life event) were significantly more likely to experience higher levels of pain intensity (r = .35, P = .02), life interference due to pain (r = .50, P = .002), and psychological distress (r = .46, P = .001). Additional analyses revealed that the CES was a significant predictor of life interference due to pain and psychological distress even after controlling for the effects of age, sex, education, and pain intensity. The experience of persistent pain can serve as a major turning point in patients' lives, affect patients' interpretations of other life events, and become a key component of patients' identities. The results of this study indicate that centrality of event, a relatively new construct, could improve our understanding of persistent pain.