Perceived Pain Control Research Articles

The QSP-31: a multidimensional questionnaire for assessing psychosocial / psychodynamic aspects in patients with somatoform pain

ABSTRACT Somatoform pain poses major challenges in medicine. There is a lack of quantitative instruments that systematically assess psychosocial aspects of somatoform pain. A better knowledge of such aspects could contribute (1) to gaining further insight into the relationship between psychodynamic and psychosocial components of pain, and (2) to facilitating the development and monitoring of improved interventions targeting psychodynamic and psychosocial mechanisms of pain. An item pool on biopsychosocial aspects of pain was developed and completed by 200 patients with somatoform pain disorder. In addition, anxiety (STAI), depression (BDI II), somatization (SOMS-2), and quality of life (SF-36) were assessed. As compared to norm data, patients reported higher scores for anxiety (STAI), depression (BDI-II) somatization (SMOS-2), and lower quality of life (SF-36). Applying item and factor analyses, a new questionnaire (QSP-31) was developed to identify psychodynamic and psychosocial aspects of pain. There was evidence for the construct validity of the six scales through confirmatory factor analysis: Relationships between pain and negative emotions, Negative attitudes towards help-seeking, Negative pain-related childhood experiences, Negative attitudes towards own body, Negative aspects of the doctor-patient relationship, and Perceived pain control. Cronbach's alpha coefficients for these scales lay within the range of .81-.92. Regarding criterion validity, moderate correlations in expected directions were found between all scales and anxiety, depression, somatic symptom severity, and quality of life, except for the scale Perceived pain control. The QSP-31 appears promising for the identification of relevant psychosocial aspects associated with the experience of pain and might be a useful instrument.

A Four-Arm Randomized Clinical Trial of Topical Pain Control for Sentinel Node Radiotracer Injections in Patients with Breast Cancer.

Radioactive tracer injections for breast cancer sentinel lymph node mapping can be painful. In this randomized trial, we compared four approaches to topical pain control for radiotracer injections. Breast cancer patients were randomized (9 April 2021-8 May 2022) to receive the institutional standard of ice prior to injection (n=44), or one of three treatments: ice plus a vibrating distraction device (Buzzy®; n=39), 4% lidocaine patch (n=44), or 4% lidocaine patch plus ice plus Buzzy® (n=40). Patients completed the Wong-Baker FACES® pain score (primary outcome) and a satisfaction with pain control received scale (secondary). Nuclear medicine technologists (n=8) rated perceived pain control and ease of administration for each patient. At study conclusion, technologists rank-ordered treatments. Data were analyzed as intention-to-treat. Wilcoxon rank-sum tests were used to compare pain scores of control versus pooled treatment arms (primary) and then control to each treatment arm individually (secondary). There were no differences in pain scores between the control and treatment groups, both pooled and individually. Eighty-five percent of patients were 'satisfied/very satisfied' with treatment received, with no differences between groups. No differences in providers' perceptions of pain were observed, although providers perceived treatments involving Buzzy© more difficult to administer (p<0.001). Providers rated lidocaine patch as the easiest, with ice being second. In this randomized trial, no differences in patient-reported pain or satisfaction with treatment was observed between ice and other topical treatments. Providers found treatments using Buzzy® more difficult to administer. Given patient satisfaction and ease of administration, ice is a reasonable standard.

Patients with preoperative opioid use and lower resilience scores are more likely to report inadequate pain control after total shoulder arthroplasty

BackgroundThe United States is in a prescriptive opioid crisis, and physicians have a responsibility to their patients and the healthcare system to mitigate irresponsible prescriptive practices. A patient’s preoperative opioid status and brief resilience score (BRS) may be used to individualize analgesic protocols and reduce opioid overprescription. The purpose of this study is to evaluate the relationship between preoperative resilience scores and patient-reported pain control after total shoulder arthroplasty (TSA). This study also examines reported pain control in patients with or without preoperative narcotic use 30 days before their procedure. MethodsPatients undergoing elective primary anatomic total shoulder arthroplasty (aTSA) or primary reverse total shoulder arthroplasty (rTSA) were asked to complete the BRS survey before their procedure and postoperative narcotic pain medication surveys at 1, 4, and 12 weeks after their operation. The patients were then stratified into 2 cohorts based on preoperative opioid usage status. Two-sample equal-variance t-tests were used to test for differences between resilience score group means and adequate pain control after TSA. The differences between preoperative opioid and no preoperative opioid usage cohorts, and perceived pain control and the number of oxycodone pills taken were analyzed for direction and statistical significance using t-tests for continuous variables and chi-squared tests for categorical variables. ResultsThe study cohort consisted of 218 patients, of whom 74 had preoperative opioid use (group O). Patients who reported inadequate pain control after TSA had consistently lower resilience scores at baseline. The BRS group means ± standard deviations after TSA for the adequate vs. inadequate pain control groups respectively were 3.84 vs. 3.48 (P = .010) at week 1, 3.83 vs. 3.53 (P = .055) at week 4, and 3.84 vs. 3.36 (P = .002) at week 12. Of the patients in group O (n = 74), a consistently smaller proportion of patients reported adequate pain control after TSA. Pain control rates among group O vs. nonusers/opioid-naïve patients (group N) respectively were 81.1% vs. 89.6% (P = .080) at week 1, 83.8% vs. 92.4% (P = .055) at week 4, and 82.4% vs. 93.0% (P = .016) at week 12. ConclusionA patient’s resilience score and preoperative opioid consumption are associated with postoperative pain control. Physicians may be able to use these 2 preoperative measures to better individualize postoperative narcotic prescriptive practices and reduce the number of unused opioids.

The chronic disease helplessness survey: developing and validating a better measure of helplessness for chronic conditions.

Learned helplessness develops with prolonged exposure to uncontrollable stressors and is therefore germane to individuals living with pain or other poorly controlled chronic diseases. This study has developed a helplessness scale for chronic conditions distinct from previous scales that blur the conceptualization of control constructs. Extant measures commonly examine controllability, not the three pillars of helplessness identified by Maier and Seligman (1976): cognitive, emotional, and motivational/motor deficits. Individuals who self-report a chronic pain condition (N = 350) responded to a Chronic Disease Helplessness Survey (CDHS) constructed to capture cognitive, motivational/motor, and emotion deficits. Exploratory factor analysis (EFA; N = 200) and confirmatory factor analysis (CFA; N = 150) were performed. The CDHS was assessed for convergent and discriminant validity. A three-factor solution corresponding to cognitive, emotional, and motivational/motor factors was identified by EFA. The solution exhibited sufficient model fit and each factor had a high degree of internal consistency. The CDHS was significantly associated with greater pain intensity and interference, PCS helplessness, lower perceived pain control, and lower general self-efficacy. Individuals with diabetes generally experience greater control strategies over daily symptoms (e.g., diet, oral medications, and insulin) than patients with chronic pain and in this study displayed significantly lower CDHS scores compared to individuals with chronic pain, demonstrating discriminant validity. This study provides preliminary evidence that the three-factor CDHS is a psychometrically sound measure of helplessness in individuals with chronic pain.

Behavioral interventions alter urologists' opioid prescribing practices.

Behavioral interventions alter urologists' opioid prescribing practices.

Mechanisms of Mindfulness Meditation, Cognitive Therapy, and Mindfulness-based Cognitive Therapy for Chronic Low Back Pain.

This study evaluated theoretically derived mechanisms and common therapeutic factors to test their role in accounting for pain-related outcome change during group-delivered cognitive therapy, mindfulness meditation, and mindfulness-based cognitive therapy for chronic low back pain. A secondary analysis of a pilot randomized controlled trial was used to explore the primary mechanisms of pretreatment to posttreatment changes in pain control beliefs, mindful observing, and pain catastrophizing, and the secondary common factor mechanisms of therapeutic alliance, group cohesion, and amount of at-home skill practice during treatment. The primary outcome was pain interference; pain intensity was a secondary outcome. Large effect size changes in the 3 primary mechanisms and the outcome variables were found across the conditions. Across all 3 treatment conditions, change in pain control beliefs and pain catastrophizing were significantly associated with improved pain interference, but not pain intensity. Therapeutic alliance was significantly associated with pain intensity improvement and change in the therapy-specific mechanisms across the 3 conditions. Mindful observing, group cohesion, and amount of at-home practice were not significantly associated with changes in the outcomes. Cognitive therapy, mindfulness meditation, and mindfulness-based cognitive therapy for chronic low back pain were all associated with significant changes in the primary mechanisms to a similar degree. Change in perceived pain control and pain catastrophizing emerged as potential "meta-mechanisms" that might be a shared pathway that contributes to improved pain-related outcomes across treatments. Further, strong working alliance may represent a critical therapeutic process that both promotes and interacts with therapeutic techniques to influence outcome.

Cognitive Mediators of Change in Physical Functioning in Response to a Multifaceted Intervention for Managing Osteoarthritis

Although non-pharmacological interventions have been shown to improve physical functioning in individuals with osteoarthritis (OA), the mechanisms by which this occurs are often unclear. This study assessed whether changes in arthritis self-efficacy, perceived pain control, and pain catastrophizing mediated changes in physical functioning following an osteoarthritis intervention involving weight management, physical activity, and cognitive-behavioral pain management. Three hundred Veteran patients of 30 primary care providers with knee and/or hip OA were cluster randomized to an OA intervention group or usual care. The OA intervention included a 12-month phone-based patient behavioral protocol (weight management, physical activity, and cognitive-behavioral pain management) plus patient-specific OA treatment recommendations delivered to primary care providers. Using linear mixed models adjusted for provider clustering, we observed that baseline to 6-month changes in arthritis self-efficacy and pain control partially mediated baseline to 12-month physical functioning improvements for the intervention group; catastrophizing did not. Findings of a mediating role of arthritis self-efficacy and pain control in intervention-related functional changes are consistent with hypotheses and align with theoretical assertions of the role of cognitions in cognitive and behavioral interventions for chronic pain. However, contrary to hypotheses, catastrophizing was not found to be a mediator of these changes.

Negative oncologic impact of poor postoperative pain control in left-sided pancreatic cancer.

AIMTo investigate the association between postoperative pain control and oncologic outcomes in resected pancreatic ductal adenocarcinoma (PDAC).METHODSFrom January 2009 to December 2014, 221 patients were diagnosed with PDAC and underwent resection with curative intent. Retrospective review of the patients was performed based on electronic medical records system. One patient without records of numerical rating scale (NRS) pain intensity scores was excluded and eight patients who underwent total pancreatectomy were also excluded. NRS scores during 7 postoperative days following resection of PDAC were reviewed along with clinicopathologic characteristics. Patients were stratified into a good pain control group and a poor pain control group according to the difference in average pain intensity between the early (POD 1, 2, 3) and late (POD 5, 7) postoperative periods. Cox-proportional hazards multivariate analysis was performed to determine association between postoperative pain control and oncologic outcomes.RESULTSA total of 212 patients were dichotomized into good pain control group (n = 162) and poor pain control group (n = 66). Median follow-up period was 17 mo. A negative impact of poor postoperative pain control on overall survival (OS) was observed in the group of patients receiving distal pancreatectomy (DP group; 42.0 mo vs 5.0 mo, P = 0.001). Poor postoperative pain control was also associated with poor disease-free survival (DFS) in the DP group (18.0 mo vs 8.0 mo, P = 0.001). Patients undergoing pancreaticoduodenectomy or pylorus-preserving pancreaticoduodenectomy (PD group) did not show associations between postoperative pain control and oncologic outcomes. Poor patients’ perceived pain control was revealed as an independent risk factor of both DFS (HR = 4.157; 95%CI: 1.938-8.915; P < 0.001) and OS (HR = 4.741; 95%CI: 2.214-10.153; P < 0.001) in resected left-sided pancreatic cancer.CONCLUSIONAdequate postoperative pain relief during the early postoperative period has important clinical implications for oncologic outcomes after resection of left-sided pancreatic cancer.

A 9-year follow-up of a self-management group intervention for persistent neck pain in primary health care: a randomized controlled trial.

Background and objectiveIn previous short-term and 2-year follow-ups, a pain and stress self-management group intervention (PASS) had better effect on pain-related disability, self-efficacy, catastrophizing, and perceived pain control than individually administered physiotherapy (IAPT) for patients with persistent tension-type neck pain. Studies that have evaluated long-term effects of self-management approaches toward persistent neck pain are sparse. The objective of this study was to compare pain-related disability, self-efficacy for activities of daily living (ADL), catastrophizing, pain, pain control, use of analgesics, and health care utilization in people with persistent tension-type neck pain 9 years after they received the PASS or IAPT.Materials and methodsOf 156 people (PASS, n = 77; IAPT, n = 79) originally included in a randomized controlled trial, 129 people (PASS, n = 63; IAPT, n = 66) were eligible and were approached for the 9-year follow-up. They were sent a self-assessment questionnaire, comprising the Neck Disability Index, the Self-Efficacy Scale, the Coping Strategies Questionnaire, and questions regarding pain, analgesics, and health care utilization. Mixed linear models for repeated measures analysis or generalized estimating equations were used to evaluate the differences between groups and within groups over time (baseline, previous follow-ups, and 9-year follow-up) and the interaction effect of “time by group”.ResultsNinety-four participants (73%) responded (PASS, n = 48; IAPT, n = 46). At 9 years, PASS participants reported less pain-related disability, pain at worst, and analgesics usage, and a trend toward better self-efficacy compared to IAPT participants. There was a difference between groups in terms of change over time for disability, self-efficacy for ADL, catastrophizing, perceived pain control, and health care visits in favor of PASS. Analyses of simple main effects at 9 years showed that the PASS group had less disability (p = 0.006) and a trend toward better self-efficacy (p = 0.059) than the IAPT group.ConclusionThe favorable effects on pain-related disability of PASS were sustained 9 years after the intervention.

Passing the time when in pain: Investigating the role of musical valence.

The effective management of pain outside of clinical settings represents a significant challenge to health services. Music listening has been successfully used as a method of pain management, with the greatest benefits to listeners evident if the music is familiar, preferred and has emotional resonance. This study examined the role of self-selected emotion-inducing music used for pain management (pain tolerance, intensity, perceived control, distraction and anxiety reduction) during the cold pressor test. In a repeated-measures design, four cold pressor tests were used to induce short-term, acute pain, whilst 41 participants listened either to happy, sad, relaxing or no music. Findings indicated that music enhanced pain tolerance over no music, and happy and relaxing music increased pain tolerance and altered time perception to a greater extent than sad music. Happy and relaxing music facilitated distraction from pain and enhanced perceived pain control. Relaxing music additionally had anxiolytic properties and reduced pain intensity. Results suggest that music’s inclusion in pain management is justified and that music with happy and relaxing components can be used to facilitate coping with pain in a non-clinical context.

Evaluating the Influence of Perceived Pain Control on Patient Satisfaction in a Hospital Setting

The authors evaluated whether a patient's perceived pain control influenced the relationships between four attributes (nursing, physician, staff, and environment) and patient satisfaction. Multiple linear regression analyses were conducted to examine overall satisfaction and intention to recommend, controlling for race, gender, age, and education. The authors found that no matter the level of pain control, nursing was always the most influential attribute in patient satisfaction. The influence of the other attributes varied, depending on the patients’ pain control. Hospital managers may improve patient satisfaction by focusing on pain management nursing care.

Corrigendum

European Journal of PainVolume 17, Issue 3 p. 463-463 CorrigendumFree Access Corrigendum This article corrects the following: Psychological risk factors for chronic post-surgical pain after inguinal hernia repair surgery: A prospective cohort study R. Powell, M. Johnston, W.C. Smith, P.M. King, W.A. Chambers, Z. Krukowski, L. McKee, J. Bruce, Volume 16Issue 4European Journal of Pain pages: 600-610 First Published online: March 6, 2012 First published: 06 February 2013 https://doi.org/10.1002/j.1532-2149.2012.00279.xAboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat doi: 10.1016/j.ejpain.2011.08.010 The authors have identified two errors in this published paper. The sample size at Time 2 (T2, 1 week after surgery) was misreported. 120 questionnaires were returned, not 119. The response rate at Time 2 was therefore 88.8%. An error was made in calculating the scales Expected Pain Control (T1) and Post-operative Pain Control (T2). All analyses were re-worked using the correct scores and the corrected Abstract, Results and Discussion sections (Text S1), corrected Tables 1–3 (Tables S1–3), and corrected Appendices (Appendix S1–2) can be found as Supporting Information in the online version of this corrigendum. The summary of findings is presented in Table 1 below. Table 1. Summary of cognitive and emotional predictors of pain outcomes Analysis Reported predictors Corrected predictors T1 risk factors for T3 Pain Presence Optimism (OR = 0.69, 95% CI = 0.52 to 0.92, p = 0.01) Optimism (OR = 0.69, 95% CI = 0.52 to 0.92, p = 0.01) T2 risk factors for T3 Pain Presence None Post-operative Pain Control (OR = 0.82, 95% CI = 0.70 to 0.96, p = 0.02) T1 predictors of T3 Worst Pain Intensity Optimism (β = −0.28, p = 0.02). Expected Pain Control (β = −0.24, p = 0.045). T2 predictors of T3 Worst Pain Intensity CSQ Perceived Pain Control (β = −0.28, p = 0.01) Post-operative Pain Control (β = −0.24, p = 0.03) CSQ Perceived Pain Control (β = −0.33, p<0.01) Supporting Information Filename Description ejp279-sup-0001-si.zip128.5 KB Text S1. Corrected Abstract, Results, and Discussion. Appendix S1. Corrected Appendix 1. Appendix S2. Corrected Appendix 2. Table S1. Corrected Table 1. Table S2. Corrected Table 2a and 2b. Table S3. Corrected Table 3a and 3b. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article. Reference Powell, R., Johnston, M., Smith, W.C., King, P.M., Chambers, W.A., Krukowski, Z., McKee, L., Bruce, J. (2012). Psychological risk factors for chronic post-surgical pain after inguinal hernia repair surgery: A prospective cohort study. European Journal of Pain, 16: 600– 610. doi: 10.1016/j.ejpain.2011.08.010 Wiley Online LibraryCASPubMedWeb of Science®Google Scholar Volume17, Issue3March 2013Pages 463-463 ReferencesRelatedInformation

Effects of perceived and exerted pain control on neural activity during pain relief in experimental heat hyperalgesia: A fMRI study

Perceived control over pain can attenuate pain perception by mechanisms of endogenous pain control and emotional reappraisal irrespective of whether this control is exerted or only perceived. Self-initiated termination of pain elicits different expectations of subsequent pain relief as compared to perceived pain control. It is unknown whether and how this perceived vs. exerted control on pain differs and affects subsequent pain relief. Using fMRI, we studied two factors of pain control on pain relief: the (i) sense of control (perceived control but no execution) and (ii) the execution of control (exerted control). To account for the impact of factual execution of pain control on pain relief we applied bearable short and hardly bearable long contact-heat stimuli which were applied either controllable or not. Using controllability as factor, there was dissociable neural activity during pain relief: following the perceived control condition neural activity was found in the orbitofrontal and mediofrontal cortex and, following the exerted control condition, in the anterolateral and dorsolateral prefrontal cortex and posterior parietal cortex. We conclude that (i) pain controllability has an impact on pain relief and (ii) the prefrontal cortex shows dissociable neural activity during pain relief following exerted vs. perceived pain control. This might reflect the higher grade of uncertainty during pain relief following perceived pain control mediated by the orbitofrontal and medial prefrontal cortex and processes of working memory and updating expectations during pain relief following exerted control mediated by the lateral prefrontal cortex.

Psychological risk factors for chronic post‐surgical pain after inguinal hernia repair surgery: A prospective cohort study

A significant proportion of patients experience chronic post-surgical pain (CPSP) following inguinal hernia surgery. Psychological models are useful in predicting acute pain after surgery, and in predicting the transition from acute to chronic pain in non-surgical contexts. This is a prospective cohort study to investigate psychological (cognitive and emotional) risk factors for CPSP after inguinal hernia surgery. Participants were asked to complete questionnaires before surgery and 1 week and 4 months after surgery. Data collected before surgery and 1 week after surgery were used to predict pain at 4 months. Psychological risk factors assessed included anxiety, depression, fear-avoidance, activity avoidance, catastrophizing, worry about the operation, activity expectations, perceived pain control and optimism. The study included 135 participants; follow-up questionnaires were returned by 119 (88.1%) and 115 (85.2%) participants at 1 week and 4 months after surgery respectively. The incidence of CPSP (pain at 4 months) was 39.5%. After controlling for age, body mass index and surgical variables (e.g. anaesthetic, type of surgery and mesh type used), lower pre-operative optimism was an independent risk factor for CPSP at 4 months; lower pre-operative optimism and lower perceived control over pain at 1 week after surgery predicted higher pain intensity at 4 months. No emotional variables were independently predictive of CPSP. Further research should target these cognitive variables in pre-operative psychological preparation for surgery.

Predictors of Pain Outcomes in Patients with Chronic Musculoskeletal Pain Co-morbid with Depression: Results from a Randomized Controlled Trial

The combination of chronic musculoskeletal pain and depression is associated with worse clinical outcomes than either condition alone. In this study, we report the predictors of pain intensity and activity interference in primary care patients with co-morbid pain and depression. This is a secondary data analysis of the 250 persons who participated in a randomized clinical trial designed to test the effectiveness of 12 weeks of optimized antidepressant therapy for both depression and pain. Using multivariate linear regression analysis, we assessed the predictive value of baseline self-efficacy, fear of movement, pain beliefs, and demographic and clinical factors on 3-month Graded Chronic Pain Scale pain intensity and activity interference outcomes. In the full model, significant sociodemographic predictors of less activity interference included being non-white (beta-5.8, P = 0.04) and being employed (beta-13.3, P < 0.0001). The latter was also predictive of less pain intensity (beta-5.6, P = 0.01). As expected, the optimized antidepressant treatment arm was associated with improved outcomes (pain intensity: beta-3.7, P = 0.0005 and activity interference: beta-6.4, P = 0.01). Whereas stronger perceived pain control (beta 3.6, P = 0.01) was associated with greater activity interference, higher degree of fear of movement (or fear avoidance) predicted greater pain intensity (beta 0.46, P = 0.04) and activity interference (beta 0.57, P = 0.05). Neither the location (low back vs hip/knee) nor duration of pain were predictive of pain intensity or interference outcomes. The findings are consistent with a bio-psychosocial model, implicating the need to consider the impact of sociodemographic variables and pain-related beliefs and cognition on pain-related outcomes for patients with co-morbid musculoskeletal pain and depression.

Predictors of Complementary and Alternative Medicine Use in Chronic Pain Patients

We used Andersen's behavioral model of healthcare utilization to assess the relationship between sociodemographic, physical and psychosocial factors, and Complementary and Alternative Medicine (CAM) use among chronic pain patients. Three practitioner-based alternative therapies were considered: acupuncture, biofeedback/relaxation training, and manipulation services. A retrospective analysis of self-reported clinical data with 5,750 black and white adults presenting for initial assessment between 1994 and 2000 at the University of Michigan Multidisciplinary Pain Center was performed. CAM therapies were used in high frequencies, with 34.7% users. Specifically 8.3% used acupuncture, 13.0% used biofeedback/relaxation, and 24.9% used manipulation techniques. Race and age were predisposing factors associated with CAM use. Blacks used less biofeedback/relaxation and manipulation services than whites. Aging was related to more acupuncture, but less biofeedback/relaxation use. Women marginally used more biofeedback/relaxation services than men, and education was positively associated with all three CAM use. Perceived pain control was a consistent enabling factor positively correlated with the use of all three CAM services. Among need factors, pain characteristics and physical health were positively associated with at least one of the modalities. Depressive symptoms were not related to CAM services use. This study identifies variable patterns of CAM usage based on sociodemographic and health factors in chronic pain patients. Overall, who uses CAM depends on the modality; however, education, pain severity, and pain duration are persistent correlates of CAM usage regardless of the therapy considered. We found that mental health, as measured by depressive symptoms, had no noticeable impact on CAM usage among chronic pain patients. The clinical, policy, and research implications of CAM use are discussed.

Predictors of outcome in a cohort of women with chronic pelvic pain – A follow-up study

Background Chronic pelvic pain (CPP) in women is a long-lasting condition. Aims To explore changes in pain intensity, adjustment to pain, pain appraisal and coping strategies as well as to evaluate whether baseline pain appraisals and coping strategies and their changes were associated with outcome in the long term. Methods A follow-up study was conducted on all consecutive women who had visited a CPP-team of a university hospital. After an average period of 3.2 years 64% of them ( N = 84) completed questionnaires at baseline and follow-up. Results A reduction in pain intensity ( p < .001, d = .6), improvement in adjustment to pain (SF-36 Physical Component Summary ( p < .001, d = .4) and depressive symptoms ( p < .01, d = .2)), as well as a reduction in catastrophizing pain ( p < .01, d = .4) and an increase in perceived pain control ( p < .01, d = .3) were observed. Neither biographic nor clinical variables were related with these changes. Pain appraisal and coping strategies at baseline did not predict changes from baseline in pain intensity. However, baseline levels of perceived pain control correlated with a change in depressive symptoms ( r = −.27, p < .05), also after adjustment for pain intensity at baseline ( r = −.28, p < .05). Changes from baseline in levels of catastrophizing pain were associated with changes in pain intensity ( r = .44, p < .01), SF-36 Physical Component Summary ( r = −.34, p < .01) and depressive symptoms ( r = .71, p < .01). Conclusion At a 3 year follow-up, improvement in pain intensity in women with CPP was not associated with baseline pain appraisals and coping strategies. A reduction in catastrophizing was related to better outcome in the long term.

Mediators, moderators, and predictors of therapeutic change in cognitive–behavioral therapy for chronic pain

Although cognitive–behavioral therapies (CBT) have been demonstrated to be effective for a variety of chronic pain problems, patients vary in their response and little is known about patient characteristics that predict or moderate treatment effects. Furthermore, although cognitive–behavioral theory posits that changes in patient beliefs and coping mediate the effects of CBT on patient outcomes, little research has systematically tested this. Therefore, we examined mediators, moderators, and predictors of treatment effects in a randomized controlled trial of CBT for chronic temporomandibular disorder (TMD) pain. Pre- to post-treatment changes in pain beliefs (control over pain, disability, and pain signals harm), catastrophizing, and self-efficacy for managing pain mediated the effects of CBT on pain, activity interference, and jaw use limitations at one year. In individual mediator analyses, change in perceived pain control was the mediator that explained the greatest proportion of the total treatment effect on each outcome. Analyzing the mediators as a group, self-efficacy had unique mediating effects beyond those of control and the other mediators. Patients who reported more pain sites, depressive symptoms, non-specific physical problems, rumination, catastrophizing, and stress before treatment had higher activity interference at one year. The effects of CBT generally did not vary according to patient baseline characteristics, suggesting that all patients potentially may be helped by this therapy. The results provide further support for cognitive–behavioral models of chronic pain and point to the potential benefits of interventions to modify specific pain-related beliefs in CBT and in other health care encounters.

Patient Perception of a Clinical Pathway for Laparoscopic Foregut Surgery

Clinical pathways have been implemented for a number of surgical procedures, yet few data are available that explore the patients' perception of these changes in clinical practice. A clinical pathway was developed for laparoscopic fundoplication, Heller myotomy, and paraesophageal hernia repair. Data collected from a cohort of patients undergoing surgery with the pathway over a 12-month period was compared with a group of patients operated on in the 12 months prior to pathway implementation. A questionnaire examining patient-based outcomes and perceptions was completed 6 weeks after surgery. From November 2001 through November 2003, 49 patients underwent primary laparoscopic foregut surgery, 27 before and 22 after pathway implementation. There were no differences in age, gender, procedure, or ASA Class. Parenteral opioid use diminished significantly without compromising the patients' perceived pain control. The number of patients undergoing postoperative investigations diminished, as did length of stay. Of the 20 post-pathway patients completing satisfaction questionnaires, 95% were satisfied or very satisfied with their care during admission. Pathway implementation resulted in a significant reduction in direct postoperative hospital costs. A clinical pathway for laparoscopic foregut surgery was successfully implemented in a single-payer system, resulting in decreased utilization of hospital resources while maintaining high patient satisfaction.

Pain Education for Underserved Minority Cancer Patients: A Randomized Controlled Trial

Previous studies found that African American and Hispanic cancer patients are at risk for undertreatment of pain. We evaluated the efficacy of a pain education intervention for underserved minority patients. Ninety-seven underserved African American and Hispanic outpatients with cancer-related pain were enrolled onto a randomized clinical trial of pain management education. The patients in the education group received a culture-specific video and booklet on pain management. The control group received a video and booklet on nutrition. A research nurse met with each patient to review the materials. We measured changes in pain intensity and pain-related interference 2 to 10 weeks after the intervention, as well as changes in quality of life, perceived pain control, functional status, analgesics, and physician pain assessments. Physicians underestimated baseline pain intensity and provided inadequate analgesics for more than 50% of the sample. Although the ratings for pain intensity and pain interference decreased over time for both groups, there was no statistically significant difference between groups. Pain education did not affect quality of life, perceived pain control, or functional status. African American patients in the education but not the control group reported a significant decrease in pain worst ratings from baseline to first follow-up (P < .01), although this decrease was not maintained at subsequent assessments. Brief education had limited impact on pain outcomes for underserved minority patients, suggesting that more intensive education for patients and interventions for physicians are needed.