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Objectives Many people living with musculoskeletal pain conditions experience a range of negative biopsychosocial responses to physical activity, referred to as increased sensitivity to physical activity (SPA), that may undermine successful rehabilitation. This exploratory study aims to provide the first prospective analysis of the potential prognostic value of 3 biopsychosocial indices of SPA in relation to rehabilitation outcomes. This study also aimed to shed light on the cross-sectional interrelationships between these 3 biopsychosocial indices of SPA. Materials and methods Adults with back pain were evaluated upon starting physical therapy and then again 3 months later. The initial testing session consisted of self-reported pain-related questionnaires and assessment of activity-related changes in pressure pain thresholds (SPA-Sensory), pain intensity ratings (SPA-Pain), and situational catastrophizing (SPA-Psych). The 3-month follow-up consisted of self-reported disability and pain questionnaires. Correlational and hierarchical linear regression analyses were conducted. Results A total of 97 participants completed both the initial visit and 3-month follow-up. The SPA-Pain index and the SPA-Psych index were significantly intercorrelated, but neither were correlated with the SPA-Sensory index. The SPA-Sensory index was not correlated with outcomes. The SPA-Pain index was correlated only with cross-sectional disability and pain outcomes. The SPA-Psych index was the only SPA index significantly correlated with outcomes both cross-sectionally and at 3-month follow-up. After controlling for baseline pain/disability and pain catastrophizing, SPA-Psych was no longer a significant prognostic factor for pain, but remained a significant prognostic factor for disability at 3-month follow-up (β=0.272, t=2.674, P=0.008, R2 Δ=5.60%). Discussion This study highlights the importance of conceptualizing and measuring SPA as a biopsychosocial (rather than unidimensional) construct and points toward the added prognostic value of this construct. Implications for future research and practice are discussed.

OBJECTIVES Pain catastrophizing has been shown to be correlated with measures of mental health problems such as depression and post-traumatic stress disorder (PTSD). However, the clinical implications of findings reported to date remain unclear. To date, no study has been conducted to determine meaningful cut-scores on measures of catastrophizing indicative of the heightened risk of mental health comorbidity. One objective of the present study was to identify the cut-score on the Pain Catastrophizing Scale (PCS) indicative of the heightened risk of the comorbidity of depression and PTSD. A second objective was to determine whether mental health comorbidity mediated the relationship between catastrophizing and occupational disability. MATERIALS AND METHODS The sample consisted of 143 individuals with whiplash injuries. Pain severity, pain catastrophizing, depression, and post-traumatic stress symptoms were assessed after admission to a rehabilitation program. Mental health comorbidity was operationally defined as obtaining a score above the clinical threshold on measures of depressive and/or post-traumatic stress symptom severity. RESULTS A receiver operating characteristic curve analysis revealed that a PCS score of 22 best distinguished between participants with and without mental health comorbidity. Results also revealed that mental health comorbidity mediated the relationship between catastrophizing and occupational disability. DISCUSSION The findings suggest that a score of ≥22 on the PCS should alert clinicians to the possibility that patients might also be experiencing clinically significant symptoms of depression or PTSD. Greater attention to the detection and treatment of mental health conditions associated with whiplash injury might contribute to more positive recovery outcomes.

Introduction: Perceptions of injustice have been associated with problematic recovery outcomes in individuals with a wide range of debilitating pain conditions. It has been suggested that, in patients with chronic pain, perceptions of injustice might arise in response to experiences characterized by illness-related pain severity, depressive symptoms, and disability. If symptoms severity and disability are important contributors to perceived injustice (PI), it follows that interventions that yield reductions in symptom severity and disability should also contribute to reductions in perceptions of injustice. The present study examined the relative contributions of postsurgical reductions in pain severity, depressive symptoms, and disability to the prediction of reductions in perceptions of injustice. Methods: The study sample consisted of 110 individuals (69 women and 41 men) with osteoarthritis of the knee scheduled for total knee arthroplasty (TKA). Patients completed measures of perceived injustice, depressive symptoms, pain, and disability at their presurgical evaluation, and at 1-year follow-up. Results: The results revealed that reductions in depressive symptoms and disability, but not pain severity, were correlated with reductions in perceived injustice. Regression analyses revealed that reductions in disability and reductions in depressive symptoms contributed modest but significant unique variance to the prediction of postsurgical reductions in perceived injustice. Discussion: The present findings are consistent with current conceptualizations of injustice appraisals that propose a central role for symptom severity and disability as determinants of perceptions of injustice in patients with persistent pain. The results suggest that the inclusion of psychosocial interventions that target depressive symptoms and perceived injustice might augment the impact of rehabilitation programs made available for individuals recovering from TKA.

OBJECTIVES: Increasing pain during physical activity is an important, but often poorly assessed, barrier to engaging in activity-based rehabilitation among people with chronic musculoskeletal pain. Preliminary work has addressed this problem by developing new clinical measures of sensitivity to physical activity (SPA). Indices of SPA are generated by evaluating how pain changes in relation to brief physical tasks. Three strategies have been identified for structuring SPA-related physical tasks (self-paced, standardized, and tailored). This cross-sectional study aimed to comparatively estimate the extent of the 3 SPA tasks' evoked pain responses, predictive value of pain severity and pain interference, and their underlying psychological and sensory constructs, among 116 adults with chronic musculoskeletal pain.MATERIALS AND METHODS: Testing included questionnaires, quantitative sensory testing, and the 3 SPA measures (self-paced, standardized, and tailored). The primary analysis estimated the predictive value of each SPA measure for pain severity and pain interference. Correlational analyses were first conducted between all variables of interest to determine what variables will be included in the hierarchical regression analysis, which in turn was conducted for each outcome.RESULTS: Analyses revealed that the tailored SPA index was most effective at evoking activity-related pain, was uniquely associated with temporal summation of pain, and was a unique predictor of pain and pain-related interference, even when controlling for established psychological and sensory risk factors.DISCUSSION: This study further emphasizes SPA as an important and unique attribute of the pain experience and reveals the added value of using a tailored approach to assess SPA.

Investigations have shown that expectancies are significant prognostic indicators of recovery outcomes following whiplash injury. However, little is currently known about the determinants of recovery expectancies following whiplash injury. The purpose of the present study was to examine the cross-sectional and prospective correlates of recovery expectancies in individuals admitted to a rehabilitation program for whiplash injury.Participants (N=96) completed measures of recovery expectancies, psychosocial variables, symptom severity, symptom duration, and disability at time 0 (admission) and time 1 (discharge).Consistent with previous research, more positive recovery expectancies at time 0 were related to reductions in pain at time 1 (r=-0.33, P0.01). Scores on measures of pain catastrophizing, fear of movement and reinjury, and depression were significantly correlated with recovery expectancies. Pain severity, duration of work disability, and neck range of motion were not significantly correlated with recovery expectancies. Over the course of treatment, 40% of the sample showed moderate to large changes (an increase of ≥20%) in recovery expectancies, there were small changes (20%) in 30% of the sample, and negative changes in 20% of the sample. A hierarchical regression showed that decreases in fear of movement and reinjury (β=-0.25, P0.05) and pain catastrophizing (β=-0.23, P0.05) were associated with increases in recovery expectancies through the course of treatment.The discussion addresses the processes linking pain-related psychosocial factors to recovery expectancies and makes recommendations for interventions that might be effective in increasing recovery expectancies.

Objectives: Pain catastrophizing has emerged as a significant risk factor for problematic recovery after musculoskeletal injury. As such, there has been an increased focus on interventions that target patients’ levels of catastrophizing. However, it is not presently clear how clinicians might best interpret scores on catastrophizing before and after treatment. Thus, the purpose of this study was to provide preliminary guidelines for the clinical interpretation of scores on pain catastrophizing among individuals with subacute pain after musculoskeletal injury. Methods: A sample of 166 occupationally disabled individuals with subacute pain due to a whiplash injury participated in this study. Participants completed a 7-week standardized multidisciplinary rehabilitation program aimed at fostering functional recovery. Participants completed the Pain Catastrophizing Scale (PCS) upon program commencement and completion. One year later, participants indicated their pain severity and involvement in employment activities. Separate receiver operating characteristic curve analyses were conducted to determine absolute pretreatment and posttreatment and percent change scores on the PCS that were best associated with clinically important levels of pain and employment status at the follow-up. Results: An absolute pretreatment PCS score of 24 best identified patients according to follow-up clinical outcomes. Posttreatment PCS scores of 14 and 15 best identified patients with high follow-up pain intensity ratings and those who did not return to work, respectively. PCS reductions of approximately 38% to 44% were best associated with return to work and low pain intensity ratings at follow-up. Discussion: The results indicate scores on catastrophizing before and after treatment that are clinically meaningful. These results may serve as preliminary guidelines to assess the clinical significance of interventions targeting pain catastrophizing in patients with subacute pain after musculoskeletal injury.

OBJECTIVES: This study examined the effect of pain interference and attentional interference on the anticipatory postural adjustments of trunk muscles in patients with nonspecific chronic low back pain. METHODS: Fifty-nine patients performed rapid flexion movements of the right arm under 6 conditions, namely a control condition and conditions with different attention demands. The latency between the activations of the shoulder and different trunk muscles, as measured with surface electromyography, was used as the outcome. Using repeated measures analysis of variance, attention conditions and group comparisons were tested between those who scored high and low on pain intensity, fear of movement, or pain catastrophizing. RESULTS: There were significant (although minimal) interactive effects but significant and potentially clinically relevant group and attention main effects. The group with the lowest scores showed delayed activity (14 to 29 ms) relative to those with higher scores. One attention-demanding condition delayed (20 to 35 ms) the latencies of some trunk muscles relative to the control condition, namely the one that was the most attention-demanding according to the reaction time results. DISCUSSION: These findings suggest that patients with chronic low back pain, who are characterized by higher scores on some pain-related variables (visual analog scale, Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale), react favorably to protect the spine from further pain and injuries but would be at greater risk of injury when performing a complex physical task requiring more attention demand.

Objective This study aims to investigate correlates of pain-related empathic accuracy in spouses of chronic pain patients. Specifically, analyses addressed: (1) the correlates of pain-related empathic accuracy, (2) the relation between pain-related empathic accuracy, and patient and spouse adaptational outcomes, and (3) the relation between pain-related empathic accuracy and relational outcomes. Methods Fifty-eight chronic pain patients (28 women and 30 men) were filmed while participating in a simulated occupational lifting task. Patients were asked to report their level of pain while lifting canisters partially filled with sand. Spouses were later asked to view the video record of their partner's performance and to estimate their partner's level of pain. Empathic accuracy was defined in terms of the overall discrepancy between patients' pain ratings and spouses' pain estimates, and by the degree of covariation between patients' pain ratings and spouses' pain estimates across trials. Results Analysis revealed that patients' pain severity, catastrophizing, fear of pain, and level of disability were significant correlates of empathic accuracy. Higher levels of pain-related empathic accuracy were associated to negative adaptational outcomes for chronic pain patients. With regard to the spouse, empathic accuracy was associated with the spouses' perceiving that they express less punitive responses when the patient is in pain. Empathic accuracy was not significantly related to relational outcomes. Discussion The results of this study suggest that empathic accuracy is associated with negative outcomes for the patient, and might not be an important correlate of marital satisfaction in couples in which one of the partners is suffering from chronic pain.

Objective: This research was designed to test the hypothesis that presurgery “catastrophizing” would predict postsurgical pain and postsurgical analgesic consumption. Methods: A sample of 48 individuals who underwent anterior cruciate ligament repair participated in the study. All participants completed the Pain Catastrophizing Scale (described by Sullivan et al in 1995) prior to surgery. Measures of pain (pain scores on a scale of 0–10) were obtained in the postanesthetic care unit, as well as 1, 2, and 7 days after surgery. Opioid and nonopioid analgesic consumption was tabulated while patients were in the hospital and after discharge. Results: Results showed that the Pain Catastrophizing Scale was a significant predictor of acute postsurgical pain in the postanesthetic care unit (r = 0.48, P = 0.004 for maximum pain in the postanesthetic care unit). Maximum pain ratings in patients with high Pain Catastrophizing Scale scores (> median of 13) were 33% to 74% higher numerically than in patients with low Pain Catastrophizing Scale scores ( median), and the duration of moderate-severe pain (>3/10) was more prolonged (45 minutes versus 28 minutes in patients with high and low Pain Catastrophizing Scale scores, respectively; P < 0.05). The Pain Catastrophizing Scale was also predictive of pain with activity at 24 hours (r = 0.65 for pain on walking, P 0.0001). The Pain Catastrophizing Scale did not predict postoperative analgesic use. Conclusion: The pattern of findings suggests that high catastrophizing scores may be a risk factor for heightened pain following surgery. Clinical and theoretical implications of the findings are addressed.

Objectives The present study examined the relation of pain catastrophizing to the severity of upper respiratory tract illness. Materials and methods Participants included 50 adults (35 female subjects, 15 male) who were self-diagnosed with upper respiratory tract illness and who agreed to complete a diary of symptoms for 7 days. Illness symptoms were grouped into three categories: pain-related, constitutional, and respiratory symptoms. Results Results showed that pain catastrophizing was associated with symptom number and symptom severity in all three categories of symptoms. The rumination subscale of the Pain Catastrophizing Scale showed the strongest relations with illness severity. The relation between pain catastrophizing and illness severity remained significant even when controlling for initial symptom severity, duration of the symptoms before the study period, and depression. Discussion The results provide the preliminary evidence that the influence of pain catastrophizing may not be restricted to pain-specific domains. The data also provide some support for the view that the excessive focus on bodily sensations may account for more severe symptoms.

OBJECTIVE:: Depressive symptoms complicate patients' recovery following musculoskeletal injury. There is strong evidence to support the utility of multidisciplinary approaches for treating comorbid pain and depressive symptoms. Despite this, a significant proportion of patients may not experience meaningful reductions in depressive symptoms following intervention. The purpose of this study was to identify barriers to change in depressive symptom during multidisciplinary rehabilitation for patients with whiplash injuries. METHODS:: 53 patients with clinically meaningful levels of depressive symptoms prior to participating in a standardized multidisciplinary rehabilitation program participated in this study. Patients completed self-report measures of depressive symptoms, demographic factors, pain intensity, disability, post-traumatic stress symptoms, pain catastrophizing and self-efficacy upon commencement and completion of the rehabilitation program. Analyses examined whether pre-treatment variables predicted change in depressive symptoms over treatment and the maintenance of clinically meaningful levels of depressive symptoms at post-treatment. RESULTS:: Duration of work absence and perceived injustice were significant unique predictors of percent change in depressive symptoms in a linear regression analysis. Perceived injustice was the only significant unique predictor of the presence of clinically meaningful levels of depressive symptoms at post-treatment in a logistic regression analysis. CONCLUSIONS:: The results suggest that the identification of patients with high levels of perceived injustice and implementation of targeted interventions for these patients might contribute to greater improvements in their depressive symptomatology. Language: en

Objectives: To evaluate the properties of the Pain Catastrophizing Scale (PCS) from a Rasch paradigm. Methods: A secondary analysis of 235 patients with work-related pain conditions was performed using the Rasch methodology. Unidimensionality, item fit, location independence, differential item functioning, response option structure, and linearity were evaluated for the 13-item PCS score. Results: Two items (8 and 12) required rescoring to address disordered response thresholds. Significant misfit to the Rasch model was corrected through the use of testlets based on the original 3 factors of the PCS (rumination, magnification, and helplessness). After rescoring and creation of testlets, the scale showed good fit to the Rasch model (χ2=6.93, P=0.91) and could be logically considered an interval-level scale. No evidence of differential item functioning was found for sex or location of pain. The items in the scale covered the spectrum of catastrophizing levels reported by the sample. A transformation matrix is presented that allows simple conversion of ordinal to interval-level scores. Discussion: The results of this secondary analysis suggest that the PCS can be appropriately evaluated as an interval-level scale when the composite 13-item score is considered, as has been standard practice to date. Implications for clinical and research use are discussed.

Background: Emerging research suggests that perceptions of injustice after musculoskeletal injury can have a significant impact on a number of pain-related outcomes. Aims: The purpose of this paper is to review evidence linking perceptions of injustice to adverse pain outcomes. For the purposes of this paper, perceived injustice is defined as an appraisal cognition comprising elements of the severity of loss consequent to injury ("Most people don't understand how severe my condition is"), blame ("I am suffering because of someone else's negligence"), a sense of unfairness ("It all seems so unfair"), and irreparability of loss ("My life will never be the same"). Results: Cross-sectional studies show that high scores on perceptions of injustice are correlated with pain catastrophizing, fear of movement, and depression. Prospective studies show that high scores on perceived injustice are a prognostic indicator of poor rehabilitation outcomes and prolonged work disability. Research shows that perceptions of injustice interfere not only with physical recovery after injury, but perceptions of injustice also impact negatively on recovery of the mental health problems that might arise subsequent to traumatic injury. Although research has yet to address the process by which perceptions of injustice impact on pain-related outcomes systematically; possible mechanisms include attentional disengagement difficulties, emotional distress, maladaptive coping, heightened displays of pain behavior, anger, and revenge motives. Conclusions: Perceived injustice appears to be associated with problematic health and mental health recovery trajectories after the onset of a pain condition. Future directions for research and treatment are addressed.

Objectives: Nearly 400 years ago, Rene Descartes proposed a model of pain perception that characterized pain as a purely physical phenomenon, devoid of psychologic influence. The characterization of pain as an exclusively sensory (or experiential) phenomenon continues to dominate current conceptualizations of pain. Methods: This paper advances the view that the exclusive focus on pain sensation or experience as the essential feature of the pain system has given rise to conceptual frameworks that are incomplete and flawed. It is argued that individuals with pain differ from individuals without pain not only in how they "feel" but they differ in how they "behave." Results: Arguments are put forward advocating for a biopsychomotor conceptualization of pain where pain behaviors are construed as integral components of the pain system. The biopsychomotor model proposes that at least 3 partially independent behavioral subsystems are integral components of pain. These include communicative pain behaviors, protective pain behaviors, and social response behaviors. Evidence is reviewed suggesting that different dimensions of pain behavior are functionally distinct, and questions are raised about the nature of motor programs responsible for the elicitation and maintenance of different forms of pain behavior. Discussion: Clinical and theoretical implications of a biopsychomotor conceptualization of pain are discussed.

Objectives Two studies are described addressing how anxiety, fear of pain, and catastrophizing impact on pain experience. Methods In study 1, 66 undergraduates (34 men, 32 women) completed measures of state and trait anxiety, fear of pain, and catastrophizing prior to participating in a cold pressor procedure. In study 2, 60 undergraduates (30 men, 30 women) completed the same measures and participated in dental hygiene treatment and rated the pain they experienced during a scaling procedure (removing deposits from the tooth surface). Results In both studies, fear of pain and catastrophizing were significantly correlated with pain intensity ratings, and fear of pain and catastrophizing were correlated with each other. Trait anxiety was correlated with catastrophizing but not with fear of pain or pain. Path analyses revealed significant paths from trait anxiety to state anxiety, from trait anxiety to catastrophizing, and from catastrophizing to pain intensity ratings. Discussion The findings suggest that although fear of pain and catastrophizing are related constructs, catastrophizing provides unique predictive ability for pain ratings, while fear of pain does not. Clinical and theoretical implications of these findings are discussed.

Objectives To describe the development, implementation, and preliminary outcome of the Pain-Disability Prevention (PDP) Program. The PDP Program is a 10-week cognitive-behavioral intervention program that aims to increase daily involvement in goal-directed activity and minimize psychological barriers to activity involvement after occupational injury. Workers' Compensation Board claimants with soft tissue injuries to the back, who were still off work 6 weeks after injury and showed evidence of at least one "yellow flag," were offered participation in the PDP Program. Design A single-group, prospective treatment outcome analysis. Participants Data from the first 104 claimants who participated in the PDP Program are summarized. Results Participation in the PDP Program was associated with a 60% success rate, where success was defined as return to work (45%) or readiness to return to work (15%). Initial scores on measures of catastrophizing, fear of movement/reinjury, and depression afforded 92% correct classification of treatment outcome. Early treatment changes in catastrophizing and fear of movement/reinjury were also predictive of treatment outcome. Conclusions The findings suggest that a psychologically based activity mobilization program can be an effective means of yielding reductions in psychological risk factors for occupational disability. Challenges to program implementation, fidelity to protocol, and issues related to cost efficacy are discussed.

The tendency to "catastrophize" during painful stimulation contributes to more intense pain experience and increased emotional distress. Catastrophizing has been broadly conceived as an exaggerated negative "mental set" brought to bear during painful experiences. Although findings have been consistent in showing a relation between catastrophizing and pain, research in this area has proceeded in the relative absence of a guiding theoretical framework. This article reviews the literature on the relation between catastrophizing and pain and examines the relative strengths and limitations of different theoretical models that could be advanced to account for the pattern of available findings. The article evaluates the explanatory power of a schema activation model, an appraisal model, an attention model, and a communal coping model of pain perception. It is suggested that catastrophizing might best be viewed from the perspective of hierarchical levels of analysis, where social factors and social goals may play a role in the development and maintenance of catastrophizing, whereas appraisal-related processes may point to the mechanisms that link catastrophizing to pain experience. Directions for future research are suggested.