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Study Design: Prospective cohort study., Objective: To examine the relationship between improvement in pain intensity and subsequent improvement in physical function and disability during the first 12 months after lumbar spine surgery., Summary of Background Data: Little is known about how reduction of pain intensity after surgery may predict improvements in physical function and disability., Methods: We prospectively enrolled 260 individuals undergoing elective surgery for degenerative lumbar spine conditions from August 2005 through August 2011. Preoperative and postoperative (3, 6, and 12 mo) assessment tools were numeric pain rating scale, Short Form 12 version 2 physical component score (physical function), and Oswestry Disability Index (disability). Changes were defined using minimum clinically important differences. The association between improvement in pain intensity and subsequent improvement in physical function and disability during the first 12 postoperative months was assessed using standard regression methods. Significance was set at a P value less than 0.05., Results: Preoperatively, mean pain intensity was 5.2 (standard deviation, 2.4), physical function was 27.9 (standard deviation, 9.2), and disability was 40.1% (standard deviation, 16.8%). Pain intensity had improved in 164 (63.1%) patients by 3 and 6 months and in 184 (70.8%) by 12 months. Patients with improvement in pain postoperatively were more likely to have subsequent improvement in physical function (odds ratio, 2.11; 95% confidence interval, 1.10-3.16) during the course of 12 postoperative months. The association between postoperative pain reduction and reduced disability was similar (odds ratio, 1.61; confidence interval, 1.12-2.33)., Conclusion: Most patients experienced clinically important postsurgical reductions in pain intensity by 3 months after surgery. Those patients were more likely to have clinically important improvement in physical function and reduction in disability during the first postoperative year., Level of Evidence: 1.

Previous studies have shown that pain, depression, and anxiety are common after trauma. A longitudinal relationship between depression, anxiety, and chronic pain has been hypothesized. Severe lower extremity trauma patients (n = 545) were followed at 3, 6, 12, and 24 months after injury using a visual analog "present pain intensity" scale and the depression and anxiety scales of the Brief Symptom Inventory. Structural model results are presented as Standardized Regression Weights (SRW). Multiple imputation was used to account for missing data. A single structural model including all longitudinal pain intensity, anxiety symptoms, and depression symptoms time-points yielded excellent fit measures. Pain weakly predicted depression (3-6 months SRW = 0.07, P = .05; 6-12 months SRW = 0.06, P = .10) and anxiety (3-6 months SRW = 0.05, P = .21; 6-12 months SRW = 0.08, P = .03) during the first year after injury, and did not predict either construct beyond 1 year. Depression did not predict pain over any time period. In contrast, anxiety predicted pain over all time periods (3-6 months SRW = 0.11, P = .012; 6-12 months SRW = 0.14, P = .0065; 12-24 months SRW = 0.18, P < .0001). The results suggest that in the early phase after trauma, pain predicts anxiety and depression, but the magnitude of these relationships are smaller than the longitudinal relationship from anxiety to pain over this period. In the late (or chronic) phase after injury, the longitudinal relationship from anxiety on pain nearly doubles and is the only significant relationship. Despite missing data and a single item measure of pain intensity, these results provide evidence that negative mood, specifically anxiety, has an important role in the persistence of acute pain., (Copyright © 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Background: Unmanaged pain has been found to predict delayed return to work, psychologic distress, and chronic pain and disability in patients with traumatic injury. However, little is known about the pain experience during hospitalization. The primary objective of this study was to determine pain intensity, pain interference, and satisfaction with pain treatment in orthopedic trauma patients at hospital discharge. A secondary objective was to examine whether patient self-efficacy and psychologic distress were associated with pain and satisfaction., Methods: Two hundred thirty-three orthopedic trauma patients were enrolled and completed a discharge assessment at a Level I trauma center. Pain was measured with the Brief Pain Inventory and satisfaction with the American Pain Society Patient Outcome Questionnaire., Results: Ninety-seven percent of patients reported pain at the time of hospital discharge, with 59% and 73% reporting moderate to severe pain intensity and interference, respectively. Overall, 86% of patients were satisfied with pain treatment. Multivariable regression analyses demonstrated that decreased self-efficacy was associated with moderate to severe pain intensity, increased depression was associated with moderate to severe pain intensity and interference, and increased pain intensity was associated with decreased satisfaction (p < 0.05)., Conclusions: Results suggest that orthopedic trauma patients have a significant pain burden but are satisfied with pain treatment during the hospital stay. Efforts are needed to improve pain assessment and management and findings imply that addressing self-efficacy and depressive symptoms may decrease pain and increase satisfaction at hospital discharge. Brief educational interventions that incorporate pain coping skills and self-management techniques may be a feasible approach to improving self-efficacy in the acute care setting. Additional recommendations include routine hospital screening for depression and increased communication between surgeons and mental health providers to identify patients at high risk for unmanaged pain and facilitate provision of early mental health services.

As part of a larger longitudinal study, the current analyses characterize the relationship among pain, psychological distress, and physical function after major lower extremity trauma. Structural equation modeling techniques were utilized to analyze data from a prospective 2-year observational study of 327 patients treated at 8 level I trauma centers. Data were gathered at 3, 6, 12, and 24 months after injury. In the models tested, higher levels of depressive and anxious distress at the preceding time point was related to lower levels of functioning at 6, 12, and 24 months, and higher levels of pain at the preceding time point were related to lower levels of functioning at 6 and 12 months, but not at 24 months. A reverse model in which lower levels of functioning led to higher levels of psychological distress or pain was tested and did not fit the data. The combination of depressive and anxious distress plays an increasingly important role in mediating the impact of pain on physical function as the recovery from lower extremity trauma progresses from early to later stages. Both pain and psychological distress contribute to reduced function during the first year after a serious injury; however, as recovery proceeds, the role of psychological distress in determining function increases. Longitudinal data on patients with severe leg trauma demonstrates that as recovery proceeds, psychological distress plays an increasingly important role in mediating the impact of pain on function., (Copyright © 2011 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

The biopsychosocial model has been used to describe the intertwined factors that may act as mechanisms in cardiovascular disease, as well as those found in pain conditions. This model may also prove useful in understanding a diagnosis that overlaps these two areas, angina. This article reviews the literature related to biological, psychological, and social mechanisms of painful ischemic episodes and discusses the interactions of those variables. We propose an integrated model that incorporates the biopsychosocial mechanisms that may be responsible for the variability in pain reporting with ischemic episodes. We show how sex differences manifested in various biopsychosocial factors may interact to influence the presence of painful versus silent myocardial ischemia. We present a plan for future research to elucidate this interaction.

Although the etiology of chronic pain following trauma is not well understood, numerous retrospective studies have shown that a significant proportion of chronic pain patients have a history of traumatic injury. The present analysis examines the prevalence and early predictors of chronic pain in a cohort of prospectively followed severe lower extremity trauma patients. Chronic pain was measured using the Graded Chronic Pain Scale, which measures both pain severity and pain interference with activities. Severe lower extremity trauma patients report significantly higher levels of chronic pain than the general population (p<0.001). Their levels are comparable to primary care migraine headache and back pain populations. A number of early predictors of chronic pain were identified, including: having less than a high school education (p<0.01), having less than a college education (p<0.001), low self-efficacy for return to usual major activities (p<0.01), and high levels of average alcohol consumption at baseline (p<0.05). In addition, high reported pain intensity, high levels of sleep and rest dysfunction, and elevated levels of depression and anxiety at 3 months post-discharge were also strong predictors of chronic pain at seven years (p<0.001 for all three predictors). After adjusting for early pain intensity, patients treated with narcotic medication during the first 3 months post-discharge had lower levels of chronic pain at 84 months. It is possible that for patients within these high risk categories, early referral to pain management and/or psychologic intervention may reduce the likelihood or severity of chronic pain.

Objectives: To describe the prevalence of amputation-related pain; to ascertain the intensity and affective quality of phantom pain, residual limb pain, back pain, and nonamputated limb pain; and to identify the role that demographics, amputation-related factors, and depressed mood may contribute to the experience of pain in the amputee., Design: Cross-sectional survey., Setting: A sample of persons who contacted the Amputee Coalition of America from 1998 to 2000 were interviewed by telephone., Participants: A stratified sample by etiology of 914 persons with limb loss., Interventions: Not applicable., Main Outcome Measures: Prevalence, intensity, and bothersomeness of residual, phantom, and back pain, depressed mood as measured by the Center for Epidemiologic Study Depression Scale, characteristics of the amputation, prosthetic use, and sociodemographic characteristics of the amputee., Results: Nearly all (95%) amputees surveyed reported experiencing 1 or more types of amputation-related pain in the previous 4 weeks. Phantom pain was reported most often (79.9%), with 67.7% reporting residual limb pain and 62.3% back pain. A large proportion of persons with phantom pain and stump pain reported experiencing severe pain (rating 7-10). Across all pain types, a quarter of those with pain reported their pain to be extremely bothersome. Identifiable risk factors for intensity and bothersomeness of amputation-related pain varied greatly by pain site. However, across all pain types, depressive symptoms were found to be a significant predictor of level of pain intensity and bothersomeness., Conclusions: Chronic pain is highly prevalent among persons with limb loss, regardless of time since amputation. A common predictor of an increased level of intensity and bothersomeness among all pain sites was the presence of depressive symptoms. Further studies are needed to elucidate the relationship between pain and depressive symptoms among amputees.

Little evidence is available to guide physical therapy (PT) following lower extremity fracture repair distal to the hip. As such, variability has been reported in the way PT is utilized post-operatively. Examination of current practice by orthopedic surgeons (OS) and physical therapists is needed to inform clinical practice guidelines in this area. To describe current PT referral practices among OS, identify patient and clinical factors that affect PT referral, and examine differences between OS and physical therapists with regard to visit frequency, duration, and use of specific PT interventions. Provider surveys. Surveys were completed by 100 OS and 347 physical therapists. Over half (54%) of OS reported referring "most patients" to PT and identified joint stiffness and strength limitations as top reasons for PT referral. Over 80% of OS and physical therapists indicated that joint stiffness, strength limitations, and patients' functional goals affected their recommendations for PT visit frequency. More physical therapists than OS reported that pain severity (55% vs 25%, p <.001), maladaptive pain behaviors (64% vs. 33%, p <.001), and patient self-efficacy (70% vs. 49%, p =.003) affected their visit frequency recommendations. While OS recommended more frequent PT for patients with peri-articular fractures, fracture type had minimal impact on the visit frequencies recommended by physical therapists. OS and physical therapists consider similar physical impairments when determining the need for PT and visit frequencies, however, physical therapists consider pain and psychosocial factors more often, with OS focusing more on injury type. [ABSTRACT FROM AUTHOR]

Objective Disparities exist in health care access, diagnosis, and treatment of chronic pain in Latino populations and other minority populations. Cognitive behavioral–based physical therapy (CBPT) interventions have been shown to be effective in predominantly non-Hispanic white populations with chronic spine pain. However, there is a need for culturally adapted CBPT interventions that focus on the conservative management of chronic spine pain. The primary purpose of the study described in this protocol is to test the efficacy of an adapted cognitive behavioral–based hybrid telerehabilitation intervention for Latino patients with chronic spine pain. Methods A single-blind, 2-arm parallel group, superiority randomized clinical trial is planned to compare an adapted CBPT intervention to Usual Care physical therapy. Goal Oriented Activity for Latinos with chronic Spine pain (GOALS/Metas) is an 8-week hybrid telerehabilitation intervention that integrates guideline-based physical therapy and pain management interventions using cognitive behavioral approaches and has been adapted for Latino patients with chronic spine pain. Usual Care physical therapy will be administered based on institutional standards at the referring health center. Outcome measures will be evaluated preintervention and at 1-week, 3-months, and 6-months postintervention. The primary outcome is pain-related disability 1-week postintervention using the Brief Pain Inventory Pain Interference subscale. Secondary outcome measures include behavioral measures of functional activity, social participation, physical activity, and sleep. Determinants of treatment effect, including pain-related psychological measures, posture and movement, self-efficacy, treatment expectancy, and therapeutic alliance, will be included in the secondary moderation and mediation analyses. Impact This clinical trial will provide information on the extent to which an adapted CBPT hybrid telerehabilitation intervention is effective in reducing pain-related disability for Latino patients with chronic spine pain. This information will be useful for clinicians to integrate in their practice, given the growing population of Latino patients who experience disparities in health care management of chronic pain. [ABSTRACT FROM AUTHOR]

The article offers information on a study regarding the relation between fear of movement beliefs on pain and disability following a spinal surgery for degenerative conditions. The differences between preoperative and postoperative fear of movement were examined. The study found the relation of postoperative but not preoperative fear of movement beliefs with pain, disability and physical health. Postoperative screening for high fear of movement beliefs is recommended.

Background Context: Pain, pain-related disability, and functional limitations are common consequences of intervertebral disc herniation (IDH). We hypothesized that surgical treatment reduces pain, leading to improvement in pain-related disability and, ultimately, better physical health.Purpose: The present study aims to evaluate pathways for improvements in quality of life during the first year after surgery for IDH by studying temporal relationships between sciatica symptoms, pain-related disability, and physical health.Design: This is a secondary analysis of a randomized controlled trial using an "as treated" dataset.Patient Sample: The sample comprised 803 patients in the Spine Patient Outcomes Research Trial.Outcome Measures: We used the Sciatica Bothersome Index, Oswestry Disability Index, and the Medical Outcomes Study Short Form 36 physical component score.Methods: We included 803 patients in the Spine Patient Outcomes Research Trial who underwent elective decompressive surgery for IDH between 2000 and 2004. Sciatica, pain-related disability, and physical health were assessed preoperatively and at 3 and 12 months postoperatively using the Sciatica Bothersome Index, Oswestry Disability Index, and Medical Outcomes Study Short Form 36 physical component score, respectively. Temporal associations of improvement in sciatica with pain-related disability and physical health were assessed using cross-lagged path analysis. p<.05 was considered significant. No funding was received in support of the present study. The authors declare no conflicts of interest.Results: Preoperatively, mean scores were 16.2±5.2 for sciatica, 54.2±20.7 for pain-related disability, and 29.8±8.4 for physical health. After adjustment for patient age and symptom duration, cross-lagged path analysis showed that sciatica reduction at 3 months was correlated with pain-related disability reduction at 3 months (ρ=.76, p<.001), and pain-related disability at 3 months was predictive of physical health at 12 months (β=-.33, p<.001) and sciatica at 12 months (β=.22, p<.001).Conclusion: Three months after surgery, patients reported reduced sciatica and pain-related disability. Improvements in pain and pain-related disability occurred within 3 months. Early reduction in pain-related disability is important because path analysis indicated that disability at 3 months was predictive of sciatica and physical health at 1 year. [ABSTRACT FROM AUTHOR]

Background Context: Positive psychosocial factors early after surgery, such as resilience and self-efficacy, may be important characteristics for informing individualized postoperative care.Purpose: To examine the association of early postoperative resilience and self-efficacy on 12-month physical function, pain interference, social participation, disability, pain intensity, and physical activity after lumbar spine surgery.Study Design/setting: Pooled secondary analysis of prospectively collected trial data from two academic medical centers.Patient Sample: Two hundred and forty-eight patients who underwent laminectomy with or without fusion for a degenerative lumbar condition.Outcome Measures: Physical function, pain inference, and social participation (ability to participate in social roles and activities) were measured using the Patient Reported Outcomes Measurement Information System. The Oswestry Disability Index, Numeric Rating Scale, and accelerometer activity counts were used to measure disability, pain intensity, and physical activity, respectively.Methods: Participants completed validated outcome questionnaires at 6 weeks (baseline) and 12 months after surgery. Baseline positive psychosocial factors included resilience (Brief Resilience Scale) and self-efficacy (Pain Self-Efficacy Questionnaire). Multivariable linear regression analyses were used to assess the associations between early postoperative psychosocial factors and 12-month outcomes adjusting for age, sex, study site, randomized group, fusion status, fear of movement (Tampa Scale for Kinesiophobia), and outcome score at baseline. This study was funded by Patient-Centered Outcomes Research Institute and Foundation for Physical Therapy Research. There are no conflicts of interest.Results: Resilience at 6 weeks after surgery was associated with 12-month physical function (unstandardized beta=1.85 [95% confidence interval [CI]: 0.29; 3.40]), pain interference (unstandardized beta=-1.80 [95% CI: -3.48; -0.12]), social participation (unstandardized beta=2.69 [95% CI: 0.97; 4.41]), and disability (unstandardized beta=-3.03 [95% CI: -6.04; -0.02]). Self-efficacy was associated with 12-month disability (unstandardized beta=-0.21 [95% CI: -0.37; -0.04].Conclusions: Postoperative resilience and pain self-efficacy were associated with improved 12-month patient-reported outcomes after spine surgery. Future work should consider how early postoperative screening for positive psychosocial characteristics can enhance risk stratification and targeted rehabilitation management in patients undergoing spine surgery. [ABSTRACT FROM AUTHOR]

Purpose/Objective: Intensive care unit (ICU) survivors frequently experience long-lasting mental health, cognitive, and physiologic challenges. Psychologists have a role in providing interventions to reduce patient distress during critical illness and improve outcomes. There is limited data regarding psychology consultations in the ICU. This brief report characterizes psychology consultations in a medical intensive care unit (MICU) in an academic medical center. Method: Psychology consultations were prospectively tracked, with patient-related data retrospectively collected and analyzed. Results: A total of 79 consecutive psychology consultations occurred at mean of 8 ± 6 days after MICU admission. Reasons for consultation were patient emotional distress (56%), rehabilitation therapy engagement (24%), family engagement (13%), cognitive disturbance (4%), and pain (4%). Patient characteristics were: mean age 56 ± 15 years, 54% women, 53% White, and 34% with psychiatric comorbidity at MICU admission. Patients referred for consultation had a longer MICU length of stay than the total MICU population (12 ± 9 days vs. 4 ± 6 days, p < .01). For consultations for emotional distress compared with limited rehabilitation therapy engagement, patient demographic characteristics were similar, with the exception of women (vs. men) being more commonly consulted for emotional distress (64 vs. 26%, p = .01). Conclusions: Patients with a longer MICU stay more commonly had a rehabilitation psychology consultation request, typically to provide support for emotional distress or engagement in rehabilitation therapy. Future research should evaluate the effectiveness of psychology interventions in the ICU. [ABSTRACT FROM AUTHOR]

Abstract: Although depressive symptoms are common among those living with back pain, there is limited information on the relationship between postsurgical pain reduction and changes in depressive symptoms. The objective of this prospective cohort study was to examine the change in pain and depressive symptoms and to characterize the relationship between pain and depressive symptoms after lumbar spine surgery. We assessed 260 individuals undergoing lumbar spine surgery preoperatively and postoperatively (3 and 6months) using a pain intensity numeric rating scale and the Patient Health Questionnaire depression scale. The relationship between change in pain (a 2-point decrease or 30% reduction from the preoperative level) and depressive symptoms was examined using standard regression methods. Preoperatively, the mean pain intensity was 5.2 (SD 2.4) points, and the mean depressive symptom score was 5.03 (SD 2.44) points. At 3months, individuals who experienced a reduction in pain (63%) were no more likely to experience a reduction in depressive symptoms (odds ratio 1.07, 95% confidence interval [CI] .58 to 1.98) than individuals who experienced no change from preoperative pain (34%). However, at 6months, individuals who experienced a reduction in pain (63%) were nearly twice as likely to experience a reduction in depressive symptoms (odds ratio 1.93, 95% CI 1.15 to 3.25) as those who experienced no change or an increase in pain (31%). We found that most individuals experienced clinically important reductions in pain after surgery. We concluded that those whose pain level was reduced at 6months were more likely to experience a reduction in depressive symptoms. [Copyright &y& Elsevier]