Ana-Maria Vranceanu

Psychosocial aspects of disabling musculoskeletal pain.

Psychosocial factors are important determinants of pain intensity and disability in patients with disabling musculoskeletal pain. The psychosocial aspects of disabling musculoskeletal pain include cognitive (e.g., beliefs, expectations, and coping style), affective (e.g., depression, pain anxiety, heightened concern about illness, and anger), behavioral (e.g., avoidance), social (e.g., secondary gain), and cultural factors. The effectiveness of cognitive behavioral therapy and other treatments that address the psychosocial aspects of disabling musculoskeletal pain has been confirmed in numerous high-quality studies.

Socioeconomic status, resources, psychological experiences, and emotional responses: a test of the reserve capacity model.

The current study used ecological momentary assessment to test several tenets of the reserve capacity model (L.C. Gallo & K. A. Matthews, 2003). Women (N = 108) with varying socioeconomic status (SES) monitored positive and negative psychosocial experiences and emotions across 2 days. Measures of intrapsychic and social resources were aggregated to represent the reserve capacity available to manage stress. Lower SES was associated with less perceived control and positive affect and more social strain. Control and strain contributed to the association between SES and positive affect. Lower SES elicited greater positive but not negative emotional reactivity to psychosocial experiences. Women with low SES had fewer resources relative to those with higher SES, and resources contributed to the association between SES and daily experiences.

Predictors of Pain Intensity and Disability After Minor Hand Surgery

PURPOSE To test the null hypothesis that there is no relationship between coping mechanisms and depression measured before surgery, and pain intensity and disability after surgery, as assessed at the time of suture removal. METHODS A total of 120 patients (39 electing surgery for carpal tunnel syndrome, 65 for trigger finger, and 16 for a benign tumor) completed questionnaires measuring depression, pain self-efficacy (confidence that one can perform various activities despite pain), pain anxiety (fear and anxiety in response to pain sensations), and pain catastrophizing (maladaptive cognitive activities such as pain-related rumination, magnification, and helplessness) before surgery. Before the surgery and at the time of suture removal (10 to 14 days after surgery) participants completed the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) and a numerical pain intensity rating scale. RESULTS At the time of suture removal, there was a significant correlation between pain intensity and depression (r = 0.45, p<.001), pain catastrophizing (r = 0.41, p<.001), pain anxiety (r = 0.32, p<.01), and self-efficacy (r = -0.29, p<.01). Disability correlated with self-efficacy (r = -0.34; p<.001) and depression (r = 0.49; p<.001), but not with pain anxiety and catastrophizing (p>.05). In multivariate analyses, depression was the sole predictor of both disability and pain intensity and accounted for 26% of the variance in DASH scores and 25% of the variance in pain intensity, after removing the influence of preoperative DASH and diagnosis, which accounted for 14% variance. CONCLUSIONS Psychosocial factors, especially depression, explain a notable proportion of the variation in pain intensity and disability after minor hand surgery. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic I.

The relationship of post-traumatic stress disorder and depression to antiretroviral medication adherence in persons with HIV.

In HIV/AIDS, symptoms of depression or post-traumatic stress may interfere with important self-care behaviors such as the ability to adhere to ones medical treatment regimen. However, these problems may frequently go undetected in HIV care settings. The present study used brief self-report screening measures of depression and post-traumatic stress disorder (PTSD) in the HIV/AIDS care settings to examine (1) frequency of positive screens for these diagnoses; (2) the degree to which those with a positive screen were prescribed antidepressant treatment; and (3) the association of continuous PTSD and depression symptom scores, and categorical (screening positive or negative) PTSD and depression screening status, to each other and to ART adherence as assessed by the Medication Event Monitoring System, regardless of antidepressant treatment. Participants were 164 HIV-infected individuals who took part in a multisite adherence intervention study in HIV treatment settings in Massachusetts. Available data from 5 time points was used, yielding 444 data points. Participants screened positive for PTSD at 20% of visits, and depression at 22% of visits. At visits when participants screened positive for both depression and PTSD, 53.6% of the time they were on an antidepressant. Those who screened positive for PTSD were more likely to also screen positive for depression. In multiple regression analyses that included both continuous and dichotomous PTSD and depression and controlled for shared variance due to clustering of multiple observations, only depression contributed significant unique variance, suggesting the primary role of depression and the secondary role of PTSD in poor adherence in individuals with HIV.

Psychological Factors Predict Disability and Pain Intensity After Skeletal Trauma

BACKGROUND The aims of this study were to (1) estimate the prevalence of clinical depression and posttraumatic stress disorder (PTSD) one to two months (Time 1) and five to eight months (Time 2) after musculoskeletal trauma and (2) determine the cross-sectional and longitudinal relationship of psychological variables (depression, PTSD, catastrophic thinking, and pain anxiety) at Time 1 to musculoskeletal disability and pain intensity at Time 1 and Time 2, after accounting for injury characteristics and demographic variables. METHODS Patients with one or more fractures that had been treated operatively completed measures of depression, PTSD, pain anxiety, catastrophic thinking, musculoskeletal disability (the Short Musculoskeletal Function Assessment [SMFA]), and pain (the Numerical Rating Scale) at rest and during activity at Time 1 (152 patients) and at Time 2 (136 patients). Additional explanatory variables included injury severity, use of opioid pain medication at Time 1, and multiple or single injuries. RESULTS The screening criteria for an estimated diagnosis of clinical depression were met by thirty-five of the 152 patients at Time 1, and twenty-nine of the 136 patients at Time 2. Screening criteria for an estimated diagnosis of PTSD were met by forty-three of the 152 patients at Time 1 and twenty-five of the 136 patients at Time 2. Cross-sectional hierarchical linear regression models that included multiple injuries, scores of the Abbreviated Injury Scale, and self-reported opioid use explained between 24% and 29% of the variance in pain and disability, respectively, at Time 1. After the addition of psychological variables, the model explained between 49% and 55% of the variance. Catastrophic thinking (as measured with use of the Pain Catastrophizing Scale) at Time 1 was the sole significant predictor of pain at rest, pain during activity, and disability (as measured with use of the SMFA) at Time 2. CONCLUSIONS We found that psychological factors that are responsive to cognitive behavioral therapy--catastrophic thinking, in particular--are strongly associated with pain intensity and disability in patients recovering from musculoskeletal trauma.

Contribution of Kinesophobia and Catastrophic Thinking to Upper-Extremity-Specific Disability

BACKGROUND Upper-extremity-specific disability correlates with mood and coping strategies. The aim of this study was to determine if two psychological factors, kinesiophobia (fear of movement) and perceived partner support, contribute significantly to variation in upper-extremity-specific disability in a model that included factors known to contribute to variation such as depression, pain anxiety, and catastrophic thinking. METHODS We performed an observational cross-sectional study of 319 patients who each had one of the following conditions: trigger finger (n = 94), carpal tunnel syndrome (n = 29), trapeziometacarpal arthrosis (n = 33), Dupuytren contracture (n = 31), de Quervain syndrome (n = 28), wrist ganglion cyst (n = 32), lateral epicondylosis (n = 41), and a fracture of the distal part of the radius treated nonoperatively six weeks previously (n = 31). Each patient completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and questionnaires measuring symptoms of depression, pain anxiety, catastrophic thinking, kinesiophobia, and perceived level of support from a partner or significant other. Stepwise multiple linear regression was used to determine significant independent predictors of the DASH score. RESULTS Men had significantly lower (better) DASH scores than women (21 versus 31; p < 0.01). DASH scores also differed significantly by diagnosis (p < 0.01), marital status (p = 0.047), and employment status (p < 0.01). The DASH score correlated significantly with depressive symptoms (p < 0.01), catastrophic thinking (p < 0.01), kinesiophobia (p < 0.01), and pain anxiety (p < 0.01) but not with perceived partner support. The best multivariable model of factors associated with greater arm-specific disability (according to the DASH score) included sex, diagnosis, employment status, catastrophic thinking, and kinesiophobia and accounted for 55% of the variation. CONCLUSIONS In this sample, kinesiophobia and catastrophic thinking were the most important predictors of upper-extremity-specific disability in a model that accounted for symptoms of depression, anxiety, and pathophysiology (diagnosis) and explained more than half of the variation in disability. Perceived partner support was not a significant factor. The consistent and predominant role of several modifiable psychological factors in disability suggests that patients may benefit from a multidisciplinary approach that optimizes mindset and coping strategies.

Correlation of DASH and QuickDASH with measures of psychological distress.

PURPOSE In an attempt to shorten the questionnaires given to patients in both clinical and research settings, we studied whether the correlation of commonly used psychological measures was comparable for the standard Disabilities of the Arm, Shoulder, and Hand (DASH) and the shorter QuickDASH questionnaires. METHODS A cohort of 839 patients with carpal tunnel syndrome, trigger finger, de Quervains disease, trapeziometacarpal arthrosis, lateral epicondylosis, or a distal radius fracture 2 weeks after surgery, who completed the DASH and 1 or more measures of psychological distress, was created from 10 databases from previously implemented studies. Correlations of the DASH and the QuickDASH with several measures of psychological factors (Center for Epidemiologic Studies Depression Scale [CES-D], Pain Catastrophizing Scale [PCS], and Pain Anxiety Symptoms Scale [PASS-40]) were calculated in both univariate and multivariable analyses. RESULTS There was a large correlation between the DASH and QuickDASH (r = 0.79; p < .001). QuickDASH scores were significantly higher than DASH scores (p < .001). Correlations of the CES-D, PCS, and PASS-40 with the DASH and QuickDASH ranged from small to medium (range, 0.21-0.31; p < .001). There were no significant differences between correlations of the DASH and the QuickDASH with the psychological factors in the cohort including all patients, nor in subgroups according to diagnosis, gender, and limb dominance. CONCLUSIONS The correlations of the DASH and QuickDASH with the CES-D, PCS, and PASS-40 were comparable. Our analysis suggests that a shorter and therefore potentially more practical measure of arm-specific disability can be used in studies that evaluate psychosocial aspects of illness behavior. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic III.

Risk Factors for Continued Opioid Use One to Two Months After Surgery for Musculoskeletal Trauma

BACKGROUND The aim of this study was to determine factors associated with self-reported ongoing use of opioid medication one to two months after operative treatment of musculoskeletal trauma. METHODS Operatively treated patients (n = 145) with musculoskeletal trauma were evaluated one to two months after surgery. Patients indicated if they were taking opioid pain medication and completed several psychological questionnaires: the Center for Epidemiologic Studies Depression Scale, the Pain Catastrophizing Scale, the Pain Anxiety Symptoms Scale, and the Posttraumatic Stress Disorder Checklist, civilian version. The Numeric Rating Scale was used to measure pain intensity. Disability was measured with use of the Short Musculoskeletal Function Assessment Questionnaire and injury severity was measured with use of the Abbreviated Injury Scale. RESULTS Patients who scored higher on the catastrophic thinking, anxiety, posttraumatic stress disorder, and depression questionnaires were significantly more likely (p < 0.001) to report taking opioid pain medications one to two months after surgery, regardless of injury severity, fracture site, or treating surgeon. The magnitude of disability as measured by the Short Musculoskeletal Function Assessment score was significantly higher (p < 0.001) in the patients who reported using opioids (40 points) compared with those who reported not using opioids (24 points). A logistic regression model not including pain intensity found that the single best predictor of reported opioid use was catastrophic thinking (odds ratio, 1.12 [95% confidence interval, 1.07 to 1.18]), which explained 23% of the variance (p < 0.001). CONCLUSIONS Patients who continue to use opioid pain medication one to two months after surgery for musculoskeletal trauma have more psychological distress, less effective coping strategies, and greater symptoms and disability than patients who do not take opioids, irrespective of injury, surgical procedure, or surgeon.

Integrating Patient Values into Evidence-Based Practice: Effective Communication for Shared Decision-Making

Increasing data suggest that the traditional clinician-centered or disease-focused, biomedical approach to illness is less effective than a biopsychosocial, evidence-based, patient-centered approach to illness, particularly for chronic pain conditions. This article distinguishes patient-centered care from more traditional and outdated biomedical decision-making models; illustrates the complexity of illness behavior with a patient example; delves into the communication issues raised by this complexity, thereby demonstrating how best evidence can sometimes run counter to biases and intuition; provides a summary of evidence that patient-centered care positively affects outcomes; and explores how the shared decision-making approach along with cultivation of good communication skills can facilitate evidence-based practice.

Determinants of Pain in Patients with Carpal Tunnel Syndrome

BackgroundCarpal tunnel syndrome causes numbness, weakness, and atrophy. Pain without numbness is not characteristic of this disease.Questions/purposesWe tested the hypothesis that among patients with carpal tunnel syndrome confirmed by electrophysiologic testing, pain catastrophizing and/or depression would be good predictors of pain intensity at the time of diagnosis, whereas nerve conduction velocity would not.Patients and MethodsFifty-four patients completed a measure of tendency to misinterpret pain, a measure of depressive symptoms, anxiety about pain, self-efficacy in response to pain, and a five-point Likert measure of pain intensity. One-tailed Spearman correlation was performed to find a correlation between pain and continuous variables. One-way ANOVA was performed to assess differences between categorical variables. For each group, all variables with significant correlations with pain intensity were included in a multiple linear regression analysis.ResultsSex, age, and electrophysiologic measures did not correlate with pain intensity. All measures of illness behavior correlated with pain intensity and were entered in a multiple linear regression model; only misinterpretation of nociception and depression were significantly associated and accounted for 39% of the variation in pain intensity.ConclusionsIllness behavior (specifically depression and misinterpretation of nociception) predicts pain intensity in patients with carpal tunnel syndrome.Level of EvidenceLevel II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.