Brittany N. Rosenbloom

Systematic review of persistent pain and psychological outcomes following traumatic musculoskeletal injury

Background Persistent pain and psychological distress are common after traumatic musculoskeletal injury (TMsI). Individuals sustaining a TMsI are often young, do not recover quickly, and place a large economic burden on society. Objectives The aim of this systematic review is to determine (1) the incidence of persistent pain following TMsI, (2) the characteristics of pain, characterized by injury severity and type, and (3) risk and protective factors associated with persistent pain following TMsI. Methods A systematic search of electronic databases (MEDLINE®, PubMed®, Embase, and PsycINFO®) was conducted for prospective, interventional, or noninterventional studies measuring the incidence of pain associated with TMsI. Results The search revealed 4388 studies. Eleven studies examined persistent pain and met inclusion criteria. Pain was assessed using a validated measure of pain intensity or pain presence in six studies. Persistent pain was reported by all studies at variable time points up to 84 months postinjury, with wide variation among studies in pain intensity (ie, from mild to very severe) and pain incidence at each time point. The incidence of pain decreased over time within each study. Two studies found significant relationships between injury severity and persistent pain. Frequently cited predictive factors for persistent pain included: symptoms of anxiety and depression, patient perception that the injury was attributable to external sources (ie, they were not at fault), cognitive avoidance of distressing thoughts, alcohol consumption prior to trauma, lower educational status, being injured at work, eligibility for compensation, pain at initial assessment, and older age. Conclusion and implications The evidence from the eleven studies included in this review indicates that persistent pain is prevalent up to 84 months following traumatic injury. Further research is needed to better evaluate persistent pain and other long-term posttraumatic outcomes.

Chronic Pain, Psychopathology, and DSM-5 Somatic Symptom Disorder:

Unlike acute pain that warns us of injury or disease, chronic or persistent pain serves no adaptive purpose. Though there is no agreed on definition of chronic pain, it is commonly referred to as pain that is without biological value, lasting longer than the typical healing time, not responsive to treatments based on specific remedies, and of a duration greater than 6 months. Chronic pain that is severe and intractable has detrimental consequences, including psychological distress, job loss, social isolation, and, not surprisingly, it is highly comorbid with depression and anxiety. Historically, pain without an apparent anatomical or neurophysiological origin was labelled as psychopathological. This approach is damaging to the patient and provider alike. It pollutes the therapeutic relationship by introducing an element of mutual distrust as well as implicit, if not explicit, blame. It is demoralizing to the patient who feels at fault, disbelieved, and alone. Moreover, many medically unexplained pains are now understood to involve an interplay between peripheral and central neurophysiological mechanisms that have gone awry. The new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, somatic symptom disorder overpsychologizes people with chronic pain; it has low sensitivity and specificity, and it contributes to misdiagnosis, as well as unnecessary stigma. Adjustment disorder remains the most appropriate, accurate, and acceptable diagnosis for people who are overly concerned about their pain.

Predicting pain outcomes after traumatic musculoskeletal injury.

Abstract Traumatic musculoskeletal injury results in a high incidence of chronic pain; however, there is little evidence about the nature, quality, and severity of the pain. This study uses a prospective, observational, longitudinal design to (1) examine neuropathic pain symptoms, pain severity, pain interference, and pain management at hospital admission and 4 months after traumatic musculoskeletal injury (n = 205), and (2) to identify predictors of group membership for patients with differing moderate-to-severe putative neuropathic pain trajectories. Data were collected on mechanism of injury, injury severity, pain (intensity, interference, neuropathic quality), anxiety (anxiety sensitivity, general anxiety, pain catastrophizing, pain anxiety), depression, and posttraumatic stress while patients were in-hospital and 4 months after injury. A third of patients had chronic moderate-to-severe neuropathic pain 4 months after injury. Specifically, 11% of patients developed moderate-to-severe pain by 4 months and 21% had symptoms immediately after injury that persisted over time. Significant predictors of the development and maintenance of moderate-to-severe neuropathic pain included high levels of general anxiety while in-hospital immediately after injury (P < 0.001) and symptoms of posttraumatic stress 4 months after injury (P < 0.001). Few patients had adequate pharmacological, physical, or psychological pain management in-hospital and at 4 months. Future research is needed among trauma patients to better understand the development of chronic pain and to determine the best treatment approaches.

Comparison of Child–Parent and Parent-Only Cognitive-Behavioral Therapy Programs for Anxious Children Aged 5 to 7 Years: Short- and Long-Term Outcomes

OBJECTIVE Childhood anxiety disorders (AD) are prevalent, debilitating disorders. The most effective treatment approach for children less than 8 years old requires further investigation. The studys primary objective was to compare 2 cognitive-behavioral therapy (CBT) group programs. CBT was delivered to children 5 to 7 years old and their parents (child-parent) or only to parents (parent-only), whereas children attended group sessions but did not receive CBT. METHOD Using a prospective, repeated measures, longitudinal study design, 77 children (29 male, mean age = 6.8 years; SD = 0.8 year) with AD and their parents participated in either a 12-week child-parent or parent-only CBT group treatment after a 3-month no-treatment wait-time. Well-validated treatment outcome measures were completed at 5 assessment time points: initial assessment, pretreatment, immediately posttreatment, 6 months, and 12 months posttreatment. A mixed models analysis was used to assess change in AD severity and global functioning improvements from baseline within each treatment and between treatments. RESULTS No significant changes were noted in child-parent or parent-only treatment during the 3-month no-treatment wait time. Both treatments saw significant improvements posttreatment and at longer-term follow-up with significant reductions in AD severity measured by clinician and parent report and increases in global functioning. Significantly greater improvements were observed in the child-parent compared to the parent-only treatment. CONCLUSION This study suggests that both parent-only and child-parent group CBT improves AD severity in children 5 to 7 years old. Study results suggest that involvement of both children and parents in treatment is more efficacious than working with parents alone.

The golden anniversary of Melzack and Wall’s gate control theory of pain: Celebrating 50 years of pain research and management

November 2015 marks the 50th anniversary of the 1965 Science publication “Pain Mechanisms: A New Theory” by Ronald Melzack and Patrick D Wall (1), in which the authors introduced the gate control theory of pain that has since revolutionized our understanding of pain mechanisms and management. The brilliance, creativity and critical thought that went into the formulation and explication of the gate control theory of pain can best be appreciated by reading the original article. Fifty years later, having become part of our scientific history and accepted as common knowledge, the essence of the theory is often conveyed by the familiar diagram in Figure 1. In 1982, the article was recognized as a Citation Classic in Eugene Garfield’s weekly publication Current

Chronic Pain and the Anxiety Disorders: Epidemiology, Mechanisms and Models of Comorbidity, and Treatment

This chapter provides an overview of the characteristics, theories, and treatments for the comorbidity between the anxiety disorders and chronic pain. Consistent with the majority of research and theory in this area, the primary focus of this chapter will be on comorbid chronic pain and posttraumatic stress disorder (PTSD), a stress- and trauma-related disorder that develops after exposure to a traumatic stressor. In the first section, we provide a definition and description of the features and epidemiology of chronic pain and the anxiety disorders. Data on the comorbidity between the two conditions is then presented, followed by a consideration of the temporal precedence of each condition in the etiology of their co-occurrence. The next section describes the three main theoretical approaches that have been taken to explain the high comorbidity rates; namely, mutual maintenance models, vulnerability models, and a combination of the two. Specific vulnerability factors, such as anxiety sensitivity and sensitivity to pain traumatization, are also discussed. The overlap between the neurocircuitry and neurophysiology common to both chronic pain and PTSD is reviewed, highlighting the role of the amygdala, prefrontal cortex (PFC), insular cortex, and anterior cingulate cortex (ACC). Two major pathways for the development of chronic pain and anxiety disorders are then considered: fear-conditioning and stress-induced analgesia. Finally, current psychological management strategies for both conditions are then considered, with an emphasis on a biopsychosocial approach to treatment. The chapter concludes with a discussion of future research directions.

A developmental perspective on the impact of chronic pain in late adolescence and early adulthood: implications for assessment and intervention

1. IntroductionThe prevalence and severity of chronic pain is well defined in children and adults. Epidemiological studies estimate that 11% to 38% of children25 and 35% to 51% of adults17 have chronic pain; for 5% to 8% of children21 and 10% to 13% of adults,36 the pain is severe and disabling. Alt