Michael K. Nicholas

The pain self-efficacy questionnaire: Taking pain into account.

Self‐efficacy beliefs in people with chronic pain have been assessed either by reference to confidence in ability to perform specific tasks or to confidence in performing more generalised constructs like coping with pain. Both approaches reflect aspects of the original conceptualisations of self‐efficacy and both have proved useful, but it is noteworthy that confidence in performing activities in the context of pain is rarely addressed. An important element in the original formulations of self‐efficacy referred to persistence in the face of obstacles and aversive experiences. In this context, self‐efficacy beliefs for people experiencing chronic pain might be expected to incorporate not just the expectation that a person could perform a particular behaviour or task, but also their confidence in being able to do it despite their pain. This aspect of the self‐efficacy construct has been included in a measure for people with chronic pain, the Pain Self‐Efficacy Questionnaire (PSEQ). The accumulated evidence from a number of published studies and a confirmatory analysis with a large cohort of heterogeneous chronic pain patients attending a pain management program provide support for the PSEQs original psychometric properties developed with a sample of chronic low back pain patients. The importance of taking the context of pain into account in the assessment of self‐efficacy beliefs in pain populations and the ways in which this measure can be used to improve the assessment of people experiencing chronic pain, before and after treatment, are examined.

A randomized controlled trial of intensive neurophysiology education in chronic low back pain

Objectives:Cognitive-behavioral pain management programs typically achieve improvements in pain cognitions, disability, and physical performance. However, it is not known whether the neurophysiology education component of such programs contributes to these outcomes. In chronic low back pain patients, we investigated the effect of neurophysiology education on cognitions, disability, and physical performance. Methods:This study was a blinded randomized controlled trial. Individual education sessions on neurophysiology of pain (experimental group) and back anatomy and physiology (control group) were conducted by trained physical therapist educators. Cognitions were evaluated using the Survey of Pain Attitudes (revised) (SOPA(R)), and the Pain Catastrophizing Scale (PCS). Behavioral measures included the Roland Morris Disability Questionnaire (RMDQ), and 3 physical performance tasks; (1) straight leg raise (SLR), (2) forward bending range, and (3) an abdominal “drawing-in” task, which provides a measure of voluntary activation of the deep abdominal muscles. Methodological checks evaluated non-specific effects of intervention. Results:There was a significant treatment effect on the SOPA(R), PCS, SLR, and forward bending. There was a statistically significant effect on RMDQ; however, the size of this effect was small and probably not clinically meaningful. Discussion:Education about pain neurophysiology changes pain cognitions and physical performance but is insufficient by itself to obtain a change in perceived disability. The results suggest that pain neurophysiology education, but not back school type education, should be included in a wider pain management approach.

Early Identification and Management of Psychological Risk Factors (“Yellow Flags”) in Patients With Low Back Pain: A Reappraisal

Originally the term “yellow flags” was used to describe psychosocial prognostic factors for the development of disability following the onset of musculoskeletal pain. The identification of yellow flags through early screening was expected to prompt the application of intervention guidelines to achieve secondary prevention. In recent conceptualizations of yellow flags, it has been suggested that their range of applicability should be confined primarily to psychological risk factors to differentiate them from other risk factors, such as social and environmental variables. This article addresses 2 specific questions that arise from this development: (1) Can yellow flags influence outcomes in people with acute or subacute low back pain? and (2) Can yellow flags be targeted in interventions to produce better outcomes? Consistent evidence has been found to support the role of various psychological factors in prognosis, although questions remain about which factors are the most important, both individually and in combination, and how they affect outcomes. Published early interventions have reported mixed results, but, overall, the evidence suggests that targeting yellow flags, particularly when they are at high levels, does seem to lead to more consistently positive results than either ignoring them or providing omnibus interventions to people regardless of psychological risk factors. Psychological risk factors for poor prognosis can be identified clinically and addressed within interventions, but questions remain in relation to issues such as timing, necessary skills, content of treatments, and context. In addition, there is still a need to elucidate mechanisms of change and better integrate this understanding into the broader context of secondary prevention of chronic pain and disability.

A classification of chronic pain for ICD-11

Chronic pain has been recognized as pain that persists past normal healing time5 and hence lacks the acute warning function of physiological nociception.35 Usually pain is regarded as chronic when it lasts or recurs for more than 3 to 6 months.29 Chronic pain is a frequent condition, affecting an estimated 20% of people worldwide6,13,14,18 and accounting for 15% to 20% of physician visits.25,28 Chronic pain should receive greater attention as a global health priority because adequate pain treatment is a human right, and it is the duty of any health care system to provide it.4,13 The current version of the International Classification of Diseases (ICD) of the World Health Organization (WHO) includes some diagnostic codes for chronic pain conditions, but these diagnoses do not reflect the actual epidemiology of chronic pain, nor are they categorized in a systematic manner. The ICD is the preeminent tool for coding diagnoses and documenting investigations or therapeutic measures within the health care systems of many countries. In addition, ICD codes are commonly used to report target diseases and comorbidities of participants in clinical research. Consequently, the current lack of adequate coding in the ICD makes the acquisition of accurate epidemiological data related to chronic pain difficult, prevents adequate billing for health care expenses related to pain treatment, and hinders the development and implementation of new therapies.10,11,16,23,27,31,37 Responding to these shortcomings, the International Association for the Study of Pain (IASP) contacted the WHO and established a Task Force for the Classification of Chronic Pain. The IASP Task Force, which comprises pain experts from across the globe,19 has developed a new and pragmatic classification of chronic pain for the upcoming 11th revision of the ICD. The goal is to create a classification system that is applicable in primary care and in clinical settings for specialized pain management. A major challenge in this process was finding a rational principle of classification that suits the different types of chronic pain and fits into the general ICD-11 framework. Pain categories are variably defined based on the perceived location (headache), etiology (cancer pain), or the primarily affected anatomical system (neuropathic pain). Some diagnoses of pain defy these classification principles (fibromyalgia). This problem is not unique to the classification of pain, but exists throughout the ICD. The IASP Task Force decided to give first priority to pain etiology, followed by underlying pathophysiological mechanisms, and finally the body site. Developing this multilayered classification was greatly facilitated by a novel principle of assigning diagnostic codes in ICD-11, termed “multiple parenting.” Multiple parenting allows the same diagnosis to be subsumed under more than 1 category (for a glossary of ICD terms refer to Table ​Table1).1). Each diagnosis retains 1 category as primary parent, but is cross-referenced to other categories that function as secondary parents. Table 1 Glossary of ICD-11 terms. The new ICD category for “Chronic Pain” comprises the most common clinically relevant disorders. These disorders were divided into 7 groups (Fig. ​(Fig.1):1): (1) chronic primary pain, (2) chronic cancer pain, (3) chronic posttraumatic and postsurgical pain, (4) chronic neuropathic pain, (5) chronic headache and orofacial pain, (6) chronic visceral pain, and (7) chronic musculoskeletal pain. Experts assigned to each group are responsible for the definition of diagnostic criteria and the selection of the diagnoses to be included under these subcategories of chronic pain. Thanks to Bedirhan Ustun and Robert Jakob of the WHO, these pain diagnoses are now integrated in the beta version of ICD-11 (http://id.who.int/icd/entity/1581976053). The Task Force is generating content models for single entities to describe their clinical characteristics. After peer review overseen by the WHO Steering Committee,39 the classification of chronic pain will be voted into action by the World Health Assembly in 2017. Figure 1 Organizational chart of Task Force, IASP, and WHO interactions. The IASP Task Force was created by the IASP council and its scope defined in direct consultation of the chairs (R.D.T. and W.R.) with WHO representatives in 2012. The Task Force reports to ... 2. Classification of chronic pain Chronic pain was defined as persistent or recurrent pain lasting longer than 3 months. This definition according to pain duration has the advantage that it is clear and operationalized. Optional specifiers for each diagnosis record evidence of psychosocial factors and the severity of the pain. Pain severity can be graded based on pain intensity, pain-related distress, and functional impairment. 2.1. Chronic primary pain Chronic primary pain is pain in 1 or more anatomic regions that persists or recurs for longer than 3 months and is associated with significant emotional distress or significant functional disability (interference with activities of daily life and participation in social roles) and that cannot be better explained by another chronic pain condition. This is a new phenomenological definition, created because the etiology is unknown for many forms of chronic pain. Common conditions such as, eg, back pain that is neither identified as musculoskeletal or neuropathic pain, chronic widespread pain, fibromyalgia, and irritable bowel syndrome will be found in this section and biological findings contributing to the pain problem may or may not be present. The term “primary pain” was chosen in close liaison with the ICD-11 revision committee, who felt this was the most widely acceptable term, in particular, from a nonspecialist perspective.

Inpatient vs. outpatient pain management: results of a randomised controlled trial

&NA; Inpatient and outpatient cognitive behavioural pain management programmers for mixed chronic pain patients were compared. Patients were randomly allocated to the 4 week inpatient programme or to the 8 half day per week outpatient programme, or to a waiting list control group. Staff, teaching materials, and setting were the same for the two treatment groups. Patients were assessed pre‐treatment, and at 1 month after discharge, and treated patients also at 6 months and 1 year after discharge, by assessors blind to treatment group; assessments included physical, functional and psychological measures, and medication use. In total, 121 mixed chronic pain patients (mean age 50 years; mean chronicity 8.1 years) were included in the study, following medical examination to ensure that no further medical treatment was appropriate. There was no change in the control group; inpatients and outpatients, comparable before treatment, both made significant improvements in physical performance and psychological function, and reduced medication use. Inpatients made greater gains, and maintained them better at 1 year; they also used less health care than outpatients. There were no outstanding predictors of improvement other than treatment group.

What do the numbers mean? Normative data in chronic pain measures

&NA; Although self‐reported measures play a central role in the assessment of pain and its treatment, it has long been recognized that interpretation of these measures is severely limited by the absence of normative data. Despite that, relatively few of the measures used in pain clinics or research studies have normative data for reference. Using a pain centre sample (n = 6124), this paper describes the development of a normative dataset on a number of commonly used pain‐related measures. The measures cover many of the key dimensions in pain assessment, including pain severity/quality, disability (physical functioning), and mood (emotional functioning). Measures of different cognitive and coping constructs are also included. Mean scores are reported for each measure according to age group, gender, pain site, as well as percentiles for different scores for patients with chronic low back pain. The potential uses for datasets of this type include the assessment and evaluation of individual cases, as well as the interpretation of published clinical trials. It is also argued that future systematic reviews of pain treatments should include consideration of such patient characteristics as pain levels, disability and mood in the studies reviewed rather than pain site and chronicity alone.

Chronic pain, work performance and litigation

&NA; The overall population impact of chronic pain on work performance has been underestimated as it has often been described in terms of work‐related absence, excluding more subtle effects that chronic pain may have on the ability to work effectively. Additionally, most studies have focussed on occupational and/or patient cohorts and treatment seeking, rather than sampling from the general population. We undertook a population‐based random digit dialling computer‐assisted telephone survey with participants randomly selected within households in order to measure the impact of chronic pain on work performance. In addition, we measured the association between pain‐related disability and litigation. The study took place in Northern Sydney Health Area, a geographically defined urban area of New South Wales, Australia, and included 484 adults aged 18 or over with chronic pain. The response rate was 73.4%. Working with pain was more common (on an average 83.8 days in 6 months) than lost work days due to pain (4.5 days) among chronic pain participants in full‐time or part‐time employment. When both lost work days and reduced‐effectiveness work days were summed, an average of 16.4 lost work day equivalents occurred in a 6‐month period, approximately three times the average number of lost work days. In multiple logistic regression modelling with pain‐related disability as the dependent variable, past or present pain‐related litigation had the strongest association (odds ratio (OR)=3.59, P=0.001). In conclusion, chronic pain had a larger impact on work performance than has previously been recognised, related to reduced performance while working with pain. A significant proportion were able to work effectively with pain, suggesting that complete relief of pain may not be an essential therapeutic target. Litigation (principally work‐related) for chronic pain was strongly associated with higher levels of pain‐related disability, even after taking into account other factors associated with poor functional outcomes.

Self-management of chronic pain: a population-based study

While effective self‐management of chronic pain is important, clinic‐based studies exclude the more typical pattern of self‐management that occurs in the community, often without reference to health professionals. We examined specific hypotheses about the use of self‐management strategies in a population‐based study of chronic pain subjects. Data came from an Australian population‐based random digit dialling computer‐assisted telephone survey and included 474 adults aged 18 or over with chronic pain (response rate 73.4%). Passive strategies were more often reported than active ones: passive strategies such as taking medication (47%), resting (31.5%), and using hot/cold packs (23.4%) were most commonly reported, while the most commonly reported active strategy was exercising (25.8%). Only 33.5% of those who used active behavioural and/or cognitive strategies used them exclusively, while 67.7% of those who used passive behavioural and/or conventional medical strategies did so exclusively. Self‐management strategies were associated with both pain‐related disability and use of health services in multiple logistic regression models. Using passive strategies increased the likelihood of having high levels of pain‐related disability (adjusted OR 2.59) and more pain‐related health care visits (adjusted OR 2.9); using active strategies substantially reduced the likelihood of having high levels of pain‐related disability (adjusted OR 0.2). In conclusion, we have shown in a population‐based study that clinical findings regarding self‐management strategies apply to the broader population and advocate that more attention be given to community‐based strategies for improving awareness and uptake of active self‐management strategies for chronic pain.

Randomized controlled trial of exercise for chronic whiplash-associated disorders

Abstract Whiplash‐associated disorders are common and incur considerable expense in social and economic terms. There are no known effective treatments for those people whose pain and disability persist beyond 3 months. We conducted a randomized, assessor‐blinded, controlled trial at two centres in Australia. All participants received 3 advice sessions. In addition the experimental group participated in 12 exercise sessions over 6 weeks. Primary outcomes were pain intensity, pain bothersomeness and function measured at 6 weeks and 12 months. Exercise and advice was more effective than advice alone at 6 weeks for all primary outcomes but not at 12 months. The effect of exercise on the 0–10 pain intensity scale was −1.1 (95%CI −1.8 to −0.3, p = 0.005) at 6 weeks and −0.2 (0.6 to −1.0, p = 0.59) at 12 months; on the bothersomeness scale the effect was −1.0 (−1.9 to −0.2, p = 0.003) at 6 weeks and 0.3 (−0.6 to 1.3, p = 0.48) at 12 months. The effect on function was 0.9 (0.3 to 1.6, p = 0.006) at 6 weeks and 0.6 (−0.1 to 1.4, p = 0.10) at 12 months. High levels of baseline pain intensity were associated with greater treatment effects at 6 weeks and high levels of baseline disability were associated with greater treatment effects at 12 months. In the short‐term exercise and advice is slightly more effective than advice alone for people with persisting pain and disability following whiplash. Exercise is more effective for subjects with higher baseline pain and disability.

An investigation of the placebo effect and age-related factors in the report of needle pain from venipuncture in children

Abstract To examine the potential role for a placebo cream in reducing reported needle pain severity in children, and the impact of age‐related factors on pain self‐report, a convenience sample of 117 children scheduled for venipuncture were randomly assigned to one of three treatments: (a) placebo cream with the suggestion that it might help reduce needle pain, (b) placebo cream with no indication as to the creams purpose, and (c) no cream (control group). In allocation to treatment, children were stratified by age group, (3–7, 8–11, 12–17 years). They rated their needle pain severity (both predicted and reported) using the Faces Pain Scale, and rated their anxiety about the procedure using the Childrens Anxiety and Pain Scale. Children in the cream groups were also asked whether they thought the cream had helped. Using video‐tapes, an independent observer, blind to the placebo manipulation, rated each childs reaction to the needle. For the two groups receiving cream, 83% of those children told it might help stated that they believed it did, as compared with only 33% of children who received the cream but were told nothing of its purpose. These beliefs, however, were not reflected in self‐report ratings of pain which showed no statistically significant treatment effect. Similarly, children who gave higher preprocedural anxiety ratings were no more likely to report less pain as a result of receiving the cream. There was, however, a treatment effect on the observers ratings: children receiving cream plus suggestion were assigned significantly lower ratings of pain‐related behaviour than those children who received the cream alone. While venipuncture was associated with only mild levels of pain, younger children, irrespective of treatment group, did report more pain than older children. Hierarchical regression analysis indicated that 60% of the variance in self‐reported pain severity scores could be accounted for by how much the child thought the needle would hurt, how anxious the child was about receiving the needle, gender (higher pain ratings associated with girls), and estimated body surface area (higher pain ratings associated with smaller bodies). We conclude that the efficacy of placebo treatments for needle pain in children may depend on the suggestion of a possible benefit rather than upon treatment application per se.