O. Franceschelli

Effects of Cognitive-behavioral Therapy (CBT) on Brain Connectivity Supporting Catastrophizing in Fibromyalgia

Objective(s): Fibromyalgia (FM) is a chronic, common pain disorder characterized by hyperalgesia. A key mechanism by which cognitive-behavioral therapy (CBT) fosters improvement in pain outcomes is via reductions in hyperalgesia and pain-related catastrophizing, a dysfunctional set of cognitive-emotional processes. However, the neural underpinnings of these CBT effects are unclear. Our aim was to assess CBT’s effects on the brain circuitry underlying hyperalgesia in FM patients, and to explore the role of treatment-associated reduction in catastrophizing as a contributor to normalization of pain-relevant brain circuitry and clinical improvement. Methods: In total, 16 high-catastrophizing FM patients were enrolled in the study and randomized to 4 weeks of individual treatment with either CBT or a Fibromyalgia Education (control) condition. Resting state functional magnetic resonance imaging scans evaluated functional connectivity between key pain-processing brain regions at baseline and posttreatment. Clinical outcomes were assessed at baseline, posttreatment, and 6-month follow-up. Results: Catastrophizing correlated with increased resting state functional connectivity between S1 and anterior insula. The CBT group showed larger reductions (compared with the education group) in catastrophizing at posttreatment (P<0.05), and CBT produced significant reductions in both pain and catastrophizing at the 6-month follow-up (P<0.05). Patients in the CBT group also showed reduced resting state connectivity between S1 and anterior/medial insula at posttreatment; these reductions in resting state connectivity were associated with concurrent treatment-related reductions in catastrophizing. Discussion: The results add to the growing support for the clinically important associations between S1-insula connectivity, clinical pain, and catastrophizing, and suggest that CBT may, in part via reductions in catastrophizing, help to normalize pain-related brain responses in FM.

The Association Between Daily Physical Activity and Pain Among Patients with Knee Osteoarthritis: The Moderating Role of Pain Catastrophizing

OBJECTIVEnThe primary objective of this study was to examine the day-to-day association between physical activity and pain intensity among a sample of patients with knee osteoarthritis (KOA) and the potential moderation of this association by negative cognitive processes.nnnMETHODSnIn this micro-longitudinal daily diary study, KOA patients (Nu2009=u2009121) completed questionnaires assessing pain (Brief Pain Inventory) and psychosocial functioning (pain catrophizing scale, WOMAC McMaster Universities Osteoarthritis Index function, Patient-Reported Outcomes Measurement Information System [PROMIS; anxiety and depression], the Godin-Shephard Leisure-Time Physical Activity questionnaire, the six-minute walking test) and were then asked to report their levels of physical activity and pain intensity once per day for a period of seven days using an electronic diary.nnnRESULTSnMultilevel modeling analyses indicated that day-to-day increases in physical activity were associated with heightened levels of pain intensity (B = 0.13 SE = 0.03, Pu2009<u20090.001). In addition, it was revealed that the association between physical activity and pain intensity was moderated by catastrophizing (B = -0.01 SE = 0.002, P < 0.05), with patients scoring higher in catastrophizing showing a relatively stronger link between day-to-day physical activity and increased knee pain. This effect was specific to catastrophizing, as depression and anxiety did not moderate the activity-pain relationship (P > 0.05).nnnCONCLUSIONSnOur findings suggest that increases in daily physical activity are associated with concurrent increases in KOA patients levels of knee pain, particularly among patients reporting higher levels of pain catastrophizing. These results may have clinical implications for the design and testing of interventions targeted at reducing catastrophizing and increasing physical activity among patients with chronic osteoarthritis pain.

The impact of anxiety and catastrophizing on interleukin-6 responses to acute painful stress

Objective To examine the influence of anxiety and pain-related catastrophizing on the time course of acute interleukin-6 (IL-6) responses to standardized noxious stimulation among patients with chronic pain. Methods Data were collected from 48 participants in the following demographically matched groups: patients with chronic pain (n=36) and healthy controls (n=12). Participants underwent a series of Quantitative Sensory Testing (QST) procedures assessing responses to mechanical and thermal stimuli during two separate visits, in a randomized order. One visit consisted of standard, moderately painful QST procedures, while the other visit involved nonpainful analogs to these testing procedures. Blood samples were taken at baseline, and then for up to 2 hours after QST in order to study the time course of IL-6 responses. Results Results of multilevel analyses revealed that IL-6 responses increased across assessment time points in both visits (p<0.001). While patients with chronic pain and healthy controls did not differ in the magnitude of IL-6 responses, psychological factors influenced IL-6 trajectories only in the chronic pain group. Among patients, increases in catastrophizing over the course of the QST session were associated with elevated IL-6 responses only during the painful QST session (p<0.05). When controlling for anxiety, results indicated that the main multilevel model among patients remained significant (p<0.05). Conclusion Under specific conditions (eg, application of a painful stressor), catastrophizing may be associated with amplified proinflammatory responses in patients with persistent pain. These findings suggest that psychosocial interventions that reduce negative pain-related cognitions may benefit patients’ inflammatory profiles.

Encoding of Self-Referential Pain Catastrophizing in the Posterior Cingulate Cortex in Fibromyalgia

Pain catastrophizing is a common feature of chronic pain, including fibromyalgia (FM), and is strongly associated with amplified pain severity and disability. While previous neuroimaging studies have focused on evoked pain response modulation by catastrophizing, the brain mechanisms supporting pain catastrophizing itself are unknown. We designed a functional magnetic resonance imaging (fMRI)–based pain catastrophizing task whereby patients with chronic pain engaged in catastrophizing‐related cognitions. We undertook this study to test our hypothesis that catastrophizing about clinical pain would be associated with amplified activation in nodes of the default mode network (DMN), which encode self‐referential cognition and show altered functioning in chronic pain.

(117) The association between daily physical activity and pain among patients with knee osteoarthritis: the moderating role of pain catastrophizing

s The Journal of Pain S5 rating was 13/24 (SD=5). We examined both univariable and multivariable regression models of disability, using 30 subject baseline characteristics as predictors. In univariable regression models, higher body mass index (BMI; p=.01), numerical rating scale (NRS) rating of LBP intensity (p=.002) and NRS global pain intensity (p=0.03), leg pain (yes/no, p=.001), foot pain (yes/no, p=.03), number of pain sites (p=.04), West Haven-Yale Multidimensional Pain Inventory Interference scale (WHYMPI-I; p<.001), Beck Depression Inventory (BDI) score (p<.001) and Pain Catastrophizing Scale (PCS) score (p<.001) were significantly associated with increased RMDQ scores. Returning to the original pool of 30 predictors, we identified the most relevant predictors of RMDQ score in amultivariable model using the least absolute shrinkage and selection operator (lasso) method. This method selected 11 predictors of RMDQ: NRS rating of low back pain intensity, presence of leg pain, back pain cause (non-specific vs. radiculopathy or spinal stenosis), distance from medical center, employment status, education, marital status, BMI, WHYMPI-I score, BDI score, and PCS score. Among pain-related clinical factors, presence of leg pain, radiculopathy, and stenosis emerged as important predictors of RMDQ score suggesting that pain complaints other than LBP influence reported disability in a LBP–specific assessment instrument. Among potentially modifiable factors, depression, pain catastrophizing, and BMI represent promising treatment targets for behavioral interventions. A04 Clinical Outcomes Measurement (116) The association between catastrophizing and daily pain intensity among patients with knee osteoarthritis: the moderating role of spousal support A Lazaridou, C Campbell, M Smith, M Martel, J Wright, J Haythornthwaite, and R Edwards; Brigham and Women’s Hospital, Harvard Medical School, Boston, MA Catastrophizing has consistently been found to be associated with negative pain outcomes, and one of the postulated mechanisms involves maladaptive interactions with the social environment. To explore the role of spousal support in the association between catastrophizing and daily pain intensity among patients with knee osteoarthritis (KOA). On the basis of the communal coping model of pain, we hypothesized that the association between catastrophizing and daily pain intensity would vary as a function of spousal support. We recruited 124 patients with KOA who were scheduled to undergo total joint replacement surgery. Patients were first asked to provide demographic information and to complete the Pain Catastrophizing Scale. Patients then provided reports of pain intensity and spousal support once a day for a period of 7 days using a personal digital assistant (PDA). Results of multilevel models (MLM) indicated that catastrophizingwas associatedwith heightened daily levels of pain, B = .63, p < .001. A two-way (catastrophizing * spousal support) interaction was thenmodeled to examine whether spousal support moderated the association between catastrophizing and daily pain intensity. Results of this multilevel moderation analysis was significant (p < .05), and revealed that the association between catastrophizing and daily pain intensity was stronger among patients reporting low spousal support (B = .56) than among patients reporting high spousal support (B = .45). Our findings are consistent with the communal coping model (CCM) and suggest that high catastrophizers might report elevated levels of pain in order to compensate for the low spousal support being received and to seek support from others in the social environment. Additional research is needed to examine the specific mechanisms underpinning these effects, and to determine whether psychosocial interventions may modulate the maladaptive interactions between catastrophizing and the social environment. (117) The association between daily physical activity and pain among patients with knee osteoarthritis: the moderating role of pain catastrophizing O Franceschelli, M Cornelius, M Martel, C Campbell, M Smith, J Haythornthwaite, J Wright, and R Edwards; Brigham & Women’s Hospital, Harvard Medical School, Boston, MA Despite the potential benefits of physical activity for patients with chronic musculoskeletal pain, it is well known that physical activity may lead to transient increases in patients’ levels of pain. To date, however, little research has been conducted on the psychological factors that might moderate (i.e., amplify or attenuate) the impact of physical activity on pain. For instance, it is possible that physical activity leads to heightened levels of pain, but only among specific subgroups of patients, such as those with high levels of catastrophizing or negative affect. The primary objective of this study was to examine the day-to-day association between physical activity and pain intensity among a sample of patients with knee osteoarthritis (KOA). We also examined whether the association between physical activity and pain was moderated by patients’ levels of catastrophizing or negative affect. In this longitudinal diary study, patients (n = 121) were first asked to provide demographic information and to complete baseline questionnaires assessing pain catastrophizing and negative affect. Patients were then asked to report their levels of physical activity and pain intensity once a day for a period of 7 days using a personal digital assistant (PDA). Multilevel modeling (MLM) analyses indicated that day-to-day increases in physical activity were associated with heightened levels of pain intensity (p < .001). Results of a multilevel moderation analysis revealed that the association between physical activity and pain intensity was moderated by catastrophizing (p < .05), with patients higher in catastrophizing showing a relatively stronger link between physical activity and increased knee pain. This association, however, was not moderated by negative affect (p >.10). Our findings suggest that engaging in physical activity is associatedwith increases in KOApatients’ levels of pain, particularly among high catastrophizers. The theoretical and clinical implications of our findings will be discussed. (118) Physical and psychological predictors of dysfunction in complex regional pain syndrome (CRPS): a Collaborative Health Outcomes Information Registry (CHOIR) study M Adelus, J Sturgeon, T Rico, V Tawfik, and S Mackey; Stanford School of Medicine, Palo Alto, CA There remains a relative dearth of studies examining meaningful predictors of physical function and pain interference in individuals with CRPS. The current study investigated predictors of pain-related dysfunction in patients with CRPS in a tertiary care pain management setting. Our sample consisted of 150 patients diagnosed with CRPS type 1 or 2, who reported outcomes at Stanford PainManagement Center, between the years of 2012 and 2015. Patients were identified using ICD9 codes associated with their clinic visit and their diagnosis was subsequently verified by chart review. Patients in the current sample predominantly identified as female (78.7%) and Caucasian (68%). Using the Collaborative HealthOutcomes Information Registry (CHOIR), clinical variables were used to predict individual differences in physical function (a measure of discrete physical activities, such as the ability to complete 1 hour of exercise or to brush one’s teeth) and pain interference (a measure of perceived interference with common domains of function due to pain). Cross-sectional models included a common set of predictors: average pain intensity, depression, pain catastrophizing, sleep disturbance, and fatigue. Our analyses revealed different predictors of pain interference and physical function. Whereas average pain (standardized B = .272, p = .003) and depression (standardized B = .247, p = 018) were significant predictors of pain interference, only fatigue (standardized B = -.300, p = .034) was a significant predictor of physical function in these fully-specified models. It is notable that perceptions of pain interference and reports of discrete physical function were predicted by different factors. Although these relationships require replication in longitudinal studies, they nevertheless provide insight into potential novel approaches to treatment for individuals with CRPS. The authors received funding from the National Institutes of Health (NIH HHSN 271201200728P, K24 DA029262, and 3T32DA035165-02S1) and the Redlich Pain Endowment. (119) Rememberedworst pain events: descriptions, ratings, and sex differences E Dannecker, A Murray, and E Culbert; University of Missouri, Columbia, MO Pain severity predicts the development of chronic pain from acute pain. Women tend to have more severe and chronic pain than men. Idiosyncratic interpretation of the response options of pain