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Assessment of Pain Anxiety, Pain Catastrophizing, and Fear of Pain in Children and Adolescents with Chronic Pain: A Systematic Review and Meta-Analysis

Fisher E, Heathcote L C, Eccleston C, Simons L E, Palermo T M. Journal of Pediatric Psychology, 2018, April 1;43(3):314-325

Reviewer:

Dr. Mark Alcock, Clinical Lead of the Queensland Interdisciplinary Paediatric Persistent Pain Service, Queensland Children’s Hospital, Brisbane.

Study group:

This was a systematic review and metaanalysis of studies that had used self-report cognitive-affective measures to assess pain anxiety, pain catastrophizing and fear of pain in patients less than 18 years old, who had pain for 3 months or longer. Studies on pain associated with a life limiting condition, acute pain and peri-operative pain were excluded.

Aims:

This systematic review stated three aims:

1. To identify cognitive-affective measures assessing pain anxiety, pain catastrophization, and fear of pain in youth with persistent pain summarizing their content, psychometric properties and use

2. To use evidence-based assessment criteria to rate each cognitive-affective measure according to guidelines from the Society of Pediatric Psychology

3. To assess the construct validity of pain anxiety, pain catastrophization and fear of pain by meta-analyzing their reported correlations with the primary outcome variables specified in the pediatric fear-avoidance model of pain (pain intensity, disability, general anxiety and depression).

Methodology:

This systematic review and meta-analysis appears to comply with the PRISMA statement (checklist and flow diagram).

Summary of the results:

1. For aim one, seven relevant cognitiveaffective measures were identified from 54 studies: a. One measure for pain anxiety – Bath Adolescent Pain Questionnaire (subscale) b. Three measures for pain catastrophizing i. Pain Catastrophizing Scale for Children (PCS-C) – most frequently used of all the measures included in the systematic review (30 studies) ii. Pain Coping Questionnaire (PCQ) – subscale iii. Pain Response Inventory (PRI) – subscale c. Three measures on Fear of Pain: i. Fear of Pain Questionnaire for Children (FOPQ-C) ii. Pediatric Pain Fear Questionnaire (PPFQ) iii. Photographic series of Daily Activities (PHODA-youth)

As an assessment of reliability, internal consistency was reported as good for all measures except the PCQ subscale. This indicates the items within each measure are likely asking about the same thing (e.g. pain anxiety, catastrophization or fear) in different ways.

2. For aim two, using the SPP evidencebased assessment criteria, 5 measures were classed as well established, and two measures PPFQ and PHODA-youth) classed as promising.

3. For aim 3, there was only enough data available from four cognitive-affective measures (PCS-C, FOPQ-C, BAPQ subscale, and PCQ-IC subscale) which enabled 10 out of a possible twentyeight meta-analysis to be completed. The results of these meta-analyses can be summarized as follows: a. Small to moderate correlations were identified between all four cognitiveaffective measures and pain-related disability b. Correlations identified between cognitive-affective measures and pain intensity were weak c. There were moderate strength correlations between PCS-C and generalized anxiety and depression

Conclusions:

This systematic review identified seven cognitive-affective measures assessing pain anxiety, pain catastrophization and pain related fear, with the pain catastrophization scale for children being the most researched measure. Five of these measures were assessed as wellestablished using guidelines from the Society of Pediatric Psychology however these guidelines are not stringent. Although internal consistency was well reported for these measures, other psychometric assessments such as testretest reliability, sensitivity to change and discriminant validity were lacking. There was a significant degree of similarity in items across all seven cognitive-affective measures, which raises the question, are the constructs of pain anxiety, catastrophization and fear separate constructs or the same?

The meta-analysis was incomplete due to limited data being available, therefore the findings should be interpreted with caution. The strongest correlation between the four measures included in the metaanalysis and the primary outcome variables specified in the pediatric fear avoidance model of pain was with pain related disability.

Reviewer's critique and take-home message:

This systematic review and meta-analysis conducted by a group of leading paediatric persistent pain researchers looks at the cognitive-affective measures available to objectively assess patients using the pediatric fear avoidance model of pain. It was a thorough review of the relevant literature and provides a good description of the included cognitiveaffective measures. However, the criteria led assessment of the measures is of questionable value, and the meta-analysis is limited, in part due to the authors decision to not take on the onerous task of contacting authors of original manuscripts for further data.

This systematic review and meta-analysis shows that the psychometric assessment of the seven included cognitive-affective measures, and their validation through correlation to specific components of the pediatric fear avoidance model of pain is incomplete. Therefore, in the clinical setting, they should be used with caution, and, as with any questionnaire, should judiciously compliment rather than replace clinical assessment.

Some of these measures have been incorporated into service benchmarking programs (for example, the BAPQ subscale on pain anxiety in the paediatric electronic persistent pain outcomes collaboration (ePPOC)), where there is a temptation misuse them as indicators of service performance despite incomplete psychometric analysis, and it being as yet unclear exactly what they are assessing. Whilst the pediatric fear avoidance model of pain has a growing evidence base, is well supported in clinical practice, and used to guide therapy for many patients, it should be noted that this model does not apply to all patients seen in the paediatric persistent pain clinic. Empirical approaches to therapy for our complex patient population has a risk of therapy failure. The importance of clinical assessment and formulation to inform the interdisciplinary team’s approach to therapy cannot be understated.

Declaration: Nil declaration to make.

Thank you to APS members Katherine Brain, Chris Hayes, Fiona Hodson and colleagues Tracy Burrows, Megan Rollo, Li Kheng Chai, Erin Clarke and Clare Collins for sharing the following recent publication:

A systematic review and meta-analysis of nutrition interventions for chronic noncancer pain

Katherine Brain, Chris Hayes, Fiona Hodson, Tracy Burrows, Megan Rollo, Li Kheng Chai, Erin Clarke and Clare Collins

Article first published online: October 2018

Journal Reference: Journal of human nutrition and dietetics: 2018.

DOI: 10.1111/jhn.12601

Link: https://onlinelibrary.wiley.com/doi/ abs/10.1111/jhn.12601

Abstract

Background

Optimizing dietary intake is an important part of pain management and associated comorbidities such as obesity and cardiovascular disease. However the current evidence for nutrition interventions for pain management has not been collated and critically evaluated. This systematic review aimed to evaluate the impact of nutrition interventions in people experiencing chronic pain on self-reported pain severity.

Methods

Keywords for ‘chronic pain’ and ‘diet therapy’ were systematically searched across eight electronic databases. Studies were considered eligible if they included an adult population (≥ 18 years) with a chronic pain condition, a nutrition intervention and a measure of pain. Relevant data was extracted and quality assessment was performed by two independent reviewers using the Academy of Nutrition and Dietetics Criteria Checklist for primary research. Where available, data from studies using a visual analogue scale (VAS) to measure pain were pooled using metaanalysis in order to determine the overall effect of dietary interventions on pain outcomes.

Results

Seventy-one studies were included with 23 being eligible for meta-analysis. Study quality was rated as positive in twenty studies, 33 neutral and four studies as negative quality. Studies included a median of 46 participants (range 12-2121) and the majority had ≥ 50% female participants. The range of mean ages varied from 30.9 to 65.7 years and range of mean BMI was 18.3kg/m2 to 31.8kg/m2. The most common measurement tool was the VAS which was used in 37 studies. The included studies were categorized by their intervention which included: (i) Altered overall diet where participants were prescribed a vegan, vegetarian or Mediterranean diet. Of the 16 studies in this category, 12 studies found a significant reduction in self-reported pain. (ii) Altered single nutrient where participants altered the intake of a specific nutrient (e.g. fat, fibre, protein and water). Two (fat and protein) of the five studies in this category had significant reduction in pain scores. (iii) Nutrition supplements were used in 46 studies with a wide variety of supplements prescribed to participants (e.g. omega-3 fatty acids, vitamin, mineral, amino acids). Of these, 11 studies showed significant results where participants had a reduction in pain scores. (iv) Four studies used fasting therapy where the participants intake was restricted to 300-350kJ/day, only one study reported a significant reduction in pain. Findings from the metaanalysis showed that, when combined, all nutrition interventions had a significant effect on pain reduction (-0.905, p<0.001), as measured using a VAS. Those studies which altered overall dietary intake (-1.415, p=0.03) or a single nutrient (-1.415, p<0.001) had the greatest effect.

Conclusions

This review highlights the importance and effectiveness of nutrition interventions for people who experience chronic pain. However, the review also demonstrated that there is a large variation in the types of nutrition interventions which have been investigated to date with varying methodological quality. It shows there is a need for more good quality studies which include nutrition advice and support, not only addressing pain itself but also weight management and other comorbidities such as cardiovascular disease.

Declaration

This study forms part of the thesis work for Katherine Brain from the University of Newcastle who was supported by the Australian Postgraduate Award and Rainbow Foundation Top Up Scholarship through Hunter Medical Research Institute (HMRI). Li Kheng Chai is supported by the University of Newcastle International Postgraduate Research Scholarship, The Barker PhD Top Up Scholarship and Emlyn and Jennie Thomas Postgraduate Medical Research Scholarship through HMRI. Tracy Burrows is supported by a University of Newcastle Faculty of Health and Medicine Early Career Brawn Fellowship and Clare Collins is a NHMRC Senior Research Fellow and a University of Newcastle Faculty of Health and Medicine Gladys M Brawn Senior Research Fellow.

Thank you to APS member Michele Sterling and colleagues Rob Smeets, Gerben Keijzers, Jacelle Warren and Justin Kenardy for sharing the following recent publication:

Physiotherapist-delivered stress inoculation training integrated with exercise versus physiotherapy exercise alone for acute whiplash-associated disorder (StressModex): a randomised controlled trial of a combined psychological/physical intervention

Michele Sterling, Rob Smeets, Gerben Keijzers, Jacelle Warren and Justin Kenardy

Article first published online: 19 January 2019

Journal Reference: British journal of Sports Medicine

DOI: 10.1136/bjsports-2018-100139.

Link: https://www.ncbi.nlm.nih.gov/ pubmed/30661011

ABSTRACT

Objective

Whiplash Associated Disorder (WAD) is a common and costly problem. There are few effective treatments for acute WAD. Early symptoms of post-injury stress predict poor recovery. We aimed to compare the effectiveness of physiotherapist-led stress inoculation training integrated with exercise to guideline-based exercise alone for people with acute whiplash-associated disorder at risk of poor recovery.

Design

StressModex is a prospective, parallel group, assessor-blinded, randomised, 12 month clinical trial.

Setting

The trial was conducted at a university centre and community physiotherapy practices in Queensland, Australia.

Participants

People with acute (< 4 weeks) whiplashassociated disorders (Grade 2 or 3) at risk of poor recovery (at least moderate pain related disability (≥32% on the Neck Disability Index) and ≥3 on the hyperarousal symptom sub-scale of the posttraumatic stress diagnostic scale) were included. They were recruited by advertisement in local and metropolitan newspapers, radio and online media, from primary care practices (GP and physiotherapy) as well as from the Emergency Department of the Gold Coast University Hospital.

Methods

Participants were randomly assigned to either physiotherapist-led stress inoculation training and guideline-based exercise (n=53) or guideline-based exercise alone (n=55). Both interventions comprised 10 sessions over 6 weeks. Sealed opaque envelopes were used to conceal allocation. The primary outcome was the Neck Disability Index (NDI) on a 0-100 scale. Outcomes were measured at 6 weeks, 6 and 12 months. Analysis was by intention to treat, and treatment effects were calculated using linear mixed models. The trial is registered with the Australian and New Zealand Clinical Trials Registry ACTRN 12614001036606.

Results

Of the 108 randomised participants (mean age 41.3 years (standard deviation 14.2) and 62% female), 102 (94.4%) completed the 6 week follow-up, 98 (90.7%) the 6 month follow-up and 98 (90.7%) the 12 month follow-up. The stress inoculation training and exercise intervention was more effective than guideline-based exercise alone for pain related disability at all follow-up points. At 6 weeks, the treatment effect on the 0-100 NDI was -10 (95% CI – 15.5 to -9.0), at 6 months was -7.8 (95% CI -13.8 to -1.8), and at 12 months was -10.1 (95% CI -16.3 to -4.0). A significant benefit of the stress inoculation and exercise intervention over guideline-based exercise was found for some secondary outcomes including mental health outcomes. No serious adverse events related to the interventions were reported.

Conclusions

A physiotherapist-led intervention of stress inoculation training and guideline-based exercise results in greater improvements in pain related disability than guidelinebased exercise alone, the most commonly recommended treatment, for patients with acute whiplash-associated disorders. These results support the utilisation of physiotherapists to deliver psychological interventions to improve outcomes post whiplash injury in those at risk of poor recovery.

Declaration

Funding for this study was received from The National Health and Medical Research Council of Australia, Grant ID: APP1069443. There are no conflicts of interest to declare.

Thank you to APS member John Quintner and colleauges Asaf Weisman and Youssef Masharawi for sharing the following recent publication:

Congenital Insensitivity to Pain – A Misnomer

John Quintner, Asaf Weisman and Youssef Masharawi.

Article first published online: 2 February 2019

Journal Reference: Journal of Pain

DOI: https://doi.org/10.1016/j. jpain.2019.01.331

Link: https://www.jpain.org/article/ S1526-5900(18)30687-4/pdf

Abstract

“Congenital insensitivity to pain (CIP)" is an umbrella term used to describe a group of rare genetic diseases also classified as "Hereditary Sensory Autonomic Neuropathies (HSAN)". These are intriguing conditions with potential to shed light on the poorly understood relationship concerning nociception and the experience of pain. However, the term CIP is epistemologically incorrect and is the product of historical circumstances. The term conflates pain and nociception and thus prevents researchers and caregivers from grasping the full dimensions of these conditions. The aims of this article are to review the epistemological problems surrounding the term, to demonstrate why the term is inaccurate and to suggest a new term: “Congenital Nociceptor Deficiency”. The suggested term better reflects the nature of the conditions, and incorporates current understandings of nociception.

Implications

The umbrella term “Congenital Insensitivity to Pain” conflates pain and nociception, which is epistemologically unacceptable. We suggest a new term – Congenital Nociceptor Deficiency - that overcomes this problem and is concordant with current neurobiological knowledge.

Declaration

The authors have nothing to declare