January 2017
David Craig, PharmD | Editor


The Journal of Pain

Highlights from The Journal of Pain (Volume 18, No. 1, January 2017 Issue)

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Study Assesses Impact of Headache on Task Attention

Nina Attridge, Christopher Eccleston, Donna Noonan, Elaine Wainwright, Edmund Keogh; Mathematics Education Centre, Loughborough University, Loughborough United Kingdom; Centre for Pain Research, University of Bath, Bath, United Kingdom; Department of Psychology, Bath Spa University, Bath, United Kingdom

A new study published in The Journal of Pain shows that headache can inhibit cognitive functioning by preventing individuals from focusing attention on specific tasks.

Researchers from multiple centers in Great Britain sought to extend the findings of a previous study showing that headache disrupts the ability to perform various attention tasks. The investigators expanded the scope of the previous research by increasing the study sample size and adding two different attention tasks. They hypothesized that task performance would be worse when participants had headaches compared with being pain free.

Results showed that headache slowed reaction times for four of five complex attention tasks. This suggests that the effect of pain on attention is dynamic but also difficult to measure when and why the effect of pain on attention varies. The study also showed that pain intensity was unrelated to task disruption, suggesting that simply having a headache affected task performance.

PTSD Linked with Chronic Pain in Torture Victims

Ruth Defrin, Yael Lahav, Zahava Solomon; Department of Physical Therapy, Sackler Faculty of Medicine and Sagol School of Neurosciences, Tel-Aviv University, Tel-Aviv, Israel; Bob Shapell School of Social Work, Tel-Aviv University, Tel-Aviv, Israel

Research reported in The Journal of Pain evaluated the role of torture or severe trauma on development of chronic pain.

High rates of chronic pain have been reported in torture survivors, and the effects of torture also have been implicated in posttraumatic stress disorder (PTSD), the most common psychiatric disorder in trauma survivors. PTSD among trauma survivors also has been associated with altered pain perception. The study authors from Tel Aviv University hypothesized that torture survivors with PSTD would exhibit more enhanced chronic and experimental pain and more dysfunctional pain modulation.

The study sample consisted of 103 men: 59 prisoners of war who were tortured and 44 veterans who fought in the same battles in the Arab–Israeli conflicts but were not captured or tortured. The subjects were administered several different experimental pain stimuli, and perceived pain intensity was measured using a visual analogue scale.

Results showed that reduced pain modulation (CPM) and enhanced temporal summation (TSP) were significantly more pronounced among the torture survivors with PTSD than the control group. Pain thresholds were similar across both groups, indicating that captivity, torture, and PTSD were not associated with changes in pain sensitivity. Despite normal pain sensitivity, torture survivors exhibited abnormal CPM and TSP, which suggest that their ability to inhibit and modulate noxious stimuli is significantly reduced.

Further, the data showed it is the duration and severity of distress or PTSD, rather than exposure to the trauma per se, that influences the perception and modulation of chronic pain.

“Overall, it appears that the magnitude and duration of PTSD and its resultant distress, rather than exposure to trauma, are implicated in the association between trauma and altered pain perception/modulation; the stronger the magnitude and the longer the duration of PTSD/distress, the higher the risk for chronic and perhaps irreversible changes in the pain system,” the authors concluded.


Highlights from PAIN (Volume 158, No. 1, January 2017 Issue)

Pain Medicine Cover

Long-Term Outcomes from Training in Self-Management of Chronic Pain in an Elderly Population: A Randomized Controlled Trial

Michael K. Nicholas, Ali Asghari, Fiona M. Blyth, Bradley M. Wood, Robin Murray, Rebecca McCabe, Alan Brnabic, Lee Beeston, Mandy Corbett, Catherine Sherrington, Sarah Overton; Pain Management Research Institute, University of Sydney at Royal North Shore Hospital, Sydney, Australia; School of Psychology, Shahed University, Tehran, Iran; School of Public Health, Concord Clinical School, University of Sydney, Sydney; Sax Institute, Sydney, Australia; ABC Consulting, Sydney; The George Institute, University of Sydney, Sydney, Australia

This study compared the outcomes, from pretreatment to 1-year follow-up, of an outpatient, cognitive-behavioral therapy (CBT)-based pain self-management program (PSM) that included exercises, pain education, and pain coping strategies for a control condition (exercise-attention control [EAC] for the treatment team). Subjects were ambulant older adult patients with chronic pain.

The improvements reported immediately posttreatment were still present during the 1-year follow-up period on the measures of usual pain, pain distress, disability, depression, and fear-avoidance beliefs. These authors contend that the general maintenance of treatment gains over 1 year should provide encouragement for those who are considering implementation of this intervention in standard practice. Overall results indicate that a relatively brief combined CBT and exercise PSM program has measurable effects that are largely maintained over a 1-year period and remain superior to exercises and attention by health professionals alone.

Those who withdrew from the study were much less confident about their ability to function normally while experiencing pain. The degree of pain catastrophizing posttreatment was more strongly related to long-term outcomes: If patients with pain did not attain a sufficiently low level of pain catastrophizing by the end of treatment, their long-term outcome could be at risk. These findings have important implications for the development of community-based pain services for older adults with chronic pain. When these findings are added to the mounting evidence favoring this approach in older adults, there is a strong case for its implementation as a standard component of clinical care for this population more generally.

Temporal Change in Headache and Its Contribution to the Risk of Developing First-Onset Temporomandibular Disorder in the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) Study

Inna E. Tchivileva, Richard Ohrbach, Roger B. Fillingim, Joel D. Greenspan, William Maixner, Gary D. Slade; Center for Pain Research and Innovation, School of Dentistry, University of North Carolina at Chapel Hill; Department of Endodontics, School of Dentistry, University of North Carolina at Chapel Hill; Department of Oral Diagnostic Sciences, University at Buffalo, Buffalo, NY; Department of Community Dentistry and Behavioral Science, University of Florida, College of Dentistry and Pain Research and Intervention Center of Excellence, Gainesville, FL; Department of Neural and Pain Sciences, School of Dentistry, University of Maryland, Baltimore, MD; Brotman Facial Pain Center, School of Dentistry, University of Maryland, Baltimore; Center for Translational Pain Medicine, Duke University, Durham, NC; Department of Anesthesiology, Duke University, Durham; Department of Dental Ecology, School of Dentistry, University of North Carolina at Chapel Hill

Temporomandibular disorder (TMD), which involves the muscles of mastication, the temporomandibular joint (TMJ), or associated orofacial structures, often is comorbid with headache, although the estimated degree of overlap varies among studies. This article used data from the large-scale prospective cohort study of first-onset TMD. This study was a part of the project titled “Orofacial Pain: Prospective Evaluation and Risk Assessment” (OPPERA). This study’s objectives were to describe the prevalence of headache in a community-based sample of U.S. adults at their time of enrollment, evaluate contribution of headache to risk for developing first-onset TMD during prospective follow-up, and describe the dynamic patterns of headache types at baseline and during follow-up.

This 5-year prospective study revealed that baseline reports of migraine, mixed headache, or headache frequency were predictive of increased risk for TMD. Both headache prevalence and frequency increased across the observation period among those who developed TMD but not among matched controls. Although patterns of change were complex when multiple types of headache were considered, incident cases of TMD were more likely to be associated with worsening in headache type and less likely associated with improvement vs matched controls. For patients with TMD, the most striking change was observed in prevalence of definite migraine, which increased 10-fold. Among all headache types experienced by patients with TMD, migraine was associated with the highest progression/remission odds ratio, whereas increased likelihood of progression for controls emerged only for tension-type headache (TTH). The finding that migraine but not TTH was a risk factor for incident TMD was especially intriguing because TMD traditionally is thought to be associated with TTH. The association between migraine and TMD may be attributable to multiple biopsychosocial factors such as shared physiology, genetics, psychological traits, and environmental influences.

Progression to migraine was the most essential factor that distinguished patients with incident TMD and controls. Screening, thorough monitoring, and adequate treatment of migraine should be implemented as a preventive strategy for reducing TMD risk. These data support the hypothesis that migraine and frequent headaches contribute to risk for TMD. Future studies should address the question of whether timely and optimal migraine therapy could reduce risk for TMD onset.

The Clinical Journal of Pain

Highlights from The Clinical Journal of Pain (Volume 33, No. 1, January 2017 Issue)


Pain Is Associated with Poorer Grades, Reduced Emotional Well-Being, and Attention Problems in Adolescents

Jessica S. Voerman, Cora de Klerk, Karin M. Vander Heyden, Jan Passchier, Wietske Idema, Reinier Timman, and Jelle Jolles; Department of Psychiatry, Section of Medical Psychology and Psychotherapy, Erasmus MC University Medical Hospital, Rotterdam; Faculty of Psychology and Education, VU University Amsterdam, Amsterdam; and Han Sports and Exercise, HAN University of Applied Sciences, Nijmegen, The Netherlands

In the general population, approximately 25% of all children and adolescents experience chronic pain (CP). Children and adolescents with CP participate less in physical activities and report reduced emotional well-being than their peers. Adolescents with recurrent pain also are frequently absent from school. Subclinical depressive symptoms are common in children and adolescents with CP. Depressed adolescents often are easily distracted and have memory difficulties; consequently, some studies suggest that the association between pain and problems in academic performance might be explained by reduced emotional well-being, attention problems, or both. This study focuses on the relationship between self-reported pain, emotional well-being, and attention and academic performance in a large sample of typical Dutch adolescents in grade 7 (12 to 13 years old). The following hypotheses were tested: (1) Pain is associated with poorer grades, reduced emotional well-being, and more attention problems, and (2) part of the association between pain and grades is explained by reduced emotional well-being, attention problems, or both.

Results suggest that pain in early adolescence is associated with poorer Dutch and mathematics grades, reduced emotional well-being, and increased attention problems. Furthermore, the association between frequent pain and Dutch grades seems to be mediated by self-reported reduced emotional well-being and attention problems. The association between frequent pain and mathematics grades seems to be mediated by emotional problems. In other words, adolescents with pain might develop problems only in academic performance when emotional problems, attention problems, or both exist.

These results stress the importance of taking seriously any pain reported by adolescents at an early stage. Problems in academic performance might be prevented in adolescents with pain, and these results can also be used to develop appropriate psychoeducational techniques to help these adolescents cope with CP and related emotional problems. Future research should examine the relationship between pain and academic performance in a longitudinal design or in a controlled intervention study, which will make it possible to draw inferences about cause and effect.

Suicidal Ideation in Adolescents with and Without Chronic Pain

Maggie H. Bromberg, Emily F. Law, Tonya M. Palermo; Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle

Suicide is a leading cause of death among adolescents. Suicidal ideation (SI; thoughts of suicide, death, or dying) is estimated to occur in 13.5%–16.9% of youth in the United States and peaks during adolescence. Adolescent SI can contribute to future risk for self-harm and death, and the overwhelming majority of individuals who make a suicide attempt experienced past SI. Risk factors for SI among adolescents include social isolation, depressive symptoms (e.g., low self-worth, sadness), poor family functioning, and female gender. Adolescents with chronic pain (CP) are particularly at risk for SI because they experience more social isolation, depressive symptoms, and family dysfunction than peers without CP. Medications commonly used to treat youth with CP, including opioids, antidepressants, and anticonvulsants, may also carry risk for worsening depressive symptoms or SI. A subset of youth with CP experience high pain intensity and severe activity limitations, which also may contribute to risk for SI. However, little attention has been paid to rates and correlates of SI in adolescents with CP.

These investigators compared the rate and severity of SI among youth with CP who were recruited from a specialty pain clinic to rates and severity among youth in the community without CP and sought to describe patterns of suicidal thoughts within each group. Consistent with findings in adults with CP, they expected to find higher rates of SI in adolescents with CP vs. peers without CP. They also examined the potential psychosocial and pain-related risk factors for SI severity, adjusting for demographic characteristics previously associated with SI in youth.

More than 34% of adolescents with CP in this sample cited SI, indicating that this common experience points to the need for routine clinical screening. SI also was common among youth without CP in this study (27.5%), which further indicates this concern should be assessed routinely in primary care settings. It is important to use nuanced screening tools to avoid a high rate of false-positives and to direct clinical resources to at-risk youth in clinical settings. Contrary to the hypothesis, adolescents with CP did not cite SI more frequently than peers without CP despite experiencing significantly higher depressive symptoms, pain, and activity limitations. Furthermore, pain-related factors surprisingly were not associated with higher SI severity for youth with CP when examined in the context of other demographic and psychosocial factors. These findings suggest that although SI is a concern for youth during adolescence, it may not be more frequent or intense in youth with CP. These results contrast with patterns of SI occurrence in adults with CP, who experience more frequent SI than adults without pain.

The only SI-related thought that was more frequently reported among youth with CP than those without CP was the idea that life was not worth living. This item implies a sense of hopelessness, which has been identified as a strong predictor of SI in individuals with and without CP. This initial study of SI in a clinical sample of adolescents provides evidence that SI occurs at a frequency and severity that is similar to that in an older adolescent population. These results suggest that SI is fairly common and should be an indication for clinical assessment, monitoring, and potential intervention.