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Beate C Sydora,1 Lindsay Jane Whelan,1,2 Benjamin Abelseth,2 Gurpreet Brar,3 Sumera Idris,3 Rachel Zhao,4 Ashley Jane Leonard,4 Brittany N Rosenbloom,5 Hance Clarke,6 Joel Katz,6,7 Sanjay Beesoon,1 Nivez Rasic2,8 1Department of Surgery Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada; 2Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; 3Health Systems Knowledge and Evaluation, Alberta Health Services, Edmonton, AB, Canada; 4Knowledge Resource Service, Alberta Health Services, Edmonton, AB, Canada; 5Toronto Academic Pain Medicine Institute, Toronto, ON, Canada; 6Department of Anesthesia and Pain Management, Toronto General Hospital, UHN, Toronto, ON, Canada; 7Department of Psychology, York University, Toronto, ON, Canada; 8Department of Anesthesiology, Perioperative & Pain Medicine, University of Calgary, Calgary, AB, CanadaCorrespondence: Nivez Rasic, Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Medical Lead, Vi Riddell Pain & Rehabilitation Program, Acute Pain Lead, Alberta Pain Strategy, Alberta Children’s Hospital, 28 Oki Drive NW, Calgary, AB, T3B 6A8, Canada, Tel +403-955-7810, Email Nivez.Rasic@albertahealthservices.ca Sanjay Beesoon, Assistant Scientific Director, Surgery Strategic Clinical Network, Alberta Health Services, 02-048 South Tower, Seventh Street Plaza, 10030 107 St NW, Edmonton, AB, T5J 3E4, Canada, Tel +780-735-1682 ; +780-218-4786, Email Sanjay.Beesoon@albertahealthservices.caPurpose: Risk factors for the development of chronic postsurgical pain (CPSP) have been reported in primary studies and an increasing number of reviews. The objective of this umbrella review was to compile and understand the published presurgical risk factors associated with the development of CPSP for various surgery types.Methods: Six databases were searched from January 2000 to June 2023 to identify meta-analyses, scoping studies, and systematic reviews investigating presurgical CPSP predictors in adult patients. Articles were screened by title/abstract and subsequently by full text by two independent reviewers. The selected papers were appraised for their scientific quality and validity. Data were extracted and descriptively analyzed.Results: Of the 2344 retrieved articles, 36 reviews were selected for in-depth scrutiny. The number of primary studies in these reviews ranged from 4 to 317. The surgery types assessed were arthroplasty (n = 13), spine surgery (n = 8), breast surgery (n = 4), shoulder surgery (n = 2), thoracic surgery (n = 2), and carpal tunnel syndrome (n = 1). One review included a range of orthopedic surgeries; six reviews included a variety of surgeries. A total of 39 presurgical risk factors were identified, some of which shared the same defining tool. Risk factors were themed into six broad categories: psychological, pain-related, health-related, social/lifestyle-related, demographic, and genetic. The strength of evidence for risk factors was inconsistent across different reviews and, in some cases, conflicting. A consistently high level of evidence was found for preoperative pain, depression, anxiety, and pain catastrophizing.Conclusion: This umbrella review identified a large number of presurgical risk factors which have been suggested to be associated with the development of CPSP after various surgeries. The identification of presurgical risk factors is crucial for the development of screening tools to predict CPSP. Our findings will aid in designing screening tools to better identify patients at risk of developing CPSP and inform strategies for prevention and treatment.Plain Language Summary: Chronic postsurgical pain (CPSP) is pain experienced predominantly at the surgical site for longer than 3 months after a surgical procedure. Depending on surgery type, it can affect between 10 and 80% of people undergoing major surgeries, which may have negative effects such as a lower quality of life, disability, and persistent opioid use. Targeted identification and management of at risk patients in the presurgical phase may decrease the risk of CPSP. This umbrella review generated a list of potential risk factors for CPSP from evidence-based reviews of the current literature.Thirty-nine presurgical risk factors were identified in this review. Risk factors are divided into six broad categories: psychological, pain-related, health-related, demographic, genetic, and social/lifestyle-related. Although the strength of evidence for individual risk factors varied across reviews, risk factors in the psychological category consistently showed a strong impact on the development of CPSP.It is vital to understand which individuals are vulnerable and at risk for CPSP. The findings of this umbrella review will aid in designing screening tools to identify surgical candidates at risk. Some risk factors, such as genetics, cannot be altered. However, many identified risk factors are modifiable and may inform strategies for the prevention and treatment of CPSP using screening tools. Our findings may guide future research to consider an in-depth analysis of risk factor characterization to group modifiable presurgical risk factors. At risk patients will be offered psychological, physical, and pharmacological treatments accordingly to mitigate their risk of developing CPSP and ultimately improve patient outcomes in surgery.Keywords: chronic postsurgical pain, risk factors, predictors, umbrella review, surgery

Brittany N Rosenbloom,1– 3 P Maxwell Slepian,1,2,4 Muhammed Abid Azam,1,2 Andrea Aternali,1 Kathryn A Birnie,5,6 Kathryn Curtis,2 Sonal Thaker,2 Salima Ladak,2 Anna Waisman,1 Hance Clarke,2,4 Joel Katz,1,2,4 Aliza Z Weinrib1,2 1Department of Psychology, York University, Toronto, ON, Canada; 2Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada; 3Toronto Academic Pain Medicine Institute, Women’s College Hospital, Toronto, ON, Canada; 4Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; 5Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, AB, Canada; 6Department of Community Health Sciences, University of Calgary, Calgary, AB, CanadaCorrespondence: Joel Katz; Aliza Z Weinrib, Department of Psychology, York University, BSB 232, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada, Email jkatz@yorku.ca; Aliza.Weinrib@gmail.comAbstract: Clinical hypnosis is an effective strategy for managing acute pain in the surgical setting. However, the opioid sparing effects of clinical hypnosis are not as well understood. This pre-registered (NCT03730350) randomized, controlled trial (RCT) examined the impact of clinical hypnosis, pre- and post-surgery, on opioid consumption during hospitalization as well as on measures of pain intensity, pain interference, depressed mood, anxiety, sleep, and pain catastrophizing. Participants (M = 57.6 years; SD = 10.9) awaiting oncologic surgery were randomized to treatment-as-usual (n = 47) or hypnosis (n = 45). Intent-to-treat analyses were conducted using linear mixed effects modeling. A significant Group × Time interaction, F(6, 323.34) = 3.32, p = 0.003, indicated an opioid sparing effect of clinical hypnosis during the acute postoperative period. Hypnosis also protected against increases in pain catastrophizing at one-week after surgery, F (1, 75.26) = 4.04, p = 0.048. A perioperative clinical hypnosis intervention had a sparing effect on opioid consumption in-hospital after major oncologic surgery. These findings extend the efficacy of clinical hypnosis as an adjunct tool for perioperative pain management.Keywords: clinical hypnosis, oncologic surgery, postoperative opioid use, postoperative pain, pain catastrophizing

Samantha R Fashler,1 M Gabrielle Pagé,2 Anton Svendrovski,3 David B Flora,1 P Maxwell Slepian,1,4,5 Aliza Z Weinrib,1,4 Alexander Huang,4,5 Joseph Fiorellino,4,5 Hance Clarke,4,5 Joel Katz1,4,5 1Department of Psychology, York University, Toronto, ON, Canada; 2Department of Anesthesiology & Pain Medicine and Department of Psychology, Université de Montréal; Research Center of the Centre hospitalier de l’Université de Montréal (CRCHUM), Montréal, QC, Canada; 3UZIK Consulting Inc, Toronto, ON, Canada; 4Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada; 5Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, CanadaCorrespondence: Samantha R Fashler; Joel Katz, Department of Psychology, York University, 4700 Keele St., BSB 232, Toronto, ON, M3J 1P3, Canada, Email samantha.fashler@vch.ca; jkatz@yorku.caPurpose: The Sensitivity to Pain Traumatization Scale (SPTS-12) was developed to assess the propensity to develop a traumatic stress response to pain. The SPTS-12 is a reliable and valid scale with a one-factor structure. The aim of the present study is to further examine the psychometric properties of the SPTS-12 by evaluating its criterion validity and how scores change over time in a sample of postsurgical patients at the Toronto General Hospital Transitional Pain Service.Participants and Methods: 361 adults (55% male; Mage = 50.6 years, SDage = 14.3) completed questionnaires assessing symptoms of pain, anxiety, depression, and trauma at multiple visits to the Transitional Pain Service after surgery. Latent-class growth mixture modeling defined prototypical longitudinal patterns (latent trajectories) of SPTS-12 scores up to two years after surgery. One-way ANOVAs examined how trajectory classes differed over time on measures of daily opioid use (mg morphine equivalents (MME)), average pain intensity, pain interference, and depressive symptoms.Results: The final model consisted of five SPTS-12 trajectory groups; two characterized by a flat and unchanging pattern and three showing a small but statistically significant decrease over time. Analysis of pain-related outcomes predicted by SPTS-12 trajectories provided evidence of criterion validity of the SPTS-12. SPTS-12 trajectories did not significantly differ on daily MME at any time. Average pain, pain interference, and depression scores significantly differed across SPTS-12 trajectory groups at two or more postsurgical visits (all p < 0.05).Conclusion: The SPTS-12 shows fairly stable patterns and predicts important pain-related and psychosocial outcomes over time. Two SPTS-12 trajectories (#2 and #5) with high scores, comprising ∼ 28% of the total sample, are associated with problematic outcomes on several pain and psychosocial measures. Targeting patients with high SPTS-12 scores for presurgical psychological treatment may prove beneficial in reducing the impact of CPSP.Keywords: chronic pain, chronic postsurgical pain, trauma, psychology, scale validation, psychosocial factors, trajectory

Sandra J Drozdz,1 Akash Goel,1– 3 Matthew W McGarr,4 Joel Katz,3,5– 7 Paul Ritvo,5,7 Gabriella F Mattina,1 Venkat Bhat,8– 10 Calvin Diep,3 Karim S Ladha1,3,10 1Department of Anesthesia, St. Michael’s Hospital, Toronto, ON, Canada; 2Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA; 3Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; 4Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; 5Department of Psychology, York University, Toronto, ON, Canada; 6Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada; 7School of Kinesiology and Health Science, York University, Toronto, ON, Canada; 8Interventional Psychiatry Program, St. Michael’s Hospital, Toronto, ON, Canada; 9Department of Psychiatry, University of Toronto, Toronto, ON, Canada; 10Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, CanadaCorrespondence: Karim S Ladha, St. Michael’s Hospital, 30 Bond St, 6th Floor Donnelly Wing, Toronto, ON, ON, Canada, Tel +1 416-864-6060 ext. 49308, Fax +1 416-864-6014, Email Karim.Ladha@mail.utoronto.caAbstract: Currently, ketamine is used in treating multiple pain, mental health, and substance abuse disorders due to rapid-acting analgesic and antidepressant effects. Its limited short-term durability has motivated research into the potential synergistic actions between ketamine and psychotherapy to sustain benefits. This systematic review on ketamine-assisted psychotherapy (KAP) summarizes existing evidence regarding present-day practices. Through rigorous review, seventeen articles that included 603 participants were identified. From available KAP publications, it is apparent that combined treatments can, in specific circumstances, initiate and prolong clinically significant reductions in pain, anxiety, and depressive symptoms, while encouraging rapport and treatment engagement, and promoting abstinence in patients addicted to other substances. Despite much variance in how KAP is applied (route of ketamine administration, ketamine dosage/frequency, psychotherapy modality, overall treatment length), these findings suggest psychotherapy, provided before, during, and following ketamine sessions, can maximize and prolong benefits. Additional large-scale randomized control trials are warranted to understand better the mutually influential relationships between psychotherapy and ketamine in optimizing responsiveness and sustaining long-term benefits in patients with chronic pain. Such investigations will assist in developing standardized practices and maintenance programs.Keywords: addiction, alternative treatment, anesthesia, chronic pain, mental health, novel therapeutic

Meaghan Ferguson,1 Anton Svendrovski,2 Joel Katz1 1Faculty of Health, Department of Psychology, York University, Toronto, Ontario, Canada; 2UZIK Consulting Inc., Toronto, Ontario, CanadaCorrespondence: Meaghan Ferguson Email MFergusonresearch@gmail.comJoel Katz Email jkatz@yorku.caPurpose: Limb loss occurs for various reasons (trauma, infection, vascular diseases, tumors, congenital absence). Limb loss is known to result in several types of pain. Little is known about pain in residents with missing limbs admitted to complex chronic care (CCC) facilities. This study examined the presence of pain and its intensity in CCC residents with and without missing limbs.Methods: The Continuing Care Reporting System was accessed for data from residents admitted to Ontario com\plex chronic care facilities assessed with the Resident Assessment Instrument Minimum Data Set, V2.0. Propensity score matching (1:1 ratio) was used to identify a control resident without missing limbs for each case. McNemar’s test was used for dichotomous pain (Y/N) and Wilcoxon Signed Ranks test for ordinal pain (4-level and 7-level pain variables). Binary and multinomial logistic regression were used to quantify the relationship between missing limbs and reports of pain.Results: Missing limbs were reported by 2961 residents (2.1%, original n=139,920) resulting in 2212 propensity matched pairs. A significantly higher proportion of missing limb cases had pain (80%) versus controls (70%), χ2=64.43, p< 0.001. Significantly higher pain levels were found in cases versus controls (z=8.47, p< 0.001 for 4-level pain; z=8.57, p< 0.001 for 7-level pain). Residents with missing limbs were 1.46 (95% CI: 1.26– 1.70) times more likely to report pain than controls, p< 0.001.Conclusion: The results point to the need to better manage pain in CCC residents with missing limbs.Keywords: complex, disease, chronic, amputation, health

John A Hovanesian,1,2 Kelly K Nichols,3 Mitchell Jackson,4 James Katz,5 Arthur Chan,6 Mrudula B Glassberg,6 Brigitte Sloesen,7 Caroline Korves,8 Catherine Nguyen,9 Annie Syntosi7 1Harvard Eye Associates, Laguna Hills, CA, USA; 2UCLA Jules Stein Eye Institute, Los Angeles, CA, USA; 3School of Optometry, University of Alabama at Birmingham, Birmingham, AL, USA; 4Jacksoneye, Lake Villa, IL, USA; 5The Midwest Center for Sight, Des Plaines, IL, USA; 6Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA; 7Novartis Pharma AG, Basel, Switzerland; 8Analysis Group, Inc., Boston, MA, USA; 9Analysis Group, Inc., Los Angeles, CA, USACorrespondence: Annie SyntosiRetina Global Patient Access, Novartis Campus, Lichtstrasse 35, Basel, 4056, SwitzerlandTel +41 763785855Email annie.syntosi@novartis.comPurpose: This study evaluated real-world treatment of dry eye disease (DED) with lifitegrast.Patients and Methods: Ophthalmologists and optometrists treating patients with DED were invited to participate through a healthcare provider (HCP)-based panel. HCPs completed a provider survey and contributed data toward a chart review for up to five qualifying patients with DED who initiated lifitegrast ophthalmic solution (index date) between 01/01/2017 (US) or 01/01/2018 (Canada) and 06/30/2019. Patient demographics, treatments, clinical characteristics, and outcomes (ie, severity, signs, symptoms) were collected for the 6-month pre-index period and up to 12-months post-index.Results: For this study, 517 HCPs contributed 600 patient charts. Among 554 and 281 patients with follow-up at 6 and 12-months post-index, 512 (92.4%) and 238 (84.7%) patients had ongoing lifitegrast treatment, respectively. Other DED-related treatments were less frequently used post-index with lifitegrast vs pre-index: over-the-counter artificial tear use (45.2% vs 75.5%), topical corticosteroids (3.8% vs 18.8%), any cyclosporine (3.0% vs 20.5%). At 3-months (n=571) and 12-months (n=320) post-index vs pre-index, fewer patients had eye dryness (47 [8.2%] and 16 [5.0%] vs 525 [87.5%]), blurred vision (28 [4.9%] and 11 [3.4%] vs 346 [57.7%]), ocular burning/stinging (25 [4.4%] and 8 [2.5%] vs 336 [56.0%]), depression (8 [1.4%] and 9 [2.8%] vs 55 [9.2%]), fatigue (4 [0.7%] and 1 [0.3%] vs 82 [13.7%]), and headache (1 [0.2%] and 0 vs 19 [3.2%]). At 3 and 12-months post-index vs pre-index, average corneal staining score was numerically lower (2.7 and 2.0 vs 6.5), and average Schirmer score (10.6 and 10 vs 6.3) and tear film break-up time (7.3 and 8.0 vs 4.8) higher.Conclusion: The majority of patients had ongoing lifitegrast treatment 6-months post-index with reduction in overall treatment burden. Improvement in DED signs and symptoms, including QoL impacts, was evident at 3 months and up to 12 months after lifitegrast initiation.Keywords: symptoms, signs, severity, QoL

Meaghan Ferguson,1 Anton Svendrovski,2 Joel Katz1 1Department of Psychology, Faculty of Health, York University, Toronto, Ontario, Canada; 2Department of Psychology, UZIK Consulting Inc, Toronto, Ontario, CanadaCorrespondence: Meaghan Ferguson; Joel KatzYork University, 232 Behavioural Science Building, 4700 Keele Street, Toronto M3J 1P3, Ontario, CanadaTel +1 647 218 6717; +1 416 736 2100 ext. 40557Email mferg@yorku.ca; jkatz@yorku.caPurpose: Disease multimorbidity and pain is a complex, yet common, problem for the aging population, and a significant burden on the health-care systems around the world. Despite this, disease comorbidity and the association with pain in a complex chronic care population is not well understood. This study examined the most prevalent disease combinations and their association with pain.Patients and Methods: The study initially included 139,920 residents, aged 18– 101 years, admitted to publicly funded hospital facilities for complex chronic care in Canada between the years 2006 and 2016. Data were acquired through the Canadian Institute for Health Information (CIHI) Facility-Based Continuing Care Reporting System (CCRS). Descriptive and chi-square statistics were used to summarize and compare the sample characteristics. Binary logistic regression analyses were used to examine the association between multimorbid disease categories and pain outcomes.Results: The sample consisted of 139,573 residents (57% female), mostly older (mean age = 77.32 years), married (40%), or widowed (36%). Residents took an average of 11.9 medications and 77% were using analgesic medications. On average, residents had diagnoses from 3.06 disease categories (SD = 1.43). Heart/circulation diseases were the most prevalent among the sample (73%), with neurological second (46%) and musculoskeletal third (44%). Overall, 73% of residents reported pain, with 43% reporting moderate pain severity. Residents with multiple disease categories were more likely to report the presence of pain (OR = 1.08, 95% CI: 1.07– 1.08, p < 0.001), with each additional disease category associated with an 8% increase in the odds of reporting pain.Conclusion: The findings from this study help identify common comorbid disease patterns related to pain in an institutionalized, complex chronic care population. This information contributes to both the pain and multimorbidity literature, and is invaluable for creating care plans to meet the demands of a challenging population.Keywords: complex chronic disease, comorbidity, disease categories, health, health psychology

Hermine Lore Nguena Nguefack,1 M Gabrielle Pagé,2,3 Joel Katz,4 Manon Choinière,2,3 Alain Vanasse,5,6 Marc Dorais,7 Oumar Mallé Samb,1 Anaïs Lacasse1 1Département des Sciences de la santé, Université du Québec en Abitibi-Témiscamingue (UQAT), Rouyn-Noranda, Québec, Canada; 2Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada; 3Département d’anesthésiologie et de médecine de la douleur, Faculté de médecine, Université de Montréal, Montréal, Québec, Canada; 4Department of Psychology, Faculty of Health, York University, Toronto, Ontario, Canada; 5Département de médecine de famille et de médecine d’urgence, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Québec, Canada; 6Centre de recherche du Centre hospitalier Universitaire de Sherbrooke (CRCHUS), Sherbrooke, Québec, Canada; 7StatSciences Inc., Notre-Dame-de-lL’île-Perrot, Québec, CanadaCorrespondence: Anaïs LacasseDépartement des sciences de la santé, Université du Québec en Abitibi-Témiscamingue (UQAT), 445, Boul. de l’Université, Rouyn-Noranda (Qc) J9X 5E4, Québec, CanadaTel +1 819 762 0971, 2722Email lacassea@uqat.caAbstract: Trajectory modelling techniques have been developed to determine subgroups within a given population and are increasingly used to better understand intra- and inter-individual variability in health outcome patterns over time. The objectives of this narrative review are to explore various trajectory modelling approaches useful to epidemiological research and give an overview of their applications and differences. Guidance for reporting on the results of trajectory modelling is also covered. Trajectory modelling techniques reviewed include latent class modelling approaches, ie, growth mixture modelling (GMM), group-based trajectory modelling (GBTM), latent class analysis (LCA), and latent transition analysis (LTA). A parallel is drawn to other individual-centered statistical approaches such as cluster analysis (CA) and sequence analysis (SA). Depending on the research question and type of data, a number of approaches can be used for trajectory modelling of health outcomes measured in longitudinal studies. However, the various terms to designate latent class modelling approaches (GMM, GBTM, LTA, LCA) are used inconsistently and often interchangeably in the available scientific literature. Improved consistency in the terminology and reporting guidelines have the potential to increase researchers’ efficiency when it comes to choosing the most appropriate technique that best suits their research questions.Keywords: modelling techniques, growth mixture modelling, group-based trajectory modelling, latent class analysis, latent transition analysis, cluster analysis, sequence analysis

Brittany N Rosenbloom,1 M Gabrielle Pagé,2 Lisa Isaac,3 Fiona Campbell,3 Jennifer N Stinson,4 James G Wright,5 Joel Katz1,6 1Department of Psychology, York University, Toronto, ON, Canada; 2Centre de recherche du Centre hospitalier de l’Université de Montréal and Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada; 3Department of Anesthesia and Pain Medicine, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada; 4Department of Anesthesia and Pain Medicine, Hospital for Sick Children, and Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada; 5Department of Surgery, University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada; 6Department of Psychology, The Hospital for Sick Children, Toronto, ON, CanadaCorrespondence: Brittany N Rosenbloom; Joel KatzDepartment of Psychology, York University, 4700 Keele St., Toronto, ON M3J 1P3, CanadaEmail bnrosen@yorku.ca; jkatz@yorku.caBackground: Chronic postsurgical pain (CPSP) is a surgical complication associated with increased functional disability, psychological distress, and economic costs. The aims of this paper were to prospectively: (1) examine the incidence of CPSP 6 and 12 months after pediatric major surgery; (2) identify pain intensity and pain unpleasantness trajectories before, and up to 12 months after, surgery; (3) identify pre-operative factors that predict pain trajectory group membership; and (4) identify predictors of 12-month functional disability.Methods: This study followed 265 children aged 8–17 years at four time points (pre-surgical [T0], in-hospital [T1], 6 [T2] and 12 [T3] months after surgery). Children and parents completed pain and psychological questionnaires. In-hospital physical activity was monitored using actigraphy.Results and discussion: The incidence of moderate-to-severe CPSP at 6 and 12 months was 35% (95% CI 29.1% to 41.9%) and 38% (95% CI 32.4% to 45.1%), respectively. Three percent (95% CI 1.17% to 6.23%) and 4% (95% CI 1.45% to 6.55%) of children reported using opioids to manage pain at 6 and 12 months, respectively. Growth mixture modeling revealed a two-class trajectory model with a quadratic slope best fit the data for both pain intensity (Bayesian information criterion [BIC] = 3977.03) and pain unpleasantness (BIC = 3644.45) over the 12 months. Preoperative functional disability and cumulative in-hospital opioid consumption predicted pain intensity trajectories. Preoperative functional disability predicted pain unpleasantness trajectories. Preoperative functional disability (OR: 1.05, 95% CI: 1.01 to 1.09) and pain unpleasantness trajectories (OR: 2.59, 95% CI: 1.05 to 6.37) predicted 12-month moderate-to-severe functional disability.Conclusion: Pre-surgical functional disability is the only factor that predicts both 12-month functional disability and the course of pain intensity and pain unpleasantness ratings over the 12-month period.Keywords: pain, pediatrics, surgery, trajectory analysis, functional disability, anxiety, depression, parents

Judith L Nicholls,1 Muhammad A Azam,1,2 Lindsay C Burns,1,2 Marina Englesakis,3 Ainsley M Sutherland,1 Aliza Z Weinrib,1,2 Joel Katz,1,2,4 Hance Clarke1,4 1Pain Research Unit, Department of Anesthesia and Pain Medicine, Toronto General Hospital, 2Department of Psychology, York University, 3Library and Information Services, University Health Network, 4Department of Anesthesia, University of Toronto, Toronto, ON, Canada Background: Inadequately managed pain is a risk factor for chronic postsurgical pain (CPSP), a growing public health challenge. Multidisciplinary pain-management programs with psychological approaches, including cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based psychotherapy, have shown efficacy as treatments for chronic pain, and show promise as timely interventions in the pre/perioperative periods for the management of PSP. We reviewed the literature to identify randomized controlled trials evaluating the efficacy of these psychotherapy approaches on pain-related surgical outcomes. Materials and methods: We searched Medline, Medline-In-Process, Embase and Embase Classic, and PsycInfo to identify studies meeting our search criteria. After title and abstract review, selected articles were rated for risk of bias. Results: Six papers based on five trials (four back surgery, one cardiac surgery) met our inclusion criteria. Four papers employed CBT and two CBT-physiotherapy variant; no ACT or mindfulness-based studies were identified. Considerable heterogeneity was observed in the timing and delivery of psychological interventions and length of follow-up (1 week to 2–3 years). Whereas pain-intensity reporting varied widely, pain disability was reported using consistent methods across papers. The majority of papers (four of six) reported reduced pain intensity, and all relevant papers (five of five) found improvements in pain disability. General limitations included lack of large-scale data and difficulties with blinding. Conclusion: This systematic review provides preliminary evidence that CBT-based psychological interventions reduce PSP intensity and disability. Future research should further clarify the efficacy and optimal delivery of CBT and newer psychological approaches to PSP. Keywords: postsurgical pain, CBT, acute pain, chronic pain, chronic postsurgical pain, multidisciplinary pain management

Kathryn Curtis,1 Sander L Hitzig,2,3 Gitte Bechsgaard,4 Candice Stoliker,5 Charlene Alton,3 Nicole Saunders,3 Nicole Leong,6 Joel Katz1 1Department of Psychology, Faculty of Health, York University, 2St John’s Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, 3Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, 4Vidya Institute, 5Student Life, University of Toronto, Toronto, 6Community Care Access Centre, London, ON, Canada Objectives: The purpose of this randomized controlled trial was to evaluate the effects of a specialized yoga program for individuals with a spinal cord injury (SCI) on pain, psychological, and mindfulness variables. Materials and methods: Participants with SCI (n=23) were outpatients or community members affiliated with a rehabilitation hospital. Participants were randomized to an Iyengar yoga (IY; n=11) group or to a 6-week wait-list control (WLC; n=12) group. The IY group participated in a twice-weekly 6-week seated IY program; the WLC group participated in the same yoga program, after the IY group’s yoga program had ended. Pain, psychological, and mindfulness measures were collected at two time points for both groups (within 1–2 weeks before and after program 1 and at a third time point for the WLC group (within 1 week after program 2).Results: Linear mixed-effect growth models were conducted to evaluate the main effects of group at T2 (postintervention), controlling for T1 (preintervention) scores. T2 depression scores were lower (F1,18=6.1, P

Joel Katz,1,2 Samantha R Fashler,1 Claire Wicks,1 M Gabrielle Pagé,3 Kaley M Roosen,1 Valery Kleiman,1 Hance Clarke2 1Department of Psychology, York University, 2Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, 3Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, QC, Canada Background: This article reports three studies describing the development and validation of the 12-item Sensitivity to Pain Traumatization Scale (SPTS-12). SPT refers to the anxiety-related cognitive, emotional, and behavioral reactions to pain that resemble the features of a traumatic stress reaction.Methods: In Study 1, a preliminary set of 79 items was administered to 116 participants. The data were analyzed by using combined nonparametric and parametric item response theory resulting in a 12-item scale with a one-factor structure and good preliminary psychometric properties. Studies 2 and 3 assessed the factor structure and psychometric properties of the SPTS-12 in a community sample of 823 participants (268 with chronic pain and 555 pain-free) and a clinical sample of 345 patients (126 with chronic post-surgical pain, 92 with other nonsurgical chronic pain, and 127 with no chronic pain) at least 6 months after undergoing coronary artery bypass graft surgery, respectively. Results: The final SPTS-12 derived from Study 1 comprised 12 items that discriminated between individuals with different levels of SPT, with the overall scale showing good to very good reliability and validity. The results from Studies 2 and 3 revealed a one-factor structure for chronic pain and pain-free samples, excellent reliability and concurrent validity, and moderate convergent and discriminant validity. Conclusion: The results of the three studies provide preliminary evidence for the validity and reliability of the SPTS-12. Keywords: chronic pain, chronic post-surgical pain, trauma, psychology, scale development, measurement, item response theory analysis, factor analysis

Aliza Z Weinrib,1,2 Lindsay C Burns,1,2 Alex Mu,1 Muhammad Abid Azam,1,2 Salima SJ Ladak,1 Karen McRae,1,3 Rita Katznelson,1,3 Saam Azargive,1 Cieran Tran,1 Joel Katz,1–3 Hance Clarke1,3 1Pain Research Unit, Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, 2Department of Psychology, York University, 3Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada Abstract: In an era of growing concern about opioid prescribing, the postsurgical period remains a critical window with the risk of significant opioid dose escalation, particularly in patients with a history of chronic pain and presurgical opioid use. The purpose of this case report is to describe the multidisciplinary care of a complex, postsurgical pain patient by an innovative transitional pain service (TPS). A 59-year-old male with complex chronic pain, as well as escalating long-term opioid use, presented with a bleeding duodenal ulcer requiring emergency surgery. After surgery, the TPS provided integrated pharmacological and behavioral treatment, including buprenorphine combined with naloxone and acceptance and commitment therapy (ACT) using the ACT Matrix. The result was dramatic pain reduction and improved functioning and quality of life after 40+ years of chronic pain, thus changing the pain trajectory of a chronic, complex, opioid-dependent patient. Keywords: transitional pain service, postsurgical pain, chronic pain, opioid dependence, opioid weaning, acceptance and commitment therapy

Samantha R Fashler, Joel Katz Department of Psychology, York University, Toronto, Ontario, Canada Abstract: Attentional biases to painful stimuli are evident in individuals with chronic pain, although the directional tendency of these biases (ie, toward or away from threat-related stimuli) remains unclear. This study used eye-tracking technology, a measure of visual attention, to evaluate the attentional patterns of individuals with and without chronic pain during exposure to injury-related and neutral pictures. Individuals with (N=51) and without chronic pain (N=62) completed a dot-probe task using injury-related and neutral pictures while their eye movements were recorded. Mixed-design analysis of variance evaluated the interaction between group (chronic pain, pain-free) and picture type (injury-related, neutral). Reaction time results showed that regardless of chronic pain status, participants responded faster to trials with neutral stimuli in comparison to trials that included injury-related pictures. Eye-tracking measures showed within-group differences whereby injury-related pictures received more frequent fixations and visits, as well as longer average visit durations. Between-group differences showed that individuals with chronic pain had fewer fixations and shorter average visit durations for all stimuli. An examination of how biases change over the time-course of stimulus presentation showed that during the late phase of attention, individuals with chronic pain had longer average gaze durations on injury pictures relative to pain-free individuals. The results show the advantage of incorporating eye-tracking methodology when examining attentional biases, and suggest future avenues of research. Keywords: attentional biases, chronic pain, avoidance, hypervigilance, dot probe

Joel Katz,1–3 Aliza Weinrib,1,2 Samantha R Fashler,2 Rita Katznelzon,1,3 Bansi R Shah,1 Salima SJ Ladak,1 Jiao Jiang,1 Qing Li,1 Kayla McMillan,1 Daniel Santa Mina,5,6 Kirsten Wentlandt,7 Karen McRae,1,3 Diana Tamir,1,3 Sheldon Lyn,1,3 Marc de Perrot,8 Vivek Rao,9 David Grant,10 Graham Roche-Nagle,11 Sean P Cleary,12 Stefan OP Hofer,13 Ralph Gilbert,14 Duminda Wijeysundera,1,3 Paul Ritvo,15 Tahir Janmohamed,16 Gerald O’Leary,1,3 Hance Clarke1,3 1Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 2Department of Psychology, York University, 3Department of Anesthesia, University of Toronto, 4Palliative Care, University Health Network, University of Toronto, 5Princess Margaret Cancer Centre, University Health Network, University of Toronto, 6Faculty of Kinesiology and Physical Education, University of Toronto, 7Department of Family and Community Medicine, University of Toronto, 8Division of Thoracic Surgery, Toronto General Hospital, 9Division of Cardiovascular Surgery, Toronto General Hospital, 10Multiorgan Transplant Program, Toronto General Hospital, 11Division of Vascular Surgery, Toronto General Hospital, 12Division of General Surgery, Toronto General Hospital, 13Division of Plastic Surgery, Toronto General Hospital, 14Division of Otolaryngology – Head and Neck Surgery, Toronto General Hospital, 15Department of Kinesiology and Health Science, York University, 16ManagingLife, Toronto, ON, CanadaAbstract: Chronic postsurgical pain (CPSP), an often unanticipated result of necessary and even life-saving procedures, develops in 5–10% of patients one-year after major surgery. Substantial advances have been made in identifying patients at elevated risk of developing CPSP based on perioperative pain, opioid use, and negative affect, including depression, anxiety, pain catastrophizing, and posttraumatic stress disorder-like symptoms. The Transitional Pain Service (TPS) at Toronto General Hospital (TGH) is the first to comprehensively address the problem of CPSP at three stages: 1) preoperatively, 2) postoperatively in hospital, and 3) postoperatively in an outpatient setting for up to 6 months after surgery. Patients at high risk for CPSP are identified early and offered coordinated and comprehensive care by the multidisciplinary team consisting of pain physicians, advanced practice nurses, psychologists, and physiotherapists. Access to expert intervention through the Transitional Pain Service bypasses typically long wait times for surgical patients to be referred and seen in chronic pain clinics. This affords the opportunity to impact patients' pain trajectories, preventing the transition from acute to chronic pain, and reducing suffering, disability, and health care costs. In this report, we describe the workings of the Transitional Pain Service at Toronto General Hospital, including the clinical algorithm used to identify patients, and clinical services offered to patients as they transition through the stages of surgical recovery. We describe the role of the psychological treatment, which draws on innovations in Acceptance and Commitment Therapy that allow for brief and effective behavioral interventions to be applied transdiagnostically and preventatively. Finally, we describe our vision for future growth. Keywords: Transitional Pain Service, chronic postsurgical pain, transition to chronic pain, opioid use, multidisciplinary treatment

Lindsay C Burns,1–3 Sarah E Ritvo,1 Meaghan K Ferguson,1 Hance Clarke,3–5 Ze’ev Seltzer,3,5 Joel Katz1,3–5 1Department of Psychology, York University, Toronto, ON, Canada; 2Arthritis Research Centre of Canada, Vancouver, BC, Canada; 3Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada; 4Department of Anesthesia, University of Toronto, Toronto, ON, Canada; 5Centre for the Study of Pain, Faculties of Dentistry and Medicine, University of Toronto, Toronto, ON, Canada Background: Total knee arthroplasty (TKA) is a common and costly surgical procedure. Despite high success rates, many TKA patients develop chronic pain in the months and years following surgery, constituting a public health burden. Pain catastrophizing is a construct that reflects anxious preoccupation with pain, inability to inhibit pain-related fears, amplification of the significance of pain vis-à-vis health implications, and a sense of helplessness regarding pain. Recent research suggests that it may be an important risk factor for untoward TKA outcomes. To clarify this impact, we systematically reviewed the literature to date on pain catastrophizing as a prospective predictor of chronic pain following TKA. Methods: We searched MEDLINE, EMBASE, and PsycINFO databases to identify articles related to pain catastrophizing, TKA, risk models, and chronic pain. We reviewed titles and abstracts to identify original research articles that met our specified inclusion criteria. Included articles were then rated for methodological quality. including methodological quality. Due to heterogeneity in follow-up, analyses, and outcomes reported across studies, a quantitative meta-analysis could not be performed. Results: We identified six prospective longitudinal studies with small-to-mid-sized samples that met the inclusion criteria. Despite considerable variability in reported pain outcomes, pain catastrophizing was identified as a significant predictor of chronic pain persisting ≥3 months following TKA in five of the studies assessed. Limitations of studies included lack of large-scale data, absence of standardized pain measurements, inadequate multivariate adjustment, such as failure to control for analgesic use and other relevant covariates, and failure to report non-significant parameter estimates. Conclusion: This study provides moderate-level evidence for pain catastrophizing as an independent predictor of chronic pain post-TKA. Directions for future research include larger, well-controlled studies with standard pain outcomes, identification of clinically-relevant catastrophizing cut-offs that predict pain outcomes, investigation of other psychosocial risk factors, and assessment of interventions aimed to reduce pain catastrophizing on chronic pain outcomes following TKA surgery. Keywords: pain catastrophizing, total knee arthroplasty, total knee replacement, knee arthroplasty, risk factors, chronic pain

Samantha R Fashler, Joel Katz Department of Psychology, York University, Toronto, ON, CanadaAbstract: The present study used eye-tracking technology to assess whether individuals who report chronic pain direct more attention to sensory pain-related words than do pain-free individuals. A total of 113 participants (51 with chronic pain, 62 pain-free) were recruited. Participants completed a dot-probe task, viewing neutral and sensory pain-related words while their reaction time and eye movements were recorded. Eye-tracking data were analyzed by mixed-design analysis of variance with group (chronic pain versus pain-free) as the between-subjects factor, and word type (sensory pain versus neutral) as the within-subjects factor. Results showed a significant main effect for word type: all participants attended to pain-related words more than neutral words on several eye-tracking parameters. The group main effect was significant for number of fixations, which was greater in the chronic pain group. Finally, the group by word type interaction effect was significant for average visit duration, number of fixations, and total late-phase duration, all greater for sensory pain versus neutral words in the chronic pain group. As well, participants with chronic pain fixated significantly more frequently on pain words than did pain-free participants. In contrast, none of the effects for reaction time were significant. The results support the hypothesis that individuals with chronic pain display specific attentional biases toward pain-related stimuli and demonstrate the value of eye-tracking technology in measuring differences in visual attention variables.Keywords: attention, chronic pain, dot-probe task, eye-tracking

M Gabrielle Pagé,1 Fiona Campbell,2,3 Lisa Isaac,2,3 Jennifer Stinson,2,4 Joel Katz1,3,5 1Department of Psychology, Faculty of Health, York University, Toronto, ON, Canada; 2Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada; 3Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; 4Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada; 5Department of Psychology, Hospital for Sick Children, Toronto, ON, Canada Background: The goal of this longitudinal study was to examine the associations among psychological factors and pain reports of children and their parents over the 12 month period after pediatric surgery. Materials and methods: Included in the study were 83 children aged 8–18 years undergoing major surgery. In each case, the child and one of their parents completed measures of pain intensity and unpleasantness, psychological function, and functional disability at 48–72 hours, 2 weeks (child only), 6 months, and 12 months after surgery. Results: The strength of the correlation coefficients between the psychological measures of the parent and their child increased significantly over time. There was a fair level of agreement between parent ratings of child acute and chronic pain (6 months after surgery) and the child's actual ratings. Parent and child pain anxiety scores 48–72 hours after surgery interacted significantly to predict pain intensity, pain unpleasantness, and functional disability levels 2 weeks after discharge from hospital. Parent pain catastrophizing scores 48–72 hours after surgery predicted child pain intensity reports 12 months later. Conclusion: These results raise the possibility that as time from surgery increases, parents exert greater and greater influence over the pain response of their children, so that by 12 months postsurgery mark, parent pain catastrophizing (measured in the days after surgery) is the main risk factor for the development of postsurgical pain chronicity. Keywords: pain anxiety, pain catastrophizing, children, parental risk factors, postsurgical pain

M Gabrielle Pagé,1 Jennifer Stinson,2,3 Fiona Campbell,2,4 Lisa Isaac,2,4 Joel Katz1,4,51Department of Psychology, York University, 2Department of Anesthesia and Pain Medicine, Hospital for Sick Children, 3Lawrence S Bloomberg Faculty of Nursing, 4Department of Anesthesia, University of Toronto, 5Department of Psychology, Hospital for Sick Children, Toronto, ON, CanadaBackground: The goals of this study were to examine the trajectory of pediatric chronic postsurgical pain (CPSP) over the first year after surgery and to identify acute postsurgical predictors of CPSP.Methods: Eighty-three children aged 8–18 years (mean 13.8, standard deviation 2.4) who underwent major orthopedic or general surgery completed pain and pain-related psychological measures at 48–72 hours, 2 weeks (pain anxiety and pain measures only), and 6 and 12 months after surgery.Results: Results showed that 1 year after surgery, 22% of children developed moderate to severe CPSP with minimal functional disability. Children who reported a Numeric Rating Scale pain-intensity score ≥ 3 out of 10 two weeks after discharge were more than three times as likely to develop moderate/severe CPSP at 6 months and more than twice as likely to develop moderate/severe CPSP at 12 months than those who reported a Numeric Rating Scale pain score < 3 (6-month relative risk 3.3, 95% confidence interval 1.2–9.0 and 12-month relative risk 2.5, 95% confidence interval 0.9–7.5). Pain unpleasantness predicted the transition from acute to moderate/severe CPSP, whereas anxiety sensitivity predicted the maintenance of moderate/severe CPSP from 6 to 12 months after surgery.Conclusions: This study highlights the prevalence of pediatric CPSP and the role played by psychological variables in its development/maintenance. Risk factors that are associated with the development of CPSP are different from those that maintain it.Keywords: chronic postsurgical pain, children, adolescents, anxiety sensitivity

Brittany N Rosenbloom,1 Sobia Khan,2 Colin McCartney,3 Joel Katz41Institute of Medical Science, University of Toronto, Toronto, Ontario, 2School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, 3Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, 4Department of Psychology, York University, Toronto, Ontario, CanadaBackground: 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.Keywords: persistent pain, psychological outcomes, traumatic injury, musculoskeletal, systematic review, pain intensity, injury severity, risk and protective factors

M Gabrielle Pagé,1 Jennifer Stinson,2,3 Fiona Campbell,2,4 Lisa Isaac,2,4 Joel Katz1,4,51Department of Psychology, Faculty of Health, York University, 2Department of Anesthesia and Pain Medicine, Hospital for Sick Children, 3Lawrence S Bloomberg Faculty of Nursing, University of Toronto, 4Department of Anesthesia, Faculty of Medicine, University of Toronto, 5Department of Psychology, Hospital for Sick Children, Toronto, ON, CanadaBackground: Post-surgical pain is prevalent in children, yet is significantly understudied. The goals of this study were to examine gender differences in pain outcomes and pain-related psychological constructs postoperatively and to identify pain-related psychological correlates of acute post-surgical pain (APSP) and predictors of functional disability 2 weeks after hospital discharge.Methods: Eighty-three children aged 8–18 (mean 13.8 ± 2.4) years who underwent major orthopedic or general surgery completed pain and pain-related psychological measures 48–72 hours and 2 weeks after surgery.Results: Girls reported higher levels of acute postoperative anxiety and pain unpleasantness compared with boys. In addition, pain anxiety was significantly associated with APSP intensity and functional disability 2 weeks after discharge, whereas pain catastrophizing was associated with APSP unpleasantness.Conclusion: These results highlight the important role played by pain-related psychological factors in the experience of pediatric APSP by children and adolescents.Keywords: acute post-surgical pain, children, adolescents, pain anxiety, pain catastrophizing

Kathryn Curtis, Anna Osadchuk, Joel KatzDepartment of Psychology, Faculty of Health, York University, Toronto, ON, CanadaObjectives: Fibromyalgia (FM) is a chronic condition characterized by widespread musculoskeletal pain, fatigue, depression, and hypocortisolism. To date, published studies have not investigated the effects of yoga on cortisol in FM. This pilot study used a time series design to evaluate pain, psychological variables, mindfulness, and cortisol in women with FM before and after a yoga intervention.Methods: Participants (n = 22) were recruited from the community to participate in a 75 minute yoga class twice weekly for 8 weeks. Questionnaires concerning pain (intensity, unpleasantness, quality, sum of local areas of pain, catastrophizing, acceptance, disability), anxiety, depression, and mindfulness were administered pre-, mid- and post-intervention. Salivary cortisol samples were collected three times a day for each of two days, pre- and post-intervention.Results: Repeated measures analysis of variance (ANOVA) revealed that mean ± standard deviation (SD) scores improved significantly (p < 0.05) from pre- to post-intervention for continuous pain (pre: 5.18 ± 1.72; post: 4.44 ± 2.03), pain catastrophizing (pre: 25.33 ± 14.77; post: 20.40 ± 17.01), pain acceptance (pre: 60.47 ± 23.43; post: 65.50 ± 22.93), and mindfulness (pre: 120.21 ± 21.80; post: 130.63 ± 20.82). Intention-to-treat analysis showed that median AUC for post-intervention cortisol (263.69) was significantly higher (p < 0.05) than median AUC for pre-intervention levels (189.46). Mediation analysis revealed that mid-intervention mindfulness scores significantly (p < 0.05) mediated the relationship between pre- and post-intervention pain catastrophizing scores.Discussion: The results suggest that a yoga intervention may reduce pain and catastrophizing, increase acceptance and mindfulness, and alter total cortisol levels in women with FM. The changes in mindfulness and cortisol levels may provide preliminary evidence for mechanisms of a yoga program for women with FM. Future studies should use an RCT design with a larger sample size.Keywords: fibromyalgia, pain, cortisol, yoga, psychological variables

Carole Drexel1, Anne Jacobson2, Nicola A Hanania3, Ben Whitfield4, Jay Katz5, Thomas Sullivan51Potomac Center for Medical Education, Columbia, MD, USA; 2Potomac Center for Medical Education, Port St John, FL, USA; 3Baylor College of Medicine, Houston, TX, USA; 4CE Outcomes, LLC, Birmingham, AL, USA; 5Rockpointe, Columbia, MD, USABackground: Major clinical gaps impede the evidence-based treatment of chronic obstructive pulmonary disease (COPD) in the primary care setting. Studies are needed to measure the effectiveness of continuing medical education (CME) on improving physician competency and performance toward evidence-based COPD care.Methods: Between September 26, 2009 and December 12, 2009, 769 primary care physicians participated in a series of 12 regional, live, interactive, case-based, multiformat, half-day CME programs on COPD. A subgroup of randomly selected participants (n = 50) and demographically matched nonparticipants (n = 50) completed surveys that included case vignettes, a validated tool for measuring physician performance in clinical practice. Cohen's d was used to calculate the magnitude of difference between participants and nonparticipants in the delivery of evidence-based care.Results: Physicians who participated in CME programs were 50% more likely to provide evidence-based COPD care than physicians who did not participate. Compared with nonparticipants, participating physicians were more likely to recognize COPD correctly in a patient presenting with dyspnea (74% versus 94%, P = 0.007), recognize that women may have a greater susceptibility than men to the toxic effects of smoking (54% versus 90%, P < 0.001), and identify the mechanisms of action of emerging therapies (33% versus 65%, P = 0.003).Conclusion: Physicians who participated in a half-day regional CME program on COPD diagnosis, staging, and treatment were significantly more likely than nonparticipants to deliver evidence-based COPD care. With multiformat, interactive, focused educational interventions, physicians can make diagnostic and therapeutic choices in the primary care setting that align more closely with current guidelines and clinical evidence in COPD management.Keywords: COPD, continuing medical education, practice patterns, outcomes measurement, case vignettes, effect size