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In line with other major surgeries including breast cancer surgery (BCS), recent studies suggest a striking rate of chronic postsurgical pain (CPSP) following breast reconstruction. This commentary will critically examine evidence for the degree to which the prevalence of CPSP following breast reconstruction is directly attributable to reconstructive surgery. The discussion will trace similarities and distinctions between breast reconstruction and BCS in considering the risk for CPSP, and describe recent advances in the definition of CPSP, highlighting methodological limitations in the general investigation of CPSP, which also characterize the study of CPSP more specifically for breast reconstruction outcome. A convenience sample of relevant studies examining CPSP following breast reconstruction reveals inadequate evidence to support a serious concern for reconstruction-induced CPSP and further that these studies fail to adhere to recommended methodological standards to effectively isolate surgery as the etiology of persistent pain reported by women following reconstructive surgery. Suggestions for future exploration of problematic chronic pain after breast reconstruction are considered.

Emotional and social adaptation is a central challenge for women with recently diagnosed breast cancer [1]. Prevalence rates for anxiety and depressive disorders among a heterogeneous sample of cancer patients are estimated to range from 10 to 40% [2,3], and women with newly diagnosed breast cancer demonstrate comparable rates of affective distress [4]. As a result, breast reconstruction outcome studies routinely assess psychological variables and their influence on various patient-specific outcomes such as aesthetic satisfaction and functional status. While these studies typically include measures of preoperative depression and anxiety as possible predictors of clinical outcomes, relatively little attention has been paid to the identification of suicidal ideation (SI) in this cohort. This may seem surprising given evidence that depression is highly prevalent among cancer patients and, when increasingly severe, presents a primary risk for SI and intention [5]. While numerous studies describe the incidence of suicide among cancer patients in general [6], and women with breast cancer more specifically [7], there is sparse information on the prevalence of suicidal ideation among these populations. The assessment of SI in breast cancer patients presenting for reconstruction is in line with the American College of Surgeons (ACS) Commission on Cancer guidelines for distress screening of all cancer patients by 2015 [8]. We examined the prevalence of preoperative anxiety and depression among women enrolled in an ongoing prospective study of post-mastectomy breast reconstruction procedure outcomes. The prevalence of moderate-to-severe SI challenged the study team to devise an identification and response system to intervene with potential at-risk patients and triage them to appropriate mental health attention. We describe this system and propose its consideration for future surgical outcome studies where depression and SI are of reasonable concern.

Background Chronic postsurgical pain (CPSP) is a reported risk for women undergoing breast reconstruction, but it remains unclear that such persistent pain is induced by reconstructive surgery. To address this concern, this prospective cohort study examined the prevalence of and risk factors associated with CPSP among women undergoing breast reconstruction. Materials and methods Women (n = 1996) recruited for the Mastectomy Reconstruction Outcomes Consortium (MROC) Study were assessed preoperatively and at two-years postoperatively for relevant medical/.surgical variables, pain experience, body physical well-being, anxiety, depression, and reconstruction procedure type and characteristics. Results Nearly half of the entire sample reported some level of preoperative pain. At two years there were statistically significant but not clinically meaningful increases in both pain intensity and chest/upper body discomfort but a decrease in affective pain rating. Average clinical pain severity was strikingly similar for preoperative and postoperative assessments. Preoperative levels of pain, acute postoperative pain, and (marginally) level of depression held consistent relationship at two-year follow-up with all outcome measures. Autologous flap reconstruction was associated with more severe CPSP compared to TE/I reconstruction. Older age, higher BMI, bilateral reconstruction, and adjuvant radiation and chemotherapy were associated with CPSP and chest/upper body discomfort for at least one outcome measure at two years. Conclusions The substantial rate of preoperative pain and comparable prevalence of preoperative and postoperative pain ratings suggest that persistent pain after breast reconstruction may not necessarily reflect surgery-induced pain. Future research will need to determine those factors that contribute to long-term pain following breast reconstruction.

Unplanned hospital readmissions are common early post-kidney transplantation. We investigated the relationship between early hospital readmissions and clinical outcomes in a single-center retrospective study that included all adult kidney transplant patients between 2004 and 2008 with follow-up to December 2012. The early hospital readmissions within the first 30 d were numbered and the diagnosis ascertained. Patients were grouped as none, once, and twice or more readmissions. Predictors of early readmissions were assessed, and clinical outcomes and patient and death-censored kidney survival were compared. Among 1064 patients, 203 (19.1%) patients had once and 83 (7.8%) patients had twice or more readmissions within 30 d. Surgical complications, infections, and acute kidney injuries/acute rejection were three most common diagnoses. The length of initial hospital stay and African American race were among the variables associated significantly with readmissions. Patients with early readmissions had lower baseline renal function (p

Chronic opioid usage (COU) for analgesia is common among patients with end-stage renal disease. In order to test whether a prior history of COU negatively affects post-kidney transplant outcomes, we retrospectively examined clinical outcomes in adult kidney transplant patients. Among 1064 adult kidney transplant patients, 452 (42.5%) reported the presence of various body pains and 108 (10.2%) reported a prior history of COU. While the overall death or kidney graft loss was not statistically different between patients with and without a history of COU, the cumulative mortality rate at 1, 3, and 5 years after transplantation, and during the entire study period, appeared significantly higher for patients with than without a history of COU (6.5, 18.5, and 20.4 vs. 3.2, 7.5, and 12.7%, respectively). Multivariate Cox regression analysis adjusted for potential confounding factors in entire cohorts and Cox regression analysis in 1:3 propensity-score matched cohorts suggest that a positive history of COU was significantly associated with nearly a 1.6- to 2-fold increase in the risk of death (hazard ratio 1.65, 95% confidence interval 1.04-2.60, and hazard ratio 1.92, 95% confidence interval 1.08-3.42, respectively). Thus, a history of chronic opioid usage prior to transplantation appears to be associated with increased mortality risk. Additional studies are warranted to confirm the observed association and to understand the mechanisms.

Introduction Postmastectomy breast reconstruction has become an increasingly important component of breast cancer treatment. Unfortunately, some patients experience severe postoperative pain, placing them at risk for increased clinical morbidity and the development of disabling chronic pain. To identify patients at risk, we prospectively evaluated patient characteristics and medical/surgical variables associated with more severe acute post-reconstruction pain. Methods Women (N = 2207; 1-week 82.8% response rate) undergoing breast reconstruction were assessed for pain experience, anxiety, depression, and sociodemographic characteristics before surgery. Pain assessments were made preoperatively and postoperatively at 1 week using validated survey instruments including the McGill Pain Questionnaire-Short Form (MPQ-SF), Numerical Pain Rating Scale (NPRS), and BREAST-Q Chest and Upper Body scale. Depressive symptoms and anxiety severity were assessed by the Patient Health Questionnaire and Generalized Anxiety Disorders Scale, respectively. Mixed-effects regression modeling was used to examine the relationships between patient characteristics and medical/surgical variables and 1-week postoperative pain. Results Younger age; bilateral reconstruction; and severity of preoperative pain, anxiety, and depression were associated with more severe acute postoperative pain on all the pain measures and BREAST-Q. Surgical procedure type indicated less severe postoperative pain for PTRAM, DIEP, and SIEA reconstructive surgery when compared with tissue expander/implant reconstruction. Conclusions This study identifies patients at risk for severe acute postoperative pain following breast reconstruction. These findings will allow plastic surgeons to better tailor postoperative care to improve patient comfort, reduce clinical morbidity, and enhance patient satisfaction with their surgical outcome.

The field of pain medicine has shifted from multidisciplinary rehabilitation to procedure-focused interventional pain medicine (IPM). Considerable controversy exists regarding the efficacy of IPM and its more narrow focus on nociception as an exclusive target of pain treatment. This topical review aims to examine pain research and treatment outcome studies that support a biopsychosocial model of pain, and to critique the clinical practice of IPM given its departure from the premises of a biopsychosocial model. A modern definition of pain and findings from clinical and basic science studies indicate that pain-related psychological factors are integral to pain perception. The clinical viability of IPM is challenged based upon its biomedical view of peripheral nociception as a primary source of pain and the potential of this viewpoint to foster maladaptive pain attributions and discourage the use of pain coping strategies among chronic pain patients. IPM should adopt a biopsychosocial perspective on pain and operate within a framework of multidisciplinary pain rehabilitation to improve its effectiveness.

Persons with spinal cord injury (SCI) suffer from a variety of secondary medical conditions that can require critical care intervention. This study examined emergency medicine (EM) utilization by veterans with SCI and also surveyed EM resident physicians’ familiarity with SCI medicine. Veterans with SCI utilize emergency care relatively frequently, with 20% requiring a visit within 1 year. Our survey found variable and, for some topics, disappointing accuracy of responses to clinical vignettes portraying SCI patients presenting for critical care. These results suggest that disparities in SCI medical treatment outcomes may result from inadequate training in SCI medicine among EM physicians.

Persistent pain is a common but undesirable outcome of breast cancer surgery. With the increasing popularity of breast reconstruction after mastectomy for breast cancer, researchers have recently directed attention to the prevalence of intractable pain due to reconstructive surgery. However, available studies that examine factors associated with the development of postreconstruction pain are limited to clinical investigations that have been descriptive, retrospective, or cross-sectional in their study design. There is obvious clinical value identifying presurgical factors that are associated with increased risk for the onset of chronic pain after breast reconstruction surgery. This prospective study examined the effect of presurgical psychological distress and somatic preoccupation in predicting persistent pain after postmastectomy reconstructive surgery. Two hundred and ninety-five women seeking reconstruction at the time of mastectomy or delayed from prior mastectomy served as the subject pool. Surgical intervention included either expander/implant or autologous tissue reconstruction. Before surgery, subjects completed psychological inventories to assess levels of affective distress, somatization, depressive and anxiety symptoms, and somatic anxiety/preoccupation. At 1- and 2-year follow-up, subjects rated the degree to which they experienced problems with breast pain, abdominal pain, and back pain. Multiple linear regression analyses indicated that affective distress, depressive and anxiety symptoms, and somatization held significant association with abdominal and back pain at both 1- and 2-year follow-up. For breast pain, all the psychological measures predicted more severe pain at 1 year, but none retained significant association at year 2. Somatic anxiety had more variable relation to pain complaints. These data highlight pain morbidity as a potential negative outcome of breast reconstruction and the significant influence of affective distress and somatic preoccupation in the development of postreconstruction chronic pain. These data support continued investigation into the role of presurgical psychological screening and intervention for women seeking reconstructive surgery.

Significant differences in surface electromyography (SEMG) have been reported between persons with low back pain (LBP) and normal, healthy controls. This manuscript presents a systematic meta-analytic review of studies examining SEMG differences between these groups. Forty-four articles were identified using MEDLINE and a review of reference lists in articles. For static SEMG, the largest effect size was observed for SEMG while standing, with subjects having LBP demonstrating higher SEMG. The effect size for flexion/relaxation measures was found to be very high (d 1.71). Studies examining SEMG during isometric exercise or muscle recovery following exercise produced inconsistent findings. Sensitivity and specificity of SEMG for dynamic SEMG measures averaged 88.8% and 81.3%. Most classification schemes were statistically determined and utilized a combina- tion of measures. Only one published study prospectively validated a classification scheme. SEMG measures of flexion-relaxation appear to distinguish LBP subjects from controls with good accuracy, and the sensitivity and specificity of SEMG can be increased by using multiple measures. Further research is needed to determine the combination of measures that are cost-effective, reliable, valid and discriminate with a high degree of accuracy between healthy persons and those with LBP. Perspective: SEMG is a simple and noninvasive measure of muscle activity. SEMG measures hold promise as an objective marker of LBP.

Objective: This study examined the relationship of level of educational (LOE) achievement to pain experience, affective disturbance, and perceived disability among women with chronic pelvic pain presenting for pain treatment. Methods: 187 patients completed a battery of self-report inventories assessing pain, psychological status, and functional ability. Educational attainment was stratified across five levels from “less than high school” to “graduate/professional school.” Results: Significant inverse associations were found between lower educational achievement and more severe pain, somatic preoccupation, emotional suffering and guardedness, and functional impairment. No differences were obtained across the groups for age, duration of pain, or symptoms of depression. Conclusions: These data provide support for the importance of socioeconomic factors, particularly LOE, in furthering our understanding of the morbidity observed among women suffering chronic pelvic pain.

Purpose: This study determined whether there is an association between psychological and socioeconomic characteristics and the long-term outcome of operative treatment for patients with sensory neurogenic thoracic outlet syndrome (N-TOS). Methods: Clinical records, preoperative psychological testing results, and long-term follow-up questionnaire data were reviewed for consecutive patients who underwent surgery for N-TOS from 1990 to 1999. Multivariate logistic regression models were developed as a means of identifying independent risk factors for postoperative disability. Results: Operative decompression of the brachial plexus via a supraclavicular approach was performed for upper extremity pain and paresthesia with no mortality and minimal morbidity in 170 patients. After an average follow-up period of 47 months, 65% of patients reported improved symptoms, and 64% of patients were satisfied with their operative outcome. However, 35% of patients remained on medication, and 18% of patients were disabled. Preoperative factors associated with persistent disability include major depression (odds ratio [OR], 15.7; P = .02), not being married (OR, 7.9; P = .04), and having less than a high school education (OR, 8.1; P = .09). Conclusion: Operative decompression was beneficial for most patients. Psychological and social factors, including depression, marital status, and education, are associated with self-reported disability. The impact of the preoperative treatment of depression on the outcome of TOS decompression should be studied prospectively. (J Vasc Surg 2001;33:1220-5.)

In the past decade, changing attitudes toward breast reconstruction among both patients and providers have led a growing number of women to seek breast reconstruction after mastectomy. Although investigators have documented the psychological, social, emotional, and functional benefits of breast reconstruction, little research has evaluated the effects of procedure choice on these outcomes. The current study prospectively evaluated and compared psychosocial outcomes for three common options for mastectomy reconstruction: tissue expander/implant, pedicle TRAM, and free TRAM techniques. In a prospective cohort design, patients undergoing postmastectomy reconstruction for the first time with expander/implant, pedicle TRAM, or free TRAM procedures were recruited from 12 centers and 23 plastic surgeons in the United States and Canada. Before reconstruction and at 1 year after reconstruction, patients were evaluated by a battery of questionnaires consisting of both generic and condition-specific surveys. Outcomes assessed included emotional well-being, vitality, general mental health, social functioning, functional well-being, social well-being, and body image. Baseline (preoperative) scores and the change in scores (the difference between postoperative and preoperative scores) were compared across procedure types using t tests and analysis of covariance. Preoperative and 1-year postoperative surveys were obtained from 273 patients. Procedure type was reported in 250 patients, of whom 56 received implant reconstructions, 128 pedicle TRAM flaps, and 66 free TRAM flaps. A total of 161 immediate and 89 delayed reconstructions were performed. Among women receiving immediate reconstruction, significant improvements were observed in all psychosocial variables except body image. However, no significant effects of procedure type on these changes over time existed. Similarly, delayed reconstruction patients had significant increases in emotional well-being, vitality, general mental health, functional well-being, and body image. Although the choice of reconstructive technique did not significantly impact most of these outcomes, significant differences existed among procedure types for three psychosocial subscales. Patients undergoing delayed expander/implant reconstructions reported greater improvements in vitality and social well-being relative to women receiving delayed TRAM procedures. By contrast, delayed TRAM patients noted significantly greater gains in body image compared with women choosing delayed expander-implant reconstruction. The authors conclude that both immediate and delayed breast reconstructions provide substantial psychosocial benefits for mastectomy patients. Although the choice of reconstructive procedure does not seem to significantly affect improvements in psychosocial status with immediate reconstruction, our data suggest that procedure type does have a significant effect on gains in vitality and body image for women undergoing delayed reconstruction.

Objective: The goal of this study was to examine the relative importance of global affective distress, self-report of depressive symptoms, and presence or absence of major depression to the experience of chronic pain. Setting: A multidisciplinary pain program at a university medical center was the setting for this study. Patients: Subjects in this study were 211 consecutive patients with chronic pain. Outcome Measures: Pain duration, compensation, and litigation status were controlled for in the statistical analyses, as each correlated significantly with at least one of the measures of affect. Global affective distress was assessed using the Global Severity Index (GSI) from the Brief Symptom Inventory. The Beck Depression Inventory and the Center for Epidemiological Studies Depression Scale were used as measures of self-report of depressive symptoms. Presence or absence of major depression was based on DSM-IV criteria. Results and Conclusions: The GSI, Beck Depression Inventory, and Center for Epidemiological Studies Depression Scale were significantly correlated with each measure of the experience of pain, although clinical depression was only significantly related to self-reported disability and negative thoughts about pain. The self-report measures of depression maintained their relation to the dependent measures when the somatic items from the scales were removed, suggesting that the relations were not spuriously due to the influence of pain symptoms on the scales. When examining the unique contribution of each variable to the experience of pain (by simultaneously controlling for the other measures of affect), the GSI was uniquely related to the sensory and affective components of pain. Self-report of depressive symptoms was more highly related to a measure of the evaluative component of pain and uniquely related to self-reported disability and negative thoughts about pain. The results are discussed within the context of theoretical models of the relation between pain and affect, and suggestions for future research are presented.

Many authors report that a high percentage of patients with chronic pain have no or insufficient underlying physical pathology to explain their pain. Even when patients do have an identified diagnosis, many patients profess to have little understanding of the source of their pain or fear that they may suffer from more severe pathology. This may be particularly true for patients with chronic musculoskeletal pain given the lack of “objective” findings for soft tissue pain complaints. In the present study, we examined whether chronic neck and back pain patients were able to identify the physiologic source of their pain, and based on their responses patients were placed in one of three groups: (1) patients who did not know the cause of their pain; (2) patients who did know the cause and agreed with their clinical diagnosis; and (3) patients who identified a cause for their pain that was different from their clinical diagnosis. The sample was comprised primarily of individuals with musculoskeletal pain problems (70%) referred to an outpatient chronic pain rehabilitation program. Each patient completed a pretreatment test battery, and group differences were examined on responses to the McGill Pain Questionnaire, Survey of Pain Attitudes, Brief Symptom Inventory, Coping Strategies Questionnaire, and Pain Disability Index. Upon initial evaluation, 47.2%(n = 85) of patients indicated that they did not know what was causing their pain. Of patients who articulated a cause for their pain, 20%(n = 36) attributed it to factors that did not agree with their diagnosis. Only 32.8%(n = 59) of persons in the entire sample were able to accurately identify the cause of their pain. Patients who disagreed with their clinical diagnosis were more likely to be diagnosed with musculoskeletal pain and reported the highest levels of pain(F(2,169) = 3.41, p > .05) as well as the greatest levels of affective distress(F(2,169) = 3.54, p > .05). Patients who were unsure of or disagreed with their diagnosis tended to report a greater belief in pain being a signal of harm(F(2,169) = 11.5, p > .001) and described themselves as more disabled(F(2,169) = 8.43, p > .001). In addition, both the “unsure” and “disagree” groups tended to use maladaptive pain strategies more frequently, and persons unsure of their diagnosis had the lowest levels of perceived control over pain. A hierarchical regression analysis examining a cognitive/behavioral model of pain disability indicated that lack of knowledge of pain etiology, a belief that pain is a signal of harm, catastrophizing and affective distress all significantly predicted increased disability, while pain intensity did not. The data suggests that lack of knowledge about the origin of pain is associated with maladaptive cognitions in relation to pain (i.e., fear of harming oneself and catastrophizing) and increased emotional distress which in turn are related to heightened disability due to pain. These data argue that educating patients regarding their diagnosis and the origin of their pain, thereby dispelling dysfunctional pain beliefs, may be an important component of pain treatment, particularly among patients with chronic musculoskeletal pain.

L atchel and Okifuji’s report on the cost-effectiveness of comprehensive pain programs (CPPs) for chronic nonmalignant pain (CNP) does an excelent job of demonstrating the superior ability of CPPs to ddress the myriad of problems associated with chronic ain. They trace the development of CPPs to the emerence of the biopsychosocial model acknowledging the omplex etiology of CNP that involves interplay between iological, psychological, and social factors. Despite the ocumented success of CPPs, the authors indicate that hese programs are significantly underutilized in the reatment of CNP. The most common reason given for heir underutilization is the perception of high cost by any third-party payers. Rational arguments refuting he claim of high costs, however, are nicely summarized y Gatchel and Okifuji as well as by Turk et al. So, if not igh costs, why are these programs underutilized? We xplore alternative explanations to this question.

We sought to determine the relationship among a history of physical or sexual abuse, pain experience, and depressive symptoms among women with chronic pelvic pain (CPP).This was a cross-sectional study of women who presented to a tertiary referral center for evaluation of CPP (N = 273). All participants completed standardized questionnaires to assess a history of physical or sexual abuse, pain severity, pain disability, and depressive symptoms. Subjects were grouped by abuse category and compared to CPP participants without history of abuse. Multinomial logistic regression models were used to determine the association between adolescent or adult and childhood physical or sexual abuse with pain intensity, pain-related disability, and depressive symptoms.Logistic regression analyses indicated that, after controlling for age and education, none of the abuse categories was associated with pain severity. However, adolescent or adult sexual abuse predicted greater pain-related disability (odds ratio, 2.39; 95% confidence interval, 1.05-5.40), while both adolescent or adult physical and sexual abuse were associated with higher levels of depression (both P.05). Level of education was significantly associated with pain intensity, pain disability, and depression.For our sample of women with CPP, a history of abuse during childhood or adulthood was not associated with differences in pain intensity, but adolescent or adult sexual abuse was associated with greater pain-related disability. A history of physical abuse or sexual abuse appears to hold a stronger relationship with current depressive symptoms than pain experience for women with CPP. Educational achievement holds a robust relationship with pain morbidity and depression for this population.

This study examined the ability of two self-report questionnaires, the Beck Depression Inventory (BDI) and the Center for Epidemiological Studies-Depression Scale (CES-D), to discriminate between chronic pain patients with and without major depression. Since previous research has suggested that medical conditions such as chronic pain can influence the endorsement of items that measure neurovegetative symptoms of depression, the accuracy of each of these questionnaires was also assessed eliminating these items.These included 132 consecutive patients with chronic pain, 44 of whom were diagnosed as suffering from major depression according to DSM-IV criteria.Patients were administered a battery of questionnaires that included the CES-D and BDI. They were also interviewed by a clinical psychologist to determine the presence or absence of major depression.Both questionnaires were able to discriminate significantly between persons with and without major depression. Removal of the somatic items on each questionnaire did not improve their accuracy. Discriminant function analysis revealed an optimal cut-off score of 21 for the BDI, and 27 for the CES-D. Overall hit rates at these cut-offs for the two questionnaires were comparable, while the CES-D had somewhat better sensitivity (81.8% vs. 68.2%). Conversely, the BDI had slightly better specificity (78.4% vs. 72.7%).The results suggest that both questionnaires have good predictive validity among chronic pain patients, and decisions regarding the use of one questionnaire rather than the other may depend upon the goals of the user and the setting within which the questionnaire is used.

Recent studies have reported a high prevalence of symptoms of post-traumatic stress disorder (PTSD) among individuals with chronic pain. Studies suggest that persons with pain and PTSD also display higher levels of affective disturbance. In the present study we examined self-reports of pain, affective disturbance, and disability among pain patients with and without symptoms of PTSD. Patients without PTSD symptoms were further subdivided into persons whose pain was the result of an accident or insidious in onset. Thus, three groups were examined: (1) persons with accident related pain and high PTSD symptoms (Accident/High PTSD); (2) persons with no or few symptoms of PTSD whose pain was accident related (Accident/Low PTSD); and (3) patients whose pain was not accident related and did not have PTSD symptoms (No Accident). No Accident patients were older than persons with accident related injuries, and both accident related pain groups were more likely than No Accident patients to be involved in litigation or receiving compensation. Thus, these variables were controlled for in the statistical analyses. Self-report of pain was also included as a covariate in the analyses examining group differences in affective disturbance and disability. Accident/High PTSD patients displayed higher levels of self-reported pain compared to the other two groups. The Accident/High PTSD group also had the highest levels of affective disturbance. Both accident groups tended to report greater disability compared to patients whose pain was not accident related. These findings suggest that PTSD symptoms in chronic pain patients are associated with increased pain and affective distress. Accident related pain, even without the presence of PTSD symptoms, appears to be associated with greater disability. The results indicate that the identification and treatment of PTSD symptoms in refractory pain patients may be a critical albeit subtle factor in the effective management of suffering and disability in this population.

Chronic pelvic pain (CPP) is often attributed to psychogenic causation. To determine if women with CPP possess a unique psychological profile, this study examined the comparative pain experience, psychological functioning, and marital/sexual satisfaction of women with either CPP or chronic migraine headache (CH). Patients with CPP reported greater dissatisfaction with their marriage and greater sexual dysfunction. No differences were obtained for ratings of depression, anxiety, mood factors, or additional personality traits. These data suggest that, in general, when psychological disorders are observed in CPP patients, they most likely reflect the effects of chronic pain rather than be causative to it.

Objectives: Psychological studies of myofascial pain and fibromyalgia typically compare these syndromes with other chronic pain conditions and combine them to ascertain psychopathological correlates. To determine differences between these groups, this study compared pain experience, disability and psychological functioning in myofascial pain and fibromyalgia. Methods: Consecutive female patients, who presented to a university pain clinic and who were diagnosed with myofascial pain [N = 34] or fibromyalgia [N = 21], were assessed by psychometric testing before intervention. Results: Myofascial pain was associated with traumatic onset and greater trait anxiety. Fibromyalgia patients reported greater severity or pain, more occupational disability and lower educational achievement. No differences were obtained on mesures of sleep, fatigue, depression or personality functioning. Conclusions: Myofascial pain and fibromyalgia patients are similar on most measures of psychological functioning although fibromyalgi...

Background/Aims: This study compared women suffering chronic pelvic pain (CPP) secondary to endometriosis (n = 30) with women experiencing CPP due to either myofascial abdominal/pelvic pain (n = 70) or pelvic adhesions (n = 38) to determine if there are specific psychological variables uniquely associated with endometriosis. Methods: This is a cross-sectional study of 138 women drawn from a convenience sample of 192 consecutive women with CPP presenting for evaluation to a university hospital chronic pain clinic. Subjects were categorized into groups based on their CPP diagnosis. Each subject completed a battery of validated inventories assessing demographic status, pain experience and other pain-related symptoms, pain disability, frequency of depressive symptoms, level of affective distress, satisfaction with pain treatment and satisfaction with their marital relationship. Results: No differences were obtained across the three groups for any of the outcome measures. Effect size computation supported the absence of clinical differences across the groups for these measures. Conclusion: These findings fail to support the presence of a unique psychological profile or disproportionate psychological disturbance for women with CPP due to endometriosis. These data illustrate the importance of considering control groups that include chronic pain when exploring psychological contributions to specific chronic pain conditions.

Symptoms of post-traumatic stress disorder (PTSD) are a common comorbidity in patients with a history of accident-related chronic pain and depression. However, little is known regarding the influence of PTSD in contributing to the affective distress, pain experience, and disability associated with chronic pain in this population. This study used structural equation modeling to examine 3 models that assess these relations in a sample of chronic pain patients with accident-related pain. Subjects were assessed for pain experience, depressive symptoms, anxiety, PTSD symptoms, pain disability, and relevant demographic variables. Pearson correlations indicated that symptoms of depression were significantly related to more severe pain, disability, and PTSD symptoms. PTSD symptoms were significantly associated with higher disability. The model of best fit indicated that after controlling for the influence of anxiety on the dependent measures, PTSD symptoms have a direct influence on severity of depressive symptoms, whereas depressive symptoms have a direct influence on pain intensity and an indirect impact on pain intensity by way of their effect on disability. These data point to the importance of unresolved PTSD symptoms in contributing to the level of depression, pain, and disability exhibited by chronic pain patients and highlight the need to consider directed and primary treatment of PTSD in pain rehabilitation programs. Perspective This study highlights the impact of symptoms of PTSD on levels of depression, disability, and pain in patients with pain secondary to physical injury. Our results suggest that pain rehabilitation programs provide directed interventions for PTSD symptoms among this population to improve pain treatment outcomes.

Background: This prospective study examined the contribution of psychological factors to the prediction of patient satisfaction with postmastectomy breast reconstruction surgery. Methods: Women presenting for breast reconstruction were administered presurgical psychological inventories. Measures of affective distress, depressive symptoms, anxiety, somatization, and somatic preoccupation were obtained from standardized inventories. At 1-year (n = 295) and 2-year (n = 205) follow-up, subjects completed ratings of their satisfaction with both the general and aesthetic results of surgery. Results: After controlling for sociodemographic variables and both surgical procedure type and timing, multiple linear regression analyses indicated that at 1-year follow-up preoperative measures of affective distress, depression, somatization, and somatic anxiety predicted less general satisfaction with surgical outcome, while presurgical levels of affective distress, depression, anxiety, somatization, and somatic anxiety predicted decreased aesthetic satisfaction. At 2-year follow-up, only preoperative affective distress retained a significant association with lowered general satisfaction with reconstructive surgery. In addition, at 2-year reassessment, aesthetic quality of surgical outcome was inversely related to all the presurgical psychological variables. Conclusions: Affective distress and somatic preoccupation negatively influence patient satisfaction with both aesthetic and general outcomes associated with postmastectomy breast reconstruction. Presurgical psychological screening and counseling of selected women who are being considered for breast reconstruction may be advisable to enhance patient satisfaction with reconstructive surgery.

This study prospectively examined the long-term effects of type (transverse rectus abdominis musculocutaneous [TRAM] versus implant) and timing (immediate versus delayed) of postmastectomy reconstructive surgery on patient reports of pain at multiple body sites. Women (n = 205) seeking immediate or delayed breast reconstruction, choosing either expander implant or autologous tissue transfer surgical procedures, provided ratings for the presence of bodily, breast, abdominal, and back pain and abdominal tightness prior to surgery and at 2-year follow-up. At baseline, nonwhite women were more likely to undergo delayed reconstruction (P < 0.05), and women seeking delayed reconstruction had less breast pain (P < 0.001) and more back pain (P < 0.01). Multiple regression analyses, controlling for ethnicity and baseline pain, indicated that women receiving TRAM flap surgery reported more problems with abdominal pain and tightness. There was a trend for implant subjects to report more frequent problems with breast pain. These results suggest the need for heightened awareness of potential long-term pain morbidity for women undergoing TRAM flap or implant breast reconstruction.

Background This study compared the presurgical psychosocial and functional status of 238 women seeking breast reconstruction, either at the time of their mastectomy (immediate) (n = 151) or after prior mastectomy (delayed) (n = 87). Delayed subjects were further categorized in groups of time-since-mastectomy to examine the effects of time on postmastectomy psychosocial adjustment. Methods Presurgical measures of quality of life, psychological distress, and somatic anxiety were obtained. Results The results revealed relative impairment of quality of life and psychosocial functioning for immediate compared with delayed subjects. Immediate subjects reported greater disturbance in general mental health functioning, more severe impairment in emotional well being related to their cancer diagnosis, and higher levels of anxiety. Immediate subjects also reported a trend toward greater disturbance in work and daily activities, more frequent interference in social activities, and less vitality. Similarly, it was noted that the immediate group reported greater impairment in physical and functional well being related to their cancer adjustment. On psychological assessment, immediate subjects were more likely to report higher levels of affective distress, depressive symptoms, and obsessive-compulsive traits. For the delayed group, no statistically significant differences in the dependent measures were obtained when comparing subjects at 1 year, 2 years, and more than 2 years after mastectomy. Conclusions Women seeking immediate reconstruction at the time of mastectomy show a relatively higher incidence of psychosocial impairment and functional disability. Women who undergo mastectomy demonstrate early restoration of psychosocial health within the first year after surgery. Patient preoperative psychosocial distress may have important implications for clinical decision-making and surgical outcome for women seeking combined mastectomy and breast reconstruction.

Roth RS, Geisser ME, Theisen-Goodvich M, Dixon PJ. Cognitive complaints are associated with depression, fatigue, female sex, and pain catastrophizing in patients with chronic pain. Arch Phys Med Rehabil 2005;86:1147–54. Objective To examine the relation between demographic, pain-related, psychosocial, affective, and treatment factors and complaints of cognitive dysfunction among patients with chronic pain. Design Cross-sectional survey. Setting A university hospital outpatient multidisciplinary chronic pain program. Participants Chronic pain patients (N=222; 135 women, 87 men) completed a battery of psychometric questionnaires as part of an initial evaluation on referral to the program. Interventions Not applicable. Main Outcome Measures Cognitive impairment was assessed with items from the Brief Symptom Inventory; measures of depressive symptoms, pain intensity, posttraumatic stress disorder (PTSD), and pain catastrophizing were obtained from the Beck Depression Inventory (negative affect, negative self, somatic/physical function), McGill Pain Questionnaire, Modified Posttraumatic Chronic Pain Test, and Coping Strategies Questionnaire, respectively; and measures of subjective sleep disturbance, fatigue, opiate use, compensation/litigation status, pain location, and relevant demographic data were obtained from an open-ended questionnaire. Results Correlational analysis indicated that female sex, pain intensity, PTSD symptoms, depressive symptoms, catastrophizing, pain location (neck), and fatigue were all positively related to cognitive complaints. Simultaneous regression analysis showed that all factors combined accounted for 52% of the variance in self-report of cognitive difficulties and that 6 variables had a significant unique contribution to the report of cognitive complaints in the following order of importance: depression-negative affect (β=.28, P P P P =.05), pain catastrophizing (β=.12, P =.08), and female sex (β=.12, P Conclusions Complaints of cognitive impairment among chronic pain patients appear to be associated with multiple factors, with particular attention to depressive symptoms, fatigue, and catastrophizing. Our results also suggest that women with chronic pain are particularly vulnerable to cognitive dysfunction.

The purpose of this study was to examine pain experience among patients with chronic wounds, assess the utility of pain assessment scales for chronic wound-related pain, and determine the relation of wound-related pain to wound stage, affective distress, depressive symptoms, and pain catastrophizing.In this cross-sectional study of patients with a mix of chronic wounds (n = 69) recruited for a study evaluating a telemedicine system for assessing chronic wounds, 19 men (12 with spinal cord injury) with wound-related pain were identified. Questionnaires included the Numerical Pain Rating Scale, McGill Pain Questionnaire, Brief Symptom Inventory, Center for Epidemiologic Studies Depression Scale, and the catastrophizing scale of the Coping Strategies Questionnaire.The McGill Pain Questionnaire was more sensitive to pain experience than a single rating of pain intensity. Wound stage was positively related to severity of pain. Pain catastrophizing was positively related to pain intensity and higher levels of affective distress and depressive symptoms.Pain associated with chronic wounds is a significant clinical challenge for both patients and health practitioners.

Objective This study examined the relation between level of educational achievement (LOE) and the clinical morbidity associated with chronic pain. Setting a multidisciplinary pain rehabilitation program located within a university hospital. Patients Two hundred ninety-nine consecutive patients with chronic spinal pain, average age 39.6 years (SD = 10.7) and with an average duration of pain of 41.9 months (SD = 51.6). Outcome measures Age, duration of pain, sex, and compensation and litigation status were controlled for in the statistical analysis because each was found to be significantly associated with LOE. Pain intensity was assessed by the McGill Pain Questionnaire. Affective distress was assessed by the Global Severity Index from the Brief Symptom Inventory. Severity of depressive symptoms was derived from scores from the Center for Epidemiological Studies-Depression Scale. Pain beliefs and pain coping strategies were assessed by the Survey of Pain Attitudes and the Coping Strategies Questionnaire, respectively. Finally, self-report of pain-related disability was assessed by the Pain Disability Index. Results and conclusions After controlling for relevant covariates, LOE was unrelated to pain intensity, severity of depressive symptoms, or affective distress, but was inversely related to self-reported disability. Persons with lower LOEs possessed a greater belief that pain is a "signal of harm," unrelated to emotional experience, disabling and uncontrollable. They also endorsed more passive and maladaptive coping strategies, including a tendency to catastrophize about their pain. Path analysis indicated that, after controlling for the influence of both the belief that pain is a "signal of harm" and catastrophizing on the association between LOE and disability, this relation loses statistical significance. These results suggest that pain-related cognitions mediate the relation between LOE and pain disability and that persons with lower LOEs are more likely to develop maladaptive pain beliefs and coping strategies.

Objective: To examine the relation between pain patients' knowledge of pain diagnosis and their satisfaction with pain treatment. It was hypothesized that myofascial pain (MP) patients would be less knowledgeable regarding their diagnosis and less satisfied with the results of pain treatment. Design: Cross-sectional. Setting: Multidisciplinary pain clinic. Patients: Patients (n = 65) were divided into two groups after multidisciplinary assessment: MP patients (n = 30) and a mixed group of chronic pain patients (MCP) (n = 35) with neurologic or rheumatologic disorders. Main Outcome Measures: Patient self-report of their knowledge of pain diagnosis and scores on standardized measures of pain intensity, depressive symptoms, and functional disability. Results: MP patients were significantly less accurate in identifying their diagnosis and the source of their pain and were more likely to believe they suffered a physiologic disturbance "more serious and different" than their physicians had suggested. MP patients were also significantly more dissatisfied with the treatment for pain by physicians and reported particular dissatisfaction with the informational aspects of physician-patient communication. No group differences were obtained for measures of pain severity, depression, disability, pain duration, or compensation/litigation status. Conclusion: MP patients appear to have less accurate beliefs regarding their pain symptoms and express more dissatisfaction with physician efforts to treat their pain. These findings emphasize the importance of patient education as a component of chronic pain intervention, particularly for MP patients.

Summary Neurodevelopmental outcome and concurrent maternal distress were examined for infants who suffered persistent pulmonary hypertension at birth and were treated with either extracorporeal membrane oxygenation (ECMO) (n= 19) or conventional ventilation (CV) (n= 15). Mothers were asked to complete inventories assessing their infant's (mean age 8.74 months) developmental growth as well as their own psychological health. Relevant sociodemographic and treatment parameters were also entered into the analysis. The results indicated that ECMO and CV infants did not differ on developmental indices and impairment rates were 15–23% respectively, similar to previous reports, in addition, ECMO and CV mothers did not differ in their reports of psychological distress. Correlational analyses revealed that length of treatment for ECMO but not CV infants significantly predicted developmental delay and maternal distress. For CV mothers, maternal distress was associated with the perception of delayed language. The results are discussed in terms of the limited morbidity associated with ECMO and CV interventions and the possible role of a ‘vulnerable child syndrome’ in understanding the maternal-infant relationship following ECMO therapy.

Medical (n 5 47) 20 (43%) 12 (26%) 14 (30%) 35 (75%) 9 (19%) Surgical (n 5 118) 23 (20%) 10 (9%) 10 (9%) 23 (20%) 4 (3%)

Summary.-15 seminary students who regularly practiced a form of Christian meditation were given the Minnesota Multiphasic Personality Inventory (MMPI) . Electroencephalographic (EEG) signals were recorded and analyzed for percent time alpha during performance of a series of mental arithmetic tasks and also during a period of meditation. Higher scores on the Hypochondriasis scale of the MMPI were associated with increase in alpha as the subject proceeded from the mental arithmetic tasks to the meditation period. This result is discussed in terms of previous research, the pre-meditation level of alpha, and the implications for the use of meditation as a therapeutic procedure. Several recent studies have demonstrated beneficial effects from the practice of meditacion of Eastern tradition. Most of this research has focused on Transcendencal Meditation, although some researchers have also investigated 2kn meditative techniques. Effects in the physiological domain include changes in metabolic, autonomic, and EEG systems (cf. Wallace & Benson, 1972). Studies of psychological effects have generally shown that meditators reported they are more at ease than non-meditators. Two abstracts of studies using the MMPI, for example, reported Transcendencal Meditators scored lower on some MMPI scales (Hypochondriasis, Psychasthenia, Schizophrenia, Social Introversion) and on the Taylor Manifest Anxiety Test than control groups of nonmeditators (Orme-Johnson, Author, Franklin, O'Connell, & Zold, 1973; OrmeJohnson, Kiehlbauch, Moore, & Bristol, 1973). Smith (1975) reviewed the literature on the beneficial psychological effects of meditation and suggested that comparisons of meditators and controls on psychological variables may be complicated by a self-selection tendency, since persons choosing to undertake a self-improvement program may differ from those who do not. Pretreatment personality variables have been examined directly by Maupin ( 1965), not as a methodological control, but rather in terms of which individuals are likely to respond best to a meditative training procedure. Maupin found that individuals having greater capacity for regression and tolerance for unrealistic experience (as measured by Rorschach responses) responded more favorably to a Zen meditacion exercise. The present data, collected in 1964 by the first author, were re-examined in light of the current interest in meditation, with a particular focus on the personality variables which influence an individual's response to meditation. The specific response examined was the change in the alpha rhythm of the EEG during meditation. The

While EMG biofeedback has been presented as a valuable therapeutic tool in the treatment of numerous psychophysiologic and pain disorders, it has been an especially important adjunct in the muscle reeducation of the hemiplegic patient.1 Several authors have demonstrated the utility of EMG biofeedback training in the rehabilitation of neuromuscular dysfunction following a cerebrovascular accident (CVA).2,3 Relatively little attention has been paid, however, to the potential role of EMG biofeedback in facilitating the remediation of upper extremity dysfunction in these patients.4,5 One common obstacle to upper extremity rehabilitation following a CVA is the development of synergy patterns. For example, when a flexor synergy pattern is present, shoulder flexion is accompanied by simultaneous elbow flexion. To assist the patient in regaining functional use of the involved extremity, Brunnstrom suggests that patterns of muscle action be introduced that deviate from the basic limb synergies.6

To examine the effects of psychological stress upon hemisphere activation, subjects' lateral eye movements to reflective questions were observed under conditions of neutral instructions and instructions designed to be stressful. An increased frequency of left eye movements during the stress condition suggested greater right than left hemisphere activation with emotional arousal.