26 February 2005

Music soothes...

Sedative music reduces anxiety and pain during chair rest after open-heart surgery
Jo A. Vossa, et.al
Open-heart surgery patients report anxiety and pain with chair rest despite opioid analgesic use. The effectiveness of non-pharmacological complementary methods (sedative music and scheduled rest) in reducing anxiety and pain during chair rest was tested using a three-group pretest–posttest experimental design with 61 adult postoperative open-heart surgery patients. Patients were randomly assigned to receive 30 min of sedative music (N=19), scheduled rest (N=21), or treatment as usual (N=21) during chair rest. Anxiety, pain sensation, and pain distress were measured with visual analogue scales at chair rest initiation and 30 min later. Repeated measures MANOVA indicated significant group differences in anxiety, pain sensation, and pain distress from pretest to posttest, P<0.001. Univariate repeated measures ANOVA (P?0.001) and post hoc dependent t-tests indicated that in the sedative music and scheduled rest groups, anxiety, pain sensation, and pain distress all decreased significantly, P<0.001–0.015; while in the treatment as usual group, no significant differences occurred. Further, independent t-tests indicated significantly less posttest anxiety, pain sensation, and pain distress in the sedative music group than in the scheduled rest or treatment as usual groups (P<0.001–0.006). Thus, in this randomized control trial, sedative music was more effective than scheduled rest and treatment as usual in decreasing anxiety and pain in open-heart surgery patients during first time chair rest. Patients should be encouraged to use sedative music as an adjuvant to medication during chair rest.

And what counts as sedative music?
Sedative music was operationalized as music without lyrics and with a sustained melodic quality, with a rate of 60–80 beats per minute and a general absence of strong rhythms or percussion (Gaston, 1951 and Good et al., 2000). The volume and pitch were controlled so that the music was heard comfortably. Participants who received sedative music selected a tape from a collection prior to chair rest by listening to a 30-s excerpt of each of the selections. The collection consisted of six types of music—synthesizer, harp, piano, orchestra, slow jazz, and flute. Good (1995) developed the selections on the first five tapes in consultation with a music therapist. The synthesizer tape included new age music, the piano tape included music popular in the United States from the 1940s to the 1980s, the orchestra tape was classical music, the harp tape included both popular and new age music, and the jazz tape was slow modern jazz (Good et al., 2000). A tape featuring American Indian flute music was added to provide a culturally acceptable selection for the American Indian population served at the hospital (DeRuyter, 2000 and Good et al., 2000). The music has been shown to reduce the sensation and distress of postoperative pain up to 31% in abdominal surgical patients (Good et al., 1999) and also to reduce labor pain (Phumdoung and Good, 2003).

The availability of choice has got to be key. Put me in a chair with Enya soothing my ears and I'll have a heart attack.*

*I'm actually somewhat serious about this. Several years ago, I donated platelets three times a month for nearly a year. Donation involves being immobile in a bed for 2 hours, so the center kindly provides you with a movie. Trouble is, they provided it whether I wanted it or not; and its a bit hard to remove headphones with a large IV plugged into each arm. They had a closet full of movies to choose from, very few that I could stomach. The discomfort of watching Men at Work for the nth time was far worse than the needles, saline infusions, or ischemic discomfort.

I can only imagine the music selection available in the ICU. Will they let you bring in your own music? Will it have to pass their scrutiny? What if I find electroclash most soothing?

Effects of experimenter characteristics and men and woment's pain reports

More on one of my favorite topics:

The effects of experimenter characteristics on pain reports in women and men
Ibolya Kállai, et.al
In pain research, one important aspect of pain is its report, i.e. its verbal and behavioral indication towards others. As the report of pain virtually always takes place in the presence of another person, for example a physician or an experimenter, a close examination of the effect this person might have on the report of pain is paramount. In a clinical context, the pain report fulfils a function by communicating the problem to the physician thus facilitating diagnosis and therapy. In the absence of the necessity to deliver a vital message, as is the case in most experimental settings, the subject's pain report is likely influenced by additional parameters (Robinson and Wise, 2003).

Several studies suggest that traditional gender roles influence the verbalization of pain (Levine and De Simone, 1991, Robinson and Wise, 2003 and Sanford et al., 2002). Generally, gender role refers to a society's widely assumed set of characteristics for each sex and may comprise beliefs regarding appropriate pain behaviors. Whereas the stereotypical male role in Western society characterizes men as stoic and intending to impress women with their ability to withstand pain, the corresponding female role expects women to exhibit increased sensitivity in order to evoke protective behavior in men (Levine and De Simone, 1991). Some authors confirmed these expectations investigating the influence of the experimenters' gender in a cold pressor test (Carter et al., 2002, Levine and De Simone, 1991 and Voss, 2001), whereas others found no such effects (Otto and Dougher, 1985). Furthermore, women generally report higher pain levels than men (Fillingim and Maixner, 1995 and Riley et al., 1998).

Apart from gender effects, other characteristics of the experimenter might also influence pain reports. Considering the typical setting of psychological experiments, a factor varying across studies is whether the experiments are conducted by students or members of the faculty. Although it is questionable whether student experimenters obtain the same results as experimenters of a higher professional level, few reports mention the professional status of the experimenter. Student experimenters may be perceived as possessing lower authority or competence compared to faculty members, leading subjects to believe that experiments conducted by students may be less important and/or safe than those carried out by faculty members. If a subject doubts the importance of the experiment or the experimenter's competence, the subject may not give his/her best and may not be willing to endure much pain.

The current study investigates not only gender effects, but also the effect of the experimenter's professional status on the subjects’ pain responsivity. We expected that subjects tested by a professional experimenter would show higher pain thresholds and pain tolerance as well as lower pain intensity ratings compared to subjects who were tested by a student experimenter. Regarding gender, we anticipated female subjects to report pain earlier and to endure it for briefer time periods than male subjects. Further, both male and female subjects were expected to demonstrate higher pain thresholds, higher pain tolerance and lower pain intensity ratings when examined by female than by male experimenters.
4. Discussion

4.1. Experimenter professional status
As expected, there was a significant main effect on pain tolerance for experimenter professional status. Pain tolerance was significantly higher when subjects were tested by a professional experimenter compared to a student experimenter and more subjects were willing to endure the pain for the full 3 min. Interestingly, this effect was not seen for pain threshold or pain intensity. This suggests that the presence of the professional experimenter did not affect the perception or report of pain, but the will to endure it.

An explanation for this effect might be that the subjects tested by the professional experimenters were motivated more strongly and attributed more importance to the experiment. Further analyses showed that the professional experimenters were perceived as possessing significantly more authority than the student experimenters. This perception of authority may have underlined the importance of the experiment and given rise to more effort on the side of the subjects. Although the higher pain tolerance in the presence of a high professional experimenter could theoretically also be mediated by the perceived competence of the experimenter, leading to greater confidence that the experimental pain-inducing situation is handled with care, we could not find statistical evidence supporting such an interpretation. Further, this effect was not due to the fact that the professional experimenters were liked better than the student experimenters as the student experimenters were rated as significantly more likeable.

4.2. Gender effects
Analysing gender effects, we found an interaction between experimenter gender and subject gender for pain tolerance. As could be expected from the literature, men tolerated pain longer when tested by a female experimenter than by a male one (e.g. Levine and De Simone, 1991). However, contrary to our expectations, women also tolerated pain longer when tested by a male experimenter. According to traditional gender role assumptions (cf. Robinson and Wise, 2003 and Sanford et al., 2002), we assumed that women would show higher pain responsivity, for example lower pain tolerance, when tested by a male experimenter, in order to appear helpless and induce male protection. The interaction observed between experimenter gender and subject gender, however, indicates that it is not only men (as we expected) but also women who display increased pain tolerance when tested by a person of the opposite sex in order to impress this person. For women, this behavior—though gender role related—is not in accordance with the traditional gender role outlined above. One reason for this finding, which is unexpected in the light of previous literature, may be that the female gender roles are in flux at the present time, especially among the student population. A further possible explanation could be that there are cultural differences regarding gender roles that would explain the differences between our German sample and the American samples investigated in previous literature (c.f. Carter et al., 2002, Levine and De Simone, 1991 and Robinson and Wise, 2003). Again, the interaction observed between experimenter gender and subject gender was not found for pain threshold or pain intensity, indicating that the will to endure the pain was affected but not the report or the perception of the pain itself.

Furthermore, we found a significant effect for experimenter gender in pain intensity. Both men and women rated pain intensity higher when tested by female experimenters. This effect is contrary to our expectations, as we assumed that, in accordance with traditional gender roles, both men and women would report lower pain intensity to female experimenters than to male experimenters. One explanation for this unexpected result might be that the pain intensity ratings were collected following the cold pressor task and not while the subjects had their hands immersed in the ice-water. For example, in the case of male subjects, it could be the case that they would rate pain intensity as ‘low’ in front of female experimenters while they are actually experiencing the pain, thereby trying to impress the woman by saying that they do not feel much pain. However, when asked to rate pain intensity after the test has already ended, as was the case in our experiment, they might try to impress the female experimenters by saying that they were able to endure high pain intensities. This result warrants further research.

In our study, we did not find any main effect involving subject gender although, according to previous literature (cf. Riley et al., 1998), we expected that women would report higher pain levels and would be less willing to endure the pain compared to men. Generally, men and women did not differ significantly in their pain thresholds, pain tolerance or pain intensity ratings, even though the descriptive differences pointed in the expected direction.

In summary, our findings indicate that pain responsivity, i.e. the will to endure pain as well as the report of pain, might be influenced in part by the characteristics of the person to whom the pain is expressed. This finding may have consequences for pain research in general and for the interpretation of already existing studies. Inconsistent results of earlier studies should be re-examined with respect to experimenters’ attributes and the relation between experimenter and subject. Additionally, in clinical settings, it should always be remembered that attributes of physicians, therapists and other health-care professionals may have an influence on the pain levels expressed by the patients.

Sex differences and catastrophizing

Catastrophizing as a mediator of sex differences in pain: differential effects for daily pain versus laboratory-induced pain
Edwards, et.al
Sex differences have been reported for many pain-related responses. For instance, women are at greater risk for pain disorders such as fibromyalgia (Unruh, 1996). Women also report more widespread pain, more pain-related affective symptoms (Mullersdorf and Soderback, 2000 and Keefe et al., 2000), and more frequent daily pain (Berkley and Holdcroft, 1999, Barsky et al., 2001 and Bassols et al., 2002). Sex differences have also been investigated in laboratory settings, with women demonstrating lower pain thresholds and higher pain ratings across a variety of noxious stimuli (Riley et al., 1998 and Fillingim, 2000). It has been suggested (Fillingim and Maixner, 1995, Fillingim et al., 1999 and Fillingim et al., 1999b) that these findings are linked, with greater pain sensitivity acting as a risk factor for enhanced clinical pain.

Although sex differences are well-documented, explaining these differences is more challenging. While some researchers emphasize socialization (Fearon et al., 1996) or emotional responsiveness (Riley et al., 2001) as potential mechanisms, others have highlighted biological factors (Berkley, 1997) or pain-coping (Unruh, 1996, Fillingim, 2000 and Myers et al., 2003). Indeed, how one copes with pain consistently predicts important clinical outcomes, including pain severity and disability (Turk and Okifuji, 2002). Generally, the most robust predictor of pain outcomes is catastrophizing (Sullivan et al., 2001), defined as a negative emotional and cognitive response to pain involving elements of magnification, helplessness, and pessimism. Catastrophizing is positively correlated with pain and depression, and some laboratory studies show an association with responses to standardized noxious stimuli (Sullivan et al., 2001).

Additionally, women report more frequent catastrophic cognitions (Sullivan et al., 2001), making catastrophizing a potential contributor to sex differences in pain. In a recent osteoarthritis study, women had higher levels of pain, pain behavior, and disability. Moreover, women reported more catastrophizing, which mediated the relationship between sex and pain-related outcomes after controlling for depression (Keefe et al., 2000). A second study reported that during a cold pressor task, females reported more pain and displayed more pain behavior than males, effects which became non-significant when catastrophizing was controlled (Sullivan et al., 2000b).

The literature, however, is inconsistent, with some studies showing no sex differences in catastrophizing (Unruh et al., 1999 and Edwards et al., 2000). Moreover, while pain-related sex differences in the laboratory are often large (Riley et al., 1998 and Fillingim, 2000), sex differences in clinical pain are inconsistent (Turk and Okifuji, 1999). Additionally, catastrophizing as a mediator of sex differences in day-to-day pain among healthy individuals has not been studied. It is important to investigate such questions in non-clinical samples, before sex differences in pain are confounded by additional factors such as sex differences in pain treatment or sex-specific selection biases. Many researchers have also not controlled for depression when evaluating catastrophizing, which is now a standard in the field (Sullivan et al., 2001). Finally, catastrophizing likely depends on contextual factors such as the threat value of pain, which may differ in laboratory settings versus clinical environments. The present investigation, therefore, studied catastrophizing as a mediator of sex differences in both day-to-day pain and experimental pain.
Our results indicate that sex differences in complaints of painful day-to-day symptoms are accounted for by the significant differences between men and women in reports of catastrophizing. However, the sex differences in catastrophizing do not account for the substantially higher threshold and tolerance for thermal and cold pain observed among men.

The present study builds upon prior work by assessing catastrophizing as a mediator of male–female differences in pain responses both inside and outside of the laboratory. Several prior studies have suggested that catastrophizing at least partially mediates observed sex differences in both clinical pain (i.e. arthritis pain) (Keefe et al., 2000) and in experimental pain responses (Sullivan et al., 2000a and Sullivan et al., 2000b). Our results are consistent with those of the former study, and suggest that catastrophizing plays an influential role in shaping sex differences in pain report in both clinical and non-clinical samples. However, it is somewhat more difficult to reconcile our findings with those of Sullivan and colleagues (Sullivan et al., 2000b), who also used a cold pressor task. They assessed pain intensity ratings and a measure of the duration of pain behaviors during the task. Correlations of between 0.33 and 0.53 were observed for the association between catastrophizing scores and pain responses. In contrast, we observed minimal correlations (r=-0.12 for CPTO and catastrophizing). One other recent cold pressor study evaluated threat appraisals (i.e. conceptually similar to catastrophizing) as a potential mediator of sex differences in cold pain tolerance (Sanford et al., 2002). The association between threat appraisals and cold pain tolerance was only marginally significant (r=-0.15); however, controlling for threat appraisals did slightly reduce the significance of sex difference in cold pressor tolerance times. The small magnitude of this association parallels our findings and suggests that catastrophizing's relationship with experimental pain responses may be contingent on the type of response measured, with ratings of pain intensity and observation of pain behaviors (see Keefe et al., 2000), being most subject to influence by cognitive and affective processes.

We should also note that assessment of catastrophizing should include the additional dimensions of rumination and magnification, as measured by the pain catastrophizing scale (PCS) (Sullivan et al., 1995).
Pain recall is subject to many biases (Haythornthwaite and Fauerbach, 2001 and Stone et al., 2004), and it may be that catastrophizing is more powerful in shaping pain recall than in determining in vivo pain responses. Indeed, in the present study, the CSQ was completed shortly after participants answered questions about recent daily pain, and their responses to questions about catastrophizing may have been influenced by those recently-recalled pain experiences.

The process of catastrophizing is closely tied to the meaning of pain (Sullivan et al., 2001); it seems probable that catastrophic interpretations are more likely to accompany daily pain relative to a brief, controllable stimulus administered in a laboratory, where subjects have foreknowledge about the stimuli (Gracely, 1999). In contrast, clinical pain is more unpredictable and threatening. For example, a study of cancer patients found that those who believed that physical therapy-induced pain was cancer-related showed higher ratings of pain intensity and unpleasantness compared to those who attributed their pain to other factors, highlighting the role of meaning and interpretation (Smith et al., 1998). Another investigation noted that pain intensity ratings are strongly affected by interpretations of stimuli as more or less tissue-damaging, a consideration that would rarely apply to most laboratory settings (Arntz and Claassens, 2004). Finally, a study of fibromyalgia patients reported strong correlations between catastrophizing and clinical pain but no associations with responses to noxious mechanical stimuli administered in a laboratory (Gracely et al., 2004).

Sex-related variation in catastrophizing appears to emerge relatively early in development, probably well before most individuals have had any substantive experience with chronic pain. Catastrophizing is more common among adolescent school girls than boys, and was associated with more pain and pain medication use in a survey of high school students (Bedard et al., 1997). Indeed, this sample consists of healthy college-age students with no history of chronic pain. Unfortunately, while it suggests some consequences of sex differences in catastrophizing, the present study can offer little insight into its causes; such information will require longitudinal studies with long follow-up periods in children and adolescents.
While sex differences in laboratory pain responses are generally robust, catastrophizing does not appear to play a role in producing these male–female discrepancies. Laboratory pain responses are related to the brain's response to noxious stimulation (Coghill et al., 2003), to quality of life (Edwards et al., 2003c), and can prospectively predict clinical pain (Granot et al., 2003). Illuminating the mechanisms producing sex differences in experimental pain responses may therefore have important clinical implications. The fact that catastrophizing did mediate sex differences in day-to-day pain supports prior work in osteoarthritis patients. Importantly, catastrophizing mediated this association even after controlling for negative mood, highlighting catastrophizing's unique effects. Catastrophizing is observed in community residents who report no current pain (Buer and Linton, 2002), is fairly stable across time (Sullivan et al., 2001), and is a risk factor for worsening pain (Keefe et al., 1989 and Haythornthwaite et al., 2003). As such, it certainly warrants further attention as a marker for individuals at high risk for the onset or worsening of pain, as a target of treatment, and as an important variable in shaping group differences in the clinical experience of pain.

Fat, protein, and pain

Dietary fat and protein interact in suppressing neuropathic pain-related disorders following a partial sciatic ligation injury in rats
Jordi Péreza, et.al
Chronic neuropathic sensory disorders (CNSD) of rats receiving a partial sciatic nerve ligation injury (the PSL model) are suppressed by dietary soy protein. Although previously shown to modify nociceptive behavior in acute pain models, dietary fat has never been tested for its putative analgesic properties in chronic pain states. Here we tested the role of dietary fat, protein and fat/protein interactions in the development of tactile allodynia and heat hyperalgesia in PSL-injured rats. Male Wistar rats were fed nine different diets, comprising of three proteins (soy, casein and albumin) and three fats (corn, soy and canola) for a week preceding PSL injury and for 2 weeks thereafter. Rats' responses to tactile and noxious heat stimuli were tested before surgery and 3, 7 and 14 days afterwards. Tactile and heat sensory abnormalities following PSL injury were significantly different among the nine dietary groups. Consumption of corn and soy fats suppressed the levels of tactile and heat allodynia and hyperalgesia, whereas consumption of soy and casein proteins was associated with lower levels of heat hyperalgesia but not tactile allodynia. A significant fat/protein interaction was found for the heat but not tactile stimuli. We conclude that dietary fat is a significant independent predictor of levels of neuropathic sensory disorders in rats and that this effect is accentuated by dietary protein. The mechanisms by which fat suppresses neuropathic disorders have yet to be determined.

Predictors of disability

Self-efficacy, fear avoidance, and pain intensity as predictors of disability in subacute and chronic musculoskeletal pain patients in primary health care
Denison, et.al
Disability is proposed to be an important outcome in pain research (Deyo et al., 1994), and 30% of persons with neck, shoulder, or back pain may be expected to report limitations in daily life (Picavet and Schouten, 2003). Psychological factors are related to both the onset and development of spinal pain and disability (Linton, 2000). Self-efficacy, i.e. one's confidence in performing a particular behavior and in overcoming barriers to that behavior (Bandura, 1977 and Bandura, 1997), is believed to be an important mediator of disability related to pain. Self-efficacy was found to influence adjustment to a pain condition (Jensen et al., 1991), and pain-related disability (Estlander et al., 1994 and Lackner et al., 1996), to mediate the relationship between pain intensity, disability, and depression (Arnstein, 2000 and Arnstein et al., 1999), to predict lifting capacity (Lackner and Carosella, 1999), and pain behaviour and avoidance (Asghari and Nicholas, 2001) in chronic pain patients.

During the last decade, fear avoidance (Kori et al., 1990 and Vlaeyen et al., 1995) has gained increased empirical support as a mediator of disability in chronic pain (Vlaeyen and Linton, 2000). Empirical support for fear avoidance in relation to disability comes from several studies (Al-Oubadi et al., 2000, Buer and Linton, 2002, Crombez et al., 1999, Fritz and George, 2002, Fritz et al., 2001, Geisser et al., 2000 and Picavet et al., 2002). In a primary health care setting, however, van den Hout et al. (2001) showed that pain intensity and pain catastrophizing were better predictors of disability than pain-related fear. When prediction of disability by both self-efficacy and fear avoidance was examined simultaneously, self-efficacy was found to be the more powerful predictor (Ayre and Tyson, 2001).

Most studies concerning self-efficacy, fear avoidance, and disability have been conducted in secondary or tertiary health care settings where patients are highly selected due to the referral filtering process (Turk and Rudy, 1990). However, most MSP patients are managed in primary health care, and results from secondary or tertiary settings may not necessarily generalise to primary health care patients. Specifically, patients who remain in primary health care may be expected to be less disabled than patients who are referred to specialised pain clinics or rehabilitation clinics. Since self-efficacy may explain why patients persist in confronting daily activities in the face of obstacles such as pain, we argue that it is a more important predictive factor than fear avoidance in primary health care clients. Thus, the purpose of this study was (1) to test the hypothesis that self-efficacy is a better predictor of disability than fear avoidance variables and pain intensity in a primary health care sample of patients with subacute, chronic or recurring MSP, and (2) to replicate the findings in a second sample.
The results of this study confirmed our hypothesis that self-efficacy is a better predictor of disability than fear avoidance variables and pain intensity in a primary health care sample of patients with subacute, chronic, or recurring musculoskeletal pain. The results were replicated in a second sample. Gender, age, and pain duration were not significantly correlated to any of the variables in the regression model.

Bivariate correlation analyses showed that self-efficacy was significantly, and negatively, associated with disability, which is in accordance with the results reported by Arnstein et al., 1999 and Arnstein, 2000, and Lackner et al. (1996). In both samples self-efficacy showed the highest correlations with disability, as compared to pain catastrophizing and kinesiophobia. Self-efficacy correlated (negative association) with pain catastrophizing (r=-0.44, P<0.001), and kinesiophobia (negative association) in both samples (r=-0.32 and -0.38, P<0.001). The latter finding is consistent with the results of Ayre and Tyson (2001) who found a significant negative correlation between self-efficacy and fear avoidance in a sample of patients with chronic low back pain. However, the squared correlation coefficients, representing 10 and 15% of shared variance, respectively, in the two samples in the present study indicate that these two constructs were not overlapping to a great extent.

The bivariate analyses also showed positive and significant associations of fear avoidance variables with disability. This is in accordance with other studies reporting significant bivariate correlations (positive associations) between pain catastrophizing or pain-related fear, and disability (Crombez et al., 1999, Fritz and George, 2002, Fritz et al., 2001, Koho et al., 2001 and van den Hout et al., 2001).
The fear avoidance variables did predict a unique proportion of the variation in PDI scores in both samples, albeit considerably smaller than did self-efficacy. One explanation may be that fear avoidance is a more important construct in patients who are more dysfunctional and therefore managed in secondary and tertiary health care settings. Much of the work regarding fear avoidance and disability comes from pain clinic or rehabilitation program samples, e.g. Waddell et al., 1993, Vlaeyen et al., 1995 and Crombez et al., 1999, where patients are highly selected. The primary health care samples in the present study are likely to be more functional and better adjusted than the samples used to develop the fear avoidance construct. van den Hout et al. (2001), using a primary health care sample found, for example, that pain-related fear was a less important predictor of disability than pain intensity and pain catastrophizing. Fear avoidance has, however, been shown to predict disability (Picavet et al., 2002) and activities of daily living (Buer and Linton, 2002) in population-based samples, and to be present in acute stages of low back pain (Fritz et al., 2001). Thus, fear avoidance seems to be present in patients in different stages of MSP and at different levels of health care. Further research involving both self-efficacy and fear avoidance in different types of samples and settings will clarify this matter.

Pain intensity did not emerge as a consistently-significant predictor of disability in the two samples, which is contrary to the results reported by van den Hout et al. (2001). Because van den Hout et al. measured pain by the McGill Pain Questionnaire, which is a measure of both pain intensity and pain quality, the different modes of pain measurement may explain the differing results. Another possible explanation is that all subjects in the study of van den Hout et al. (2001) were sick-listed at entry of the study, as compared to about 37% of the subjects in both our samples (Table 1), indicating that our samples may have been less influenced by pain intensity.

Pain duration did not correlate significantly with any of the variables in the model, although pain duration ranged from 1 month to several years in both samples. Patients who are able to cope with their pain are likely to remain in primary health care (Turk and Rudy, 1990), and for those patients, pain duration may not be of great importance.
The clinical implications of the results in this study involve the need for primary health care professionals to focus on pain-related beliefs rather than on pain intensity reports in these patients. By relying on knowledge of pain duration and assessment of pain intensity alone to guide management, clinicians are likely to overlook important aspects of disability, and subsequently to engage in ineffective treatment strategies. As an alternative, systematic assessment of self-efficacy beliefs and fear avoidance beliefs regarding activities relevant for daily living would make a better starting point in the management process. Treatment strategies should focus on improving functional abilities related to specific and prioritised activities, using a small-steps approach to ensure success, thus enhancing self-efficacy and reducing fear.

Analgesia in cognitively impaired kids

Analgesia following surgery in children with and without cognitive impairment
Jeffrey L. Koha, et al.

Both children and adults with cognitive impairment (CI) have historically been excluded from research examining pain. This is unfortunate since patients with CI may be at higher risk for experiencing pain or having their pain undertreated due to the difficulty of pain assessment and communication. There are now several published reports about the general pain experience of both adult and pediatric patients with cognitive impairment. The purpose of this study was to compare the amount and type of pain medication administered in children with and without CI after surgery to ascertain if there were any differences in analgesic administration patterns between these two groups. One hundred and fifty-two children with borderline to profound CI and 138 non impaired (NI) children were recruited to participate. Analgesic administration data include type and amount of opioid, type of non-opioid medication, and prescribed discharge medications. Results of this study show that children with CI undergoing surgery received less opioid in the perioperative period than children without CI. However, children with CI received comparable amounts and types of analgesics in the postoperative period as children without CI.

Models of pain catastrophizing

Do we need a communal coping model of pain catastrophizing? An alternative explanation
Rudy Severeijnsa, et.al

Undoubtedly, one of the most robust findings in contemporary psychological pain research is the important role of pain catastrophizing. Despite the growing body of research on pain catastrophizing (for an extensive overview see Sullivan et al., 2001), there is still conceptual confusion about the construct, which revolves around the question whether or not pain catastrophizing is to be considered a form of coping. An illustrative example of the polemic around this question can be found in a 1999 issue of Pain Forum (Geisser et al., 1999, Haythornthwaite and Heinberg, 1999, Keefe et al., 1999 and Thorn et al., 1999). Related to this conceptual confusion is the lack of a guiding theoretical framework (Keefe et al., 2004). Sullivan et al. (2001) give an extensive and a thorough review of the literature on pain catastrophizing and discuss several models that can have a heuristic function and may help to sort and understand the research data on pain catastrophizing. One of these models in particular, the communal coping model (CCM) of catastrophizing (Sullivan et al., 2001 and Sullivan et al., 2000) is clearly taking root in pain research lately.

In this topical review, a case is made for placing pain catastrophizing within the transactional stress and coping model of Lazarus and Folkman (1984). It is argued that the CCM in its current formulation might actually contribute to the conceptual confusion around the construct of pain catastrophizing that was mentioned previously. This finally leads to the question of whether we actually need a CCM of catastrophizing.
In their transactional model of stress and coping, Lazarus and Folkman (1984) make a clear distinction between the concepts of beliefs, appraisal, and coping.

With the concept of beliefs, Lazarus and Folkman (1984) refer to a person characteristic that is an important determinant of appraisal. Particularly important for the present discussion are generalized beliefs about personal control that have to do with feelings of mastery and confidence. They are conceptualized as stable personality dispositions.

According to Lazarus and Folkman (1984), appraisal can be understood as an evaluative process. They distinguish between primary appraisals that involve evaluating a particular event as irrelevant, benign-positive, or stressful with regard to a person's wellbeing and secondary appraisals that involve evaluating a particular event with respect to coping options and their possible effectiveness. Both interact with each other and influence whether and which coping efforts will be attempted.

Finally, coping is defined as both behavioral and cognitive efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person (Lazarus and Folkman, 1984).

In 1995, Sullivan et al. (1995) already discussed that at a descriptive level there are similarities between the three subscales of the pain catastrophizing scale (PCS) on the one hand (i.e. magnification, rumination, and helplessness) and primary and secondary appraisal processes on the other hand. Magnification and rumination may reflect a focus on and evaluation of painful stimuli as extremely threatening whereas helplessness reflects the evaluation of painful stimuli as unable to cope with. Furthermore, people may possess enduring beliefs or schema about the threat value of painful stimuli or their ability to effectively cope with painful stimuli (Sullivan et al., 1995).


Based on the finding that pain catastrophizing mediates the gender–pain relationship, Sullivan et al., 2000 and Keefe et al., 2000 proposed a communal coping model (CCM) of pain catastrophizing. In this model, pain catastrophizing is conceptualized as being part of a broader, interpersonal or communal coping style in which it serves a social communicative function. At the core of the model is the tenet that dealing with stress within a social, interpersonal, or relational context, for instance by soliciting social support, assistance, or empathic reactions from (significant) others, might be more important than pain or stress reduction per se. To the extent that catastrophizing serves this goal it may be considered adaptive although it has detrimental consequences for the pain problem itself.

However, placing pain catastrophizing within a communal coping framework passes over the fact that pain catastrophizing is a theoretical construct with an explicitly cognitive connotation. Therefore, it is rather confusing to operationalize catastrophizing other than in a cognitive way. Furthermore, these catastrophizing cognitions or appraisals cannot serve a social communicative function in and of themselves because they are not observable. Rather, their sheer existence can only be inferred by asking people to complete the PCS or the CSQ or from the behavior, either verbal or nonverbal, of those who catastrophize about pain. This behavior, of course, may or may not serve a social communicative function. So, pain catastrophizing could only serve a social communicative function indirectly. Again, however, it is quite confusing to define the nature of a process, which is cognitive in the case of pain catastrophizing, in terms of its potential function or one of its effects. Analogously, although one of the effects of pain behavior might be that people become less active and develop a disuse syndrome, this does not mean that pain behavior should be defined in terms of disuse. Therefore, we argue here that the term ‘pain catastrophizing’ should be used in its pure, that is, cognitive meaning. By placing catastrophizing within a coping framework, the conceptual confusion that already exists may even be enhanced.

According to Sullivan et al. (2001), several research findings support a CCM explanation of catastrophizing. For example, Keefe et al. (1997) found that catastrophizing was related to lower spousal ratings of self-efficacy for pain. More recently, some hypotheses, derived from the CCM have been examined in research. Keefe et al. (2003) found that cancer patients who catastrophized about their pain reported receiving higher levels of caregiver instrumental support. Caregivers of these patients reported having higher levels of stress and critical behaviors and rated the patients as having more pain and engaging in more pain behaviors. Giardino et al. (2003) showed that there was a positive association between pain catastrophizing on the one hand and solicitousness and pain reports on the other hand. Perceived solicitousness and the type of social relationship (spouse or partner versus someone else) moderated the association between catastrophizing and pain reports. Finally, Sullivan et al. (2004) found that compared to low catastrophizers, high catastrophizers displayed pain behaviors for a longer duration and used fewer pain coping strategies in the presence of an observer.

Overall, the results of these studies seem to support a CCM interpretation of pain catastrophizing in that they, at least partially, confirm some of the predictions derived from the CCM, and demonstrate that pain catastrophizing has interpersonal correlates. Nevertheless, the question is justified whether the same predictions can also be derived from existing models of pain catastrophizing, in particular the appraisal model of pain catastrophizing for which supporting research data have been found as well.

According to the appraisal model of pain catastrophizing primary appraisal processes (magnification and rumination) and secondary appraisal processes (helplessness) interact and determine whether and which coping efforts will be attempted. Indeed, several studies that have started from the transactional model of stress and coping have found specific relations between appraisals of stressful events and ways of coping (Dunkel-Schetter et al., 1992, Dunkel-Schetter et al., 1987, Folkman et al., 1986, Knussen and Lee, 1998 and Turner et al., 1987). More specifically, researchers have found that threats to one's own physical health were associated with more seeking of social support (Folkman et al., 1986). Also, events that were appraised as highly stressful were characterized by support from significantly more people and by greater amounts of informational and emotional support than were events that were appraised as low in stress (Dunkel-Schetter et al., 1987). Finally, perceived stressfulness of having cancer was associated with significantly greater coping through social support (Dunkel-Schetter et al., 1992).

The point to be made here is that from this perspective and based on these findings, predictions may be made that individuals who focus on their pain (rumination), think that something terrible might happen to them because of the pain (magnification), and feel unable to effectively cope with their pain (helplessness), may adopt a coping style that, either intentionally or not, elicits social support and attention by means of overtly displaying distress, fear, helplessness, or pain behavior. The prediction of the CCM that the presence of other people serves as a discriminative stimulus for these overt displays of distress is not surprising in this context, for what is the use of showing, for example, that you are helpless if there is no one around to respond or to help you?

In a recent study by Sullivan et al. (2004) in which supportive evidence for the CCM is reported, it is proposed in the discussion section that ‘strategies used to maximize the proximity of others may be motivated, at least in part, by low levels of coping efficacy’ (italics by the present authors). However, in our opinion they fail to follow this hypothesis to its logical and ultimate consequence, which is that exactly for that reason it may be unnecessary to hypothesize that some individuals prefer a more communal or interpersonal approach to coping and that catastrophizing plays an important role in communicating this approach. Rather, within an appraisal model of catastrophizing, it is the features of catastrophizing itself that directly impinge on these interpersonal correlates. In this view, the predictions derived from the CCM of pain catastrophizing can also be accounted for by the appraisal model of pain catastrophizing.

Summarizing the previous discussion, some tentative conclusions and recommendations can be made. First, an appraisal model of pain catastrophizing offers an attractive theoretical framework, is supported by research data, and might function as a guide for future catastrophizing research. Second, pain catastrophizing should be defined in terms of its cognitive nature and not in terms of its potential function or effects. Third, the fact that catastrophizing has interpersonal correlates is intrinsic to the very nature of pain catastrophizing and can be attributed to the effects of appraisals of threat and helplessness (that is, low levels of coping efficacy) on coping behavior (that is, overt display of distress and helplessness, as well as pain behavior), which in turn is likely to evoke social attention and support. Finally, to the extent that these conclusions can be validated empirically we doubt that there is a need for a CCM of catastrophizing in which it is hypothesized that individuals who catastrophize about their pain do so because they prefer an interpersonal approach to dealing with painful stimuli. Instead, we would rather argue the opposite, namely that these individuals seek assurance and social support because they focus on their pain, experience their pain as threatening, and feel helpless in dealing with their pain. Of course, further research will have to demonstrate which of these two models, the CCM or the appraisal model, has more merits.

Editorial on headaches and depression in Pain 11(3)

The relation between depression and headache is
complex. In clinical practice depressive mood is frequently
encountered in patients with frequent headaches, including
tension-type headache (TTH), but overt major depression is
rather rare. In a cohort of subjects with TTH of any severity
the incidence of depression was not increased (Merikangas
et al., 1994). There is a bidirectional relationship in lifetime
prevalence between migraine and major depression,
suggesting a shared cause. Severe non-migrainous headaches
(most of which were frequent tension-type headaches),
however, were not predicted by major depression,
while they were themselves predictive of first-onset major
depression (Breslau et al., 2000). It was therefore felt by
some that depression was merely a secondary phenomenon
in disabling TTH, the more so that such headaches can be
ameliorated by tricyclics at low doses supposed to have little
or no antidepressant effect.

The study by Janke et al. (2004) in this issue is of
paramount importance for this discussion as it shows for the
first time that major depression favours the occurrence of
stress-induced headache in subjects suffering from frequent
TTH and that this is associated with increased pericranial
palpation tenderness. Pressure-pain thresholds were also
decreased at an extracephalic site in the depressed TTH
sufferers. The neurobiological mechanisms through which
depression promotes TTH are likely to be central sensitisation
and dysfunctioning of descending pain control pathways.
It cannot be concluded from the study whether
depression per se or increased stress in the depressed subjects
are responsible for the observed changes. From findings with
brain stem reflexes we have previously hypothesised that the
limbic control of descending pain control systems might be
abnormal in chronic TTH patients (Schoenen, 1990).

Fortunately for our PhD students, the study by Janke
et al. (2004) does not answer all questions. For instance,
they were not able to recruit depressed subjects with less
than 12 headaches per year, which by itself suggests that
depression may cause TTH, but leaves open the question
whether depression is able to favour TTH by itself.
Although the study convincingly shows that depression
predisposes to stress-induced headache episodes, it does not
prove that it is the major culprit in frequent or chronic TTH.
It could only be an aggravating factor like for instance
hormonal changes in the perimenstrum (which was not
taken into account in the present study). The fact that
specific serotonin reuptake blockers, though effective
antidepressants, are not useful for chronic TTH (Schoenen,
2000) would not favour a primary pathogenic role for
depression. The subjects recruited by Janke et al. (2004) had
major depression which is not the rule in clinical samples of
TTH patients. It would be interesting to know whether
depressive mood (scores !18 on Beck’s inventory) also
increases onset of TTH following laboratory stress. Finally,
considering the abovementioned bidirectional relationship
between migraine and depression, it seems worthwhile to
perform a similar study in migraineurs in order to determine
if depression favours migraine attacks or certain interval
headaches which can be indistinguishable from TTH.
In summary, despite its limitations this study is a
milestone in headache research as it provides experimental
evidence that depression may be the villain in tension-type
headache, and not just a bystander.

J. Schoenen
Departments of Neuroanatomy and Neurology,
University of Liege, 20,

16 February 2005


In the new issue of Philosophy and Public Affairs, David Sussman gives essentially my view on why torture is bad.
torture forces its victim into the position of colluding against himself through his own affects and emotions, so that he experiences himself as simultaneously powerless and yet actively complicit in his own violation....torture turns out to be not just an extreme form of cruelty, but the pre-eminent instance of a kind of forced self-betrayal, more akin to rape than other kinds of violence

Damn, there's one less article I'll be sending out. That said, its worth a read. Check it out if you have access.