Can we impact transition from acute to chronic pain?

In this post I will review an article by Rabbitts et al from late 2020 addressing the predictors of acute and chronic pain in adolescents undergoing major musculoskeletal surgery.

Pain is a common experience after surgery and adolescents are at elevated risk for both acute and chronic pain after surgery. This can significantly delay recovery and affect quality of life which means providers need to be savvy in their management of acute pain. I would like to think that the factors are modifiable and allows us to take a pre-emptive approach when considering a surgical procedure in any adolescent. Until now, these factors have been largely unexplored.

Research suggests that psychosocial factors play a role in the development of chronic post-surgical pain (CPSP). There seems to be a gap in the various conditions that are explored and their impact on CPSP. For example emotional factors, such as depressive symptoms and sleep quality, have not consistently been explore in high quality studies.

Rabbitts et al conducted a prospective longitudinal cohort study in youth undergoing major musculoskeletal surgery. One-hundred nineteen patients were recruited with the following characteristics:

- between the ages of 10 to 18 years

- scheduled to undergo major musculoskeletal surgery (spinal fusion for idiopathic

spinal deformity, Nuss procedure for pectus deformity, hip or femur osteotomy)

- able to read and understand English

Youth and parents completed a validated self-report questionnaire measures assessing presurgery assessing psychosocial risk factors once the week prior to surgery. Youth reported daily pain intensity using an online diary for 7 days, and additional pain and health outcomes.

Youth measures included the following:

- pain intensity (daily x 7 days) using numeric rating scale (NRS)

- daily medication use

- Pediatric quality of life inventory (Peds QL short form, acute version)

- pain characteristics - extent on which pain limited activities in the prior 7 days

- emotional upset due to pain during the preceding 7 days

- Widespread pain index (WPI) - locations where they have experienced pain or

tenderness during the past 7 days from 19 locations

- Pain catastrophizing scale - child version (PCA-C) - 13-item measure assess

endorsement of thoughts and feelings of magnification, rumination, and

helplessness in response to pain

- Revised child anxiety and depression scale (RCADS) - 47 item self-report

questionnaire

- Insomnia severity index (ISI)

- Adolescent sleep wake scale (ASWS) - assessed adolescent sleep quality in the

preceding month

Parent measures included the following:

- Pain catastrophizing scale-parent version (PCS-P) - 13 items assessing parent's

cognitive and emotional response to their child experiencing pain

- Family assessment device (FAD) - general functioning subscale

- Demographic questionnaire

RESULTS

One-hundred nineteen youth (75 girls, 44 boys); mean age 14.9 years

- Acute postoperative pain (APSP) defined by moderate-severe pain on the majority

of days and impaired HRQOL at 2-wk was experienced by 27.2%

- Youth who met criteria for APSP reported significantly higher pain interference on

activities and emotional upset from pain at 2-week compared with those without

APSP.

- Over the 7 days monitoring period, youth used an opioid on 21.4% of days at the 2-

week postsurgery assessment.

- Over the counter (OTC) analgesics was reported on 54.4% of days.

At 4-month after surgery

- 19.8% of youth met criteria for CPSP (defined by more than minimal pain on the

majority of diary days and impaired HRQOL at 4-month postsurgery); youth with

CPSP reported...

- higher pain interference on activities (51.7 vs 21.4)

- higher emotional upset from pain (3.0 vs 2.1)

- the rate of CPSP was significantly higher among youth who met criteria for APSP as

compared with those who did not (50 vs 9.1%)

- no participants reported any opioid use over the 7 days diary monitoring period at

4-month

- OTC analgesic use was reported on 7.3% of days over the 7 day monitoring period

Before surgery...

- 5.1 % of youth met the cutoff for clinical depression

- 4.3 % met cutoff for clinical anxiety

- 11% had moderate to severe levels of insomnia before surgery

Predictors of APSP

- Baseline pain variables were significantly associated with APSP; psychological / behavioral and parent/family factors were not

- For each 1 point higher mean pain intensity rating during the week preceding surgery, the odds of APSP was 96% higher at 2-week after surgery

Predictors of CPSP

- Adolescent depressive symptoms and sleep quality were significantly associated with CPSP status at 4-month postsurgery. Each point higher level of depressive symptoms before surgery was associated with a 22% higher odds of CPSP at 4-month.

- Each 1 point higher sleep quality score before surgery was associated with 74% lower odds of developing CPSP at 4-month. (Better sleep is associated with improved pain perception after surgery).

Discussion

Findings revealed that distinct domains predicted acute and chronic postsurgical pain

- Presurgery pain intensity was the only significant predictor of APSP at 2-week postsurgery

- Presurgery adolescent emotional and behavioral factors were significant predictors associated with chronic pain at 4-month.

- Adolescent pain catastrophizing, anxiety symptoms, and insomnia symptoms were not predictive of CPSP.

Altered sensory pain processing may potentially be one factor underlying the relationship between higher preoperative pain and APSP.

Pain trajectories become established during the first 2 weeks of recovery and pain may persist over the year after surgery in a subgroup of youth.

Why this Matters

- Depressive symptoms and poor sleep quality can be screened for and modified with cognitive-behavioral treatments

- preparations can then be made to optimize sleep prior to the surgical procedure

with a focus on avoiding the habits associated with poor sleep and improving the

bedtime routine

- maintain regular awakening and bedtime on a consistent basis

- minimize or no naps (this disrupts circadian rhythm)

- see my previous post about sleep habits here on PreEmpt Pain

- in those patients who have high pain scores prior to a surgical procedure, discuss

realistic expectations and consider a systematic approach to pain management (see

my app); while there has been a huge focus on 'opioid-free surgery', dependent

upon the surgical procedure, it may make sense to provide opioid in the hospital

(along with first-line and non-pharmacologic treatments) to avoid an opioid

prescription at hospital discharge.

- While pain catastrophizing by the parent or youth was not necessarily associated with the development of CPSP, this tendency still requires acknowledgement by the provider and should prompt us to listen attentively and express it is normal to experience some pain after these procedures. Having the ability to listen to the patient, ask questions about their experience, and develop a sound pain management plan will improve your therapeutic relationship with the patient and will positively impact their return to functioning.

Take Home Message

- ask about the daily average of pain scores over the past week in patients coming for surgery

- if pre-existing pain score is high, do not necessarily expect to get pain score

decreased significantly after a surgical procedure, unless pain is directly related to

physiological or anatomical reason addressed by surgery

- take caution in chasing high pre-existing pain scores

- if time allows, explore for the possibility of sleep disturbances and the presence of depression prior to a surgical procedure

- encourage normal wake and bedtimes

- no digital devices one hour prior to bed

- practice relaxation in bed

- use your bed only for sleeping, not for homework, watching NetFlix, FaceTiming

friends

- ask about mood and refer to provider for assessment / counseling if indicated;

reinforce to patient this will help their recovery from the surgery

- encourage hospital pre-visit to review the events of the morning of the procedure; encourage your patient to ask questions about the process, reassure them; tell them it is normal to be nervous; allow them to make choices in an age-appropriate manner

- approach pain management in a systematic way dependent upon the intensity of the expected pain / surgical procedure (I'll do a post on this topic soon).

- encourage functioning (being up and out of bed as expected by the surgeon); improved mobility often helps individuals heal faster in many domains and minimizes complications

- reinforce that the goal cannot be 'no pain' but also understand that activities associated with breakthrough pain should be addressed in pharmacologic (medicine) and non-pharmacologic ways at the same time.

Rabbitts JA, Palermo TA, Zhou C, Meyyappan A, Chen L. Psychocial predictors of acute and chronic pain in adolescents undergoing major musculoskeletal surgery. The Journal of Pain.2020.21(11):1236-46.

https://pubmed.ncbi.nlm.nih.gov/32553622/

Do you have a mechanism in place to optimize pain management in these patients having musculoskeletal surgery? I'd love to hear your thoughts here.

Do you anticipate any challenges in taking these approaches above?

Do you wish there was an app that you could use or share with your patients on reinforcing these strategies?

We'd love to hear your comments on the forum.

Become a member (log in or sign in at the top of the page on the right) to check out the PreEmpt Pain app that addresses these issues.