Factors Contributing to Lingering Pain after Surgery: The Role of Patient Expectations

2021 ◽  
Author(s):  
Mark D. Willingham ◽  
Molly R. Vila ◽  
Arbi Ben Abdallah ◽  
Michael S. Avidan ◽  
Simon Haroutounian
Keyword(s):  
Postoperative Pain ◽  
Odds Ratio ◽  
Tertiary Hospital ◽  
Acute Postoperative Pain ◽  
Preoperative Pain ◽  
Postsurgical Pain ◽  
Systematic Assessment ◽  
Modifiable Factors ◽  
Chronic Postsurgical Pain ◽  
Negative Expectations

Background Pain that lingers beyond the early weeks after the acute postoperative period is an important risk factor for chronic postsurgical pain. This study examined the hypothesis that patients’ expectations about their postsurgical pain would be independently associated with lingering postsurgical pain. Methods The study included 3,628 patients who underwent diverse surgeries between February 2015 and October 2016 in a single U.S. tertiary hospital and participated in the Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY-SOS) observational study. Preoperatively, patients were asked about their expectations about pain 1 month after surgery. Patients were considered to have lingering postsurgical pain if they endorsed having pain in the area related to their surgeries during a follow-up survey obtained 1 to 3 months postoperatively. The independent associations between preselected perioperative variables and lingering postsurgical pain were evaluated. Results Of the cohort, 36% (1,308 of 3,628) experienced lingering postsurgical pain. Overall, two thirds (2,414 of 3,628) expected their postsurgical pain to be absent or improved from baseline, and 73% of these had their positive expectations fulfilled. A total of 19% (686 of 3,628) expected new, unabated, or worsened pain, and only 39% (257 of 661) of these had their negative expectations fulfilled. Negative expectations were most common in patients with presurgical pain unrelated to the reason for surgery, undergoing surgeries not typically performed to help alleviate pain. Endorsing negative expectations was independently associated with lingering postsurgical pain (odds ratio, 1.56; 95% CI, 1.23 to 1.98; P < 0.001). Additional major factors associated with lingering postsurgical pain included recollection of severe acute postoperative pain (odds ratio, 3.13; 95% CI, 2.58 to 3.78; P < 0.001), undergoing a procedure typically performed to help alleviate pain (odds ratio, 2.18; 95% CI, 1.73 to 2.75; P < 0.001), and preoperative pain related to surgery (odds ratio, 1.91; 95% CI, 1.52 to 2.40; P < 0.001). Conclusions Lingering postsurgical pain is relatively common after diverse surgeries and is associated with both fixed surgical characteristics and potentially modifiable factors like pain expectations and severe acute postoperative pain. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

scholarly journals FRI0412 DOES SEVERE ACUTE POSTOPERATIVE PAIN RESULT IN MORE LONG-TERM PAIN AFTER TOTAL HIP OR KNEE ARTHROPLASTY (THA OR TKA) FOR OSTEOARTHRITIS?

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 805.2-805
Author(s):  
D. A. J. M. Latijnhouwers ◽  
C. H. Martini ◽  
R. G. H. H. Nelissen ◽  
H. M. J. Van der Linden ◽  
T. P. M. Vliet Vlieland ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Acute Pain ◽  
Missing Values ◽  
Rating Scale ◽  
Acute Postoperative Pain ◽  
Preoperative Pain ◽  
Mixed Effect ◽  
Total Hip ◽  
Chronic Postsurgical Pain

Background:Chronic pain is a frequently reported unfavourable outcome of total hip and knee arthroplasties (THA/TKA) (7-23% and 10-34%, respectively) in osteoarthritis (OA) patients (1), which is difficult to treat as underlying mechanisms are not fully understood. Acute postoperative pain has been identified as risk factor for development of long-term pain in other surgical procedures, such as mastectomy and thoracotomy (2). However, the effect of acute postoperative pain on development of long-term pain in THA and TKA patients is unknown.Objectives:To investigate if acute pain following THA/TKA in OA patients is associated with long-term pain and if acute pain affects the course of pain up to 1-year postoperatively.Methods:From a longitudinal multicenter study, OA patients scheduled for primary THA or TKA were included. Acute pain scores, using Numeric Rating Scale (NRS), were routinely collected as part of standard care (≤72 hours after surgery). In case of ≥2 NRS scores the two highest scores were averaged (n=160), else the single score was taken. Pain was dichotomized into severe (NRS≥5) and mild (NRS<5). Pain was assessed preoperatively, at 3 (only THA), 6 and 12 months postoperatively using HOOS/KOOS subscale pain. Separate mixed-effect models for THA and TKA patients were used, with dichotomized acute pain as fixed-effect and long-term pain as outcome, while adjusting for confounders (age, sex, BMI, preoperative pain, mental component scale of the SF12 (MCS-12), and duration of the surgery and hospitalization). We included an interaction between time of measurement and acute postoperative pain to analyse whether effect modification was present. Missing values in preoperative pain and MCS-12 were imputed using multiple imputation methods.Results:81 THA and 87 TKA patients were included, of whom 32.1% and 56.3% reported severe acute pain. The results did not show an associated between severe acute pain and long term pain (THA: β=2.0, 95%-CI:-10.9-7.0; TKA: β=3.8, 95%-CI:-10.6-2.9). Furthermore, It seems that there is no effect present of difference in severity of acute pain and the course of pain over time (THA 6-months: β=6.4, 95%-CI:1.9-10.9 and 12-months: β=0.2, 95%-CI:-4.4-4.8; TKA 12-months: β=3.2, 95%-CI:-0.5-6.8).Conclusion:We did not find an association between acute pain and the development of long-term pain nor that severity of acute pain affects the course of postoperative pain in THA and TKA patients. The fact that THA and TKA patients often experience chronic preoperative pain might be a possible explanation for this finding. Nonetheless, future studies including additional measures of acute pain and pain sensitization in patients with chronic preoperative pain are necessary to draw stronger conclusions.References:[1]Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ open. 2012;2(1):e000435.[2]Katz J, Seltzer Ze. Transition from acute to chronic postsurgical pain: risk factors and protective factors. Expert review of neurotherapeutics. 2009;9(5):723-44.Acknowledgments:We would like to thank the study group that consists of: B.L. Kaptein, Leiden University Medical Center, Leiden; S.B.W Vehmeijer, Reinier de Graaf Hospital, Delft; R. Onstenk, Groene Hart Hospital, Gouda; S.H.M. Verdegaal, Alrijne Hospital, Leiderdorp; H.H. Kaptijn, LangeLand Hospital, Zoetermeer; W.C.M. Marijnissen, Albert Schweitzer Hospital, Dordrecht; P.J. Damen, Waterland Hospital, Hoorn; the NetherlandsDisclosure of Interests:None declared

Hyperesthesia one year after breast augmentation surgery increases the odds for persisting pain at four years A prospective four-year follow-up study

2010 ◽  
Vol 1 (2) ◽  
pp. 75-81 ◽  
Author(s):  
Torill Kaasa ◽  
Luis Romundstad ◽  
Helge Roald ◽  
Knut Skolleborg ◽  
Audun Stubhaug
Keyword(s):  
Postoperative Pain ◽  
Breast Augmentation ◽  
Summary Score ◽  
Spontaneous Pain ◽  
Acute Postoperative Pain ◽  
Postsurgical Pain ◽  
Follow Up Study ◽  
Chronic Postsurgical Pain ◽  
Sensory Changes

AbstractIn this long-term follow-up study of 175 women, we investigated the prevalence of and factors associated with persisting pain and sensory changes four years after augmentation mammoplasty. Previously the women had participated in an acute postoperative pain study, and follow-up investigations at 6 weeks and 1 year after surgery. In the present study, the women were mailed questionnaires about pain, sensory changes, and affection of daily life, quality of life and pain catastrophizing 4 years after surgery.One hundred and sixteen women answered the questionnaire. The fraction of women reporting evoked- and/or spontaneous pain during the last 24 h had declined from 20% at 1 year to 14% at 4 years. Hyperesthesia had declined from 46% at 1 year to 32% at 4 years, while the change in hypoesthesia was small, 47% at 1 year to 51% at 4 years. Methylprednisolone and parecoxib given pre incisionally reduced acute postoperative pain and reduced the prevalence of hyperesthesia after 6 weeks/1 year, but after 4 years we found no significant differences between the test drug groups. Those having concomitant pain and hyperesthesia at 6 weeks and 1 year had high odds for persisting pain at 4 years (OR 7.8, 95% CI 2.1–29.8, P = 0.003; OR 13.2, 95% CI 2.5–71.3, P = 0.003). In patients without pain but with hyperesthesia at 1 year, the hyperesthesia increased the odds for pain at 4 years (OR 2.6 95% CI 1.1–6.1, P = 0.03). Hypoesthesia at 6 weeks or at 1 year did not affect the odds for pain at 4 years. A good general health condition (mental and physical) was associated with reduced odds for pain at 4 years (OR = 0.56, 95% CI 0.35–0.88, P = 0.01). However, using the Short Form health survey, SF-12, the Mental Component Summary Score seemed to affect the odds for chronic pain more than the Physical Component Summary Score.To conclude, the prevalence of pain and hyperesthesia after breast augmentation declined from 1 to 4 years. Nevertheless, the most striking finding in the current trial was that pain coinciding with hyperesthesia at 6 weeks and 1 year resulted in highly increased odds for persistent postoperative pain. Even hyperesthesia alone, without pain, increased the odds for chronic postsurgical pain. Thus, the present study suggests hyperesthesia as an independent risk factor for chronic postsurgical pain.

scholarly journals Postoperative Pain and Analgesic Requirements in the First Year after Intraoperative Methadone for Complex Spine and Cardiac Surgery

2020 ◽  
Vol 132 (2) ◽  
pp. 330-342 ◽  
Author(s):  
Glenn S. Murphy ◽  
Michael J. Avram ◽  
Steven B. Greenberg ◽  
Torin D. Shear ◽  
Mark A. Deshur ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Postoperative Pain ◽  
Spinal Surgery ◽  
Ordinal Data ◽  
Median Score ◽  
Postsurgical Pain ◽  
Surgical Closure ◽  
Chronic Postsurgical Pain ◽  
To Receive ◽  
Weekly Frequency

Abstract Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Methadone is a long-acting opioid that has been reported to reduce postoperative pain scores and analgesic requirements and may attenuate development of chronic postsurgical pain. The aim of this secondary analysis of two previous trials was to follow up with patients who had received a single intraoperative dose of either methadone or traditional opioids for complex spine or cardiac surgical procedures. Methods Preplanned analyses of long-term outcomes were conducted for spinal surgery patients randomized to receive 0.2 mg/kg methadone at the start of surgery or 2 mg hydromorphone at surgical closure, and for cardiac surgery patients randomized to receive 0.3 mg/kg methadone or 12 μg/kg fentanyl intraoperatively. A pain questionnaire assessing the weekly frequency (the primary outcome) and intensity of pain was mailed to subjects 1, 3, 6, and 12 months after surgery. Ordinal data were compared with the Mann–Whitney U test, and nominal data were compared using the chi-square test or Fisher exact probability test. The criterion for rejection of the null hypothesis was P &lt; 0.01. Results Three months after surgery, patients randomized to receive methadone for spine procedures reported the weekly frequency of chronic pain was less (median score 0 on a 0 to 4 scale [less than once a week] vs. 3 [daily] in the hydromorphone group, P = 0.004). Patients randomized to receive methadone for cardiac surgery reported the frequency of postsurgical pain was less at 1 month (median score 0) than it was in patients randomized to receive fentanyl (median score 2 [twice per week], P = 0.004). Conclusions Analgesic benefits of a single dose of intraoperative methadone were observed during the first 3 months after spinal surgery (but not at 6 and 12 months), and during the first month after cardiac surgery, when the intensity and frequency of pain were the greatest.

scholarly journals Predictive Factors of Chronic Post-Surgical Pain at 6 Months Following Knee Replacement: Influence of Postoperative Pain Trajectory and Genetics

2016 ◽  
Vol 5;19 (5;19) ◽  
pp. E729-E741
Author(s):  
Dr Célia Lloret-Linares
Keyword(s):  
Logistic Regression ◽  
Postoperative Pain ◽  
Knee Replacement ◽  
Predictive Factors ◽  
High Intensity ◽  
Walking Ability ◽  
Single Center ◽  
Multivariate Logistic Regression ◽  
Postsurgical Pain ◽  
Chronic Postsurgical Pain

Background: The frequency of chronic postsurgical pain (CPSP) after knee replacement remains high, but might be decreased by improvements to prevention. Objectives: To identify pre- and postsurgical factors predictive of CPSP 6 months after knee replacement. Study Design: Single-center prospective observational study. Setting: An orthopedic unit in a French hospital. Methods: Consecutive patients referred for total or unicompartmental knee arthroplasty from March to July 2013 were prospectively invited to participate in this study. For each patient, we recorded preoperative pain intensity, anxiety and depression levels, and sensitivity and pain thresholds in response to an electrical stimulus. We analyzed OPRM1 and COMT single-nucleotide polymorphisms. Acute postoperative pain (APOP) in the first 5 days after surgery was modeled by a pain trajectory. Changes in the characteristics and consequences of the pain were monitored 3 and 6 months after surgery. Bivariate analysis and multivariate logistic regression were conducted to identify predictors of CPSP. Results: We prospectively evaluated 104 patients in this study, 74 (28.8%) of whom reported CPSP at 6 months. Three preoperative factors were found to be associated with the presence of CPSP in multivariate logistic regression analysis: high school diploma level (OR = 3.83 [1.20 – 12.20]), consequences of pain in terms of walking ability, as assessed with the Brief Pain Inventory short form “walk” item (OR = 4.06 [1.18 – 13.94]), and a lack of physical activity in adulthood (OR = 4.01 [1.33 – 12.10]). One postoperative factor was associated with the presence of CPSP: a high-intensity APOP trajectory. An association of borderline statistical significance was found with the A allele of the COMT gene (OR = 3.4 [0.93 – 12.51]). Two groups of patients were identified on the basis of their APOP trajectory: high (n = 28, 26%) or low (n = 80, 74%) intensity. Patients with high-intensity APOP trajectory had higher anxiety levels and were less able to walk before surgery (P < 0.05). Limitations: This was a single-center study and the sample may have been too small for the detection of some factors predictive of CPSP or to highlight the role of genetic factors. Conclusion: Our findings suggest that several preoperative and postoperative characteristics could be used to facilitate the identification of patients at high risk of CPSP after knee surgery. All therapeutic strategies decreasing APOP, such as anxiety management or performing knee replacement before the pain has a serious effect on ability to walk, may help to decrease the risk of CPSP. Further prospective studies testing specific management practices, including a training program before surgery, are required. Key words: Chronic postsurgical pain, opioids, arthroplasty, pain trajectory, genetics, COMT, predictive factors

scholarly journals Antidepressant Drugs for Prevention of Acute and Chronic Postsurgical Pain

2014 ◽  
Vol 121 (3) ◽  
pp. 591-608 ◽  
Author(s):  
Karen Wong ◽  
Rachel Phelan ◽  
Eija Kalso ◽  
Imelda Galvin ◽  
David Goldstein ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Therapeutic Potential ◽  
Antidepressant Treatment ◽  
Antidepressant Drugs ◽  
Safety Evaluation ◽  
Pain Reduction ◽  
Chronic Postoperative Pain ◽  
Postsurgical Pain ◽  
Chronic Postsurgical Pain ◽  
Antidepressant Use

Abstract Background: This review evaluates trials of antidepressants for acute and chronic postsurgical pain. Methods: Trials were systematically identified using predefined inclusion and exclusion criteria. Extracted data included the following: pain at rest and with movement, adverse effects, and other outcomes. Results: Fifteen studies (985 participants) of early postoperative pain evaluated amitriptyline (three trials), bicifadine (two trials), desipramine (three trials), duloxetine (one trial), fluoxetine (one trial), fluradoline (one trial), tryptophan (four trials), and venlafaxine (one trial). Three studies (565 participants) of chronic postoperative pain prevention evaluated duloxetine (one trial), escitalopram (one trial), and venlafaxine (one trial). Heterogeneity because of differences in drug, dosing regimen, outcomes, and/or surgical procedure precluded any meta-analyses. Superiority to placebo was reported in 8 of 15 trials for early pain reduction and 1 of 3 trials for chronic pain reduction. The majority of positive trials did not report sufficient data to estimate treatment effect sizes. Many studies had inadequate size, safety evaluation/reporting, procedure specificity, and movement-evoked pain assessment. Conclusions: There is currently insufficient evidence to support the clinical use of antidepressants—beyond controlled investigations—for treatment of acute, or prevention of chronic, postoperative pain. Multiple positive trials suggest the therapeutic potential of antidepressants, which need to be replicated. Other nontrial evidence suggests potential safety concerns of perioperative antidepressant use. Future studies are needed to better define the risk–benefit ratio of antidepressants in postoperative pain management. Higher-quality trials should optimize dosing, timing and duration of antidepressant treatment, trial size, patient selection, safety evaluation and reporting, procedure specificity, and assessment of movement-evoked pain relevant to postoperative functional recovery.

scholarly journals Improving Analgesic Efficacy and Safety of Thoracic Paravertebral Block for Breast Surgery: A Mixed-Effects Meta-Analysis

2015 ◽  
Vol 5;18 (5;9) ◽  
pp. E757-E780 ◽  
Author(s):  
Abdullah S. Terkawi
Keyword(s):  
Postoperative Pain ◽  
Breast Surgery ◽  
Meta Analysis ◽  
Mixed Effects ◽  
Opioid Consumption ◽  
Paravertebral Block ◽  
Efficacy And Safety ◽  
Thoracic Paravertebral Block ◽  
Postsurgical Pain ◽  
Chronic Postsurgical Pain

Background: While most trials of thoracic paravertebral nerve blocks (TPVB) for breast surgery show benefit, their effect on postoperative pain intensity, opioid consumption, and prevention of chronic postsurgical pain varies substantially across studies. Variability may result from use of different drugs and techniques. Objectives: To examine the use of TPVB in breast surgery, and to determine which method(s) provide optimal efficacy and safety. Study Design: Mixed-Effects Meta-Analysis. Methods: We conducted a systematic review of randomized trials comparing TPVB to no intervention using random-effects models. To evaluate the contributions of various techniques, clinical approaches were included as moderators in mixed-effects models. Results: A total of 24 randomized controlled trials (RCTs) with 1,822 patients were included. Use of TPVB decreased postoperative pain scores at rest and movement at the first 2, 24, 48, and 72 hours. TPVB modestly decreased intraoperative and postoperative opioid consumption, reduced nausea and vomiting, and shortened hospitalization, but to a probably clinically irrelevant degree. Blocks also appeared to reduce the incidence of chronic postsurgical pain at 6 months. Adding fentanyl to the TPVB improved pain at rest (at 24, 48, and 72 hours) and movement (at 24 and 72 hours). Multilevel blocks provided better postoperative pain control, but only during movement (at 2, 48, and 72 hours). Fewer procedural complications (especially hypotension, epidural spread, and Horner’s syndrome) occurred when anatomical landmarks were supplemented with ultrasound guidance. Limitations: The number of studies available was limited in the meta-analytic model of incidence of chronic post-surgical pain. Conclusion: TPVB reduces postoperative pain and opioid consumption, and has a limited beneficial effect on the quality of recovery. From all the techniques that were evaluated, only the addition of fentanyl, and performing multilevel blocks were associated with improved acute analgesia. TPVB may reduce chronic postsurgical pain at 6 months. Key words: Thoracic paravertebral block, breast surgery, anesthesia, acute pain, chronic pain, nausea, vomiting, length of stay, techniques, variability, meta-regression, meta-analysis, moderators

scholarly journals Patient and Procedural Determinants of Postoperative Pain Trajectories

2021 ◽  
Vol 134 (3) ◽  
pp. 421-434
Author(s):  
Terrie Vasilopoulos ◽  
Richa Wardhan ◽  
Parisa Rashidi ◽  
Roger B. Fillingim ◽  
Margaret R. Wallace ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Odds Ratio ◽  
Multivariable Analysis ◽  
Oral Morphine ◽  
Surgical Patient ◽  
Opioid Use ◽  
Acute Postoperative Pain ◽  
Patient Factors ◽  
Pain Group ◽  
Pain Trajectories

Background The primary goal of this study was to evaluate patterns in acute postoperative pain in a mixed surgical patient cohort with the hypothesis that there would be heterogeneity in these patterns. Methods This study included 360 patients from a mixed surgical cohort whose pain was measured across postoperative days 1 through 7. Pain was characterized using the Brief Pain Inventory. Primary analysis used group-based trajectory modeling to estimate trajectories/patterns of postoperative pain. Secondary analysis examined associations between sociodemographic, clinical, and behavioral patient factors and pain trajectories. Results Five distinct postoperative pain trajectories were identified. Many patients (167 of 360, 46%) were in the moderate-to-high pain group, followed by the moderate-to-low (88 of 360, 24%), high (58 of 360, 17%), low (25 of 360, 7%), and decreasing (21 of 360, 6%) pain groups. Lower age (odds ratio, 0.94; 95% CI, 0.91 to 0.99), female sex (odds ratio, 6.5; 95% CI, 1.49 to 15.6), higher anxiety (odds ratio, 1.08; 95% CI, 1.01 to 1.14), and more pain behaviors (odds ratio, 1.10; 95% CI, 1.02 to 1.18) were related to increased likelihood of being in the high pain trajectory in multivariable analysis. Preoperative and intraoperative opioids were not associated with postoperative pain trajectories. Pain trajectory group was, however, associated with postoperative opioid use (P &lt; 0.001), with the high pain group (249.5 oral morphine milligram equivalents) requiring four times more opioids than the low pain group (60.0 oral morphine milligram equivalents). Conclusions There are multiple distinct acute postoperative pain intensity trajectories, with 63% of patients reporting stable and sustained high or moderate-to-high pain over the first 7 days after surgery. These postoperative pain trajectories were predominantly defined by patient factors and not surgical factors. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Opioid-Induced Hyperalgesia, Tolerance, and Chronic Postsurgical Pain: A Dilemma Complicating Postoperative Pain Management

2018 ◽  
Author(s):  
Dalia H. Elmofty
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Surgical Techniques ◽  
Cyclooxygenase Inhibitors ◽  
Opioid Tolerance ◽  
Postsurgical Pain ◽  
Perioperative Pain ◽  
Chronic Postsurgical Pain ◽  
Opioid Induced Hyperalgesia ◽  
Perioperative Pain Management

Perioperative pain management continues to be a challenge for physicians. Postoperative pain can compromise patient progress and lead to poor outcomes or chronic pain. Opioid medications, the mainstay of treatment for perioperative pain, can cause opioid-induced hyperalgesia and opioid tolerance. Attempts should be made to modify factors that increase the risk for chronic postsurgical pain. Certain patient factors and anesthetic and surgical techniques have been implicated. Incorporating multimodal methods for perioperative pain management using nonconventional opioids, such as methadone, cyclooxygenase inhibitors, NMDA antagonists, and regional techniques can improve outcomes and prevent opioid-induced hyperalgesia, opioid tolerance, and chronic postsurgical pain in patients on long-term opioid therapy.

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