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      A Step Towards a Better Understanding of Pain Phenotypes: Latent Class Analysis in Chronic Pain Patients Receiving Multimodal Inpatient Treatment

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          The number of non-responders to treatment among patients with chronic pain (CP) is high, although intensive multimodal treatment is broadly accessible. One reason is the large variability in manifestations of CP. To facilitate the development of tailored treatment approaches, phenotypes of CP must be identified. In this study, we aim to identify subgroups in patients with CP based on several aspects of self-reported health.

          Patients and Methods

          A latent class analysis (LCA) was carried out in retrospective data from 411 patients with CP of different origins. All patients experienced severe physical and psychosocial consequences and were therefore undergoing multimodal inpatient pain treatment. Self-reported measures of pain (visual analogue scales for pain intensity, frequency, and impairment; Pain Perception Scale), emotional distress (Patient Health Questionnaire, PHQ-9; Generalized Anxiety Disorder Scale, GAD-7) and physical health (Short Form Health Survey; SF-8) were collected immediately after admission and before discharge. Instruments assessed at admission were used as input to the LCA. Resulting classes were compared in terms of patient characteristics and treatment outcome.


          A model with four latent classes demonstrated the best model fit and interpretability. Classes 1 to 4 included patients with high (54.7%), extreme (17.0%), moderate (15.6%), and low (12.7%) pain burden, respectively. Patients in class 4 showed high levels of emotional distress, whereas emotional distress in the other classes corresponded to the levels of pain burden. While pain as well as physical and mental health improved in class 1, only the levels of depression and anxiety improved in patients in the other groups during multimodal treatment.


          The specific needs of these subgroups should be taken into account when developing individualized treatment programs. However, the retrospective design limits the significance of the results and replication in prospective studies is desirable.

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          Most cited references 35

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          Psychological factors in chronic pain: evolution and revolution.

          Research has demonstrated the importance of psychological factors in coping, quality of life, and disability in chronic pain. Furthermore, the contributions of psychology in the effectiveness of treatment of chronic pain patients have received empirical support. The authors describe a biopsychosocial model of chronic pain and provide an update on research implicating the importance of people's appraisals of their symptoms, their ability to self-manage pain and related problems, and their fears about pain and injury that motivate efforts to avoid exacerbation of symptoms and further injury or reinjury. They provide a selected review to illustrate treatment outcome research, methodological issues, practical, and clinical issues to identify promising directions. Although there remain obstacles, there are also opportunities for psychologists to contribute to improved understanding of pain and treatment of people who suffer from chronic pain. The authors conclude by noting that pain has received a tremendous amount of attention culminating in the passage of a law by the U.S. Congress designating the period 2001-2011 as the "The Decade of Pain Control and Research."
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            Chronic pain-associated depression: antecedent or consequence of chronic pain? A review.

            To determine the current status for the association of chronic pain and depression and to review the evidence for whether depression is an antecedent or consequence of chronic pain (CP). A computer and manual literature review yielded 191 studies that related to the pain-depression association. These reports were reviewed and sorted into seven categories relating to the topic of this paper. Eighty-three studies were then selected according to inclusion criteria and subjected to a structured review. Any medical treatment setting including pain treatment as inclusion criteria for selection of studies. Any patients with any type of chronic pain. The reviewed studies were consistent in indicating that there is a statistical relationship between chronic pain and depression. For the relationship between pain and depression, there was greater support for the consequence and scar hypotheses than the antecedent hypothesis. Depression is more common in chronic pain patients (CPPs) than in healthy controls as a consequence of the presence of CP. At pain onset, predisposition to depression (the scar hypothesis) may increase the likelihood for the development of depression in some CPPS. Because of difficulties in measuring depression in the presence of CP, the reviewed studies should be interpreted with caution.
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              Treatment expectancy and credibility are associated with the outcome of both physical and cognitive-behavioral treatment in chronic low back pain.

              Patients' initial beliefs about the success of a given pain treatment are shown to affect final treatment outcome. The Credibility/Expectancy Questionnaire (CEQ) has recently been developed as measure of treatment credibility and expectancy. The objectives of this study were (1) to investigate the factor structure of the CEQ in a sample of chronic low back pain (CLBP) patients by means of a confirmatory factor analysis, (2) to examine the association between treatment credibility and expectancy and patient characteristics, and (3) to assess whether treatment expectancy and credibility are associated with the outcome of rehabilitation treatment. CLBP patients (n=167) were randomized to either active physical therapy (n=51), cognitive-behavioral therapy (n=57), or a combination therapy (n=59), and completed the CEQ after a careful explanation of the treatment rationale. Confirmatory factor analysis supported the 2-factor structure (credibility/expectancy) of the CEQ. Lower credibility was associated with higher pain-related fear and lower internal control of pain, and lower expectancy with higher levels of pain-related fear and no radiating pain. Multiple linear regression analyses revealed that after controlling for age, sex, treatment center, pain-intensity at baseline, duration of disability, and irrespective of the treatment offered, expectancy was significantly associated with disability and satisfaction. Credibility was significantly associated with patient-specific symptoms and satisfaction. For global perceived effect, treatment expectancy was predictive in active physical therapy only, and treatment credibility was a significant predictor in combination therapy only. Although the associations found were low to modest, these results underscore the importance of expectancy and credibility for the outcome of different active interventions for CLBP and might contribute to the development of more effective treatments.

                Author and article information

                J Pain Res
                J Pain Res
                Journal of Pain Research
                14 May 2020
                : 13
                : 1023-1038
                [1 ]Department of Psychosomatic Medicine, Center for Internal Medicine and Dermatology, Charité – Universitätsmedizin Berlin , Berlin, Germany
                [2 ]Quantitative Health Sciences, Outcomes Measurement Science, University of Massachusetts Medical School , Worcester, MA, USA
                Author notes
                Correspondence: Alexander Obbarius Department of Psychosomatic Medicine, Center for Internal Medicine and Dermatology, Charité – Universitätsmedizin Berlin , Charitéplatz 1, 10117 Berlin, Germany Tel +4930450653890 Email alexander.obbarius@charite.de
                © 2020 Obbarius et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 1, Tables: 5, References: 60, Pages: 16
                Original Research


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