Psychological influences on repetition-induced summation of activity-related pain in patients with chronic low back pain

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Volume 141, Issues 1–2 , January 2009, Pages 70-78
Psychological influences on repetition-induced summation of activity-related pain in patients with chronic low back pain
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Michael J.L. Sullivan a
https://doi.org/10.1016/j.pain.2008.10.017 Get rights and content
Abstract
This study examined the role of pain catastrophizing , fear of movement and depression as determinants of repetition-induced summation of activity-related pain. The sample consisted of 90 (44 women and 46 men) work-disabled individuals with chronic low back pain. Participants were asked to lift a series of 18 canisters that varied according to weight (2.9 kg, 3.4 kg, 3.9 kg) and distance from the body. The canisters were arranged in a 3 × 6 matrix and the weights were distributed such that each ‘column’ of three canisters was equated in terms of physical demands. Participants rated their pain after each lift, and in a separate trial, estimated the weight of each canister. Mean activity-related pain ratings were computed for each Column of the task. An index of repetition-induced summation of pain was derived as the change in pain ratings across the six ‘columns’ of the task. Pain catastrophizing, fear of movement and depression were significantly correlated with condition-related pain (e.g., MPQ) and activity-related pain ratings. Women rated their pain as more intense than men, and estimated weights to be greater than men. A repetition-induced summation of pain effect was observed where pain ratings increased as participants lifted successive canisters. Fear of movement, but not pain catastrophizing or depression, was associated with greater repetition-induced summation of pain. The findings point to possible neurophysiological mechanisms that could help explain why fear of pain is a robust predictor of pain-related disability. Mechanisms of repetition-induced summation of activity-related pain are discussed.
Introduction
Numerous investigations have addressed the role of pain severity as a determinant of occupational disability following musculoskeletal injury [7], [56]. Research findings have been mixed. Some studies have reported that pain severity immediately following injury is a significant predictor of prolonged pain and occupational disability [21], [41]. Other studies have reported that pain severity is not a predictor of occupational disability [35], [55]. Even when significant relations are found, pain severity rarely accounts for more than 10–20% of the variance in measures of occupational disability [7], [11], [36].
It is possible that the disability-relevant dimensions of pain have not been adequately assessed in previous research. The bulk of research examining the relation between pain severity and occupational disability has relied on static measures of pain [7], [35], [56]. For the purposes of this study, static measures of pain refer to measures that describe an individuals’ pain experience at one point in time. Static measures of pain may not provide the best index of an individual’s pain experience during physical activity, particularly the repeated nature of physical activity associated with the performance of occupational duties. Change in pain that occurs as a function of repeated physical activity might be a more disability-relevant dimension of pain than static measures of pain.
In other domains of pain research, it has been shown that repeated noxious stimulation can contribute to increases in pain, in spite of constant stimulus intensity [33]. Temporal summation of pain is a term used to describe increases in pain severity across repeated noxious stimulation. At least in animals, temporal summation of pain has been shown to result from sensitization of second-order neurons in the spinal cord [20], [32], [53]. In humans, temporal summation of pain has been demonstrated primarily in response to experimenter-delivered thermal, electrical or pressure stimulation, with standardized duration of stimulation and inter-stimulus intervals [1], [8], [53]. Summation of pain in response to self-initiated repeated physical activity has not been systematically investigated [2].
One objective of the present research was to examine whether summation of pain could be demonstrated in individuals with chronic low back pain (CLBP) in response to repeated low intensity physical activity. Individuals with CLBP rated their pain as they lifted canisters that varied according to weight and distance from the body. Since it cannot be assumed that the mechanisms of summation of pain are similar in response to repeated noxious stimulation and repeated physical activity, the term repetition-induced summation of pain will be used to refer to increases in pain following repeated physical activity.
An additional objective was to examine the psychological correlates of repetition-induced summation of pain in patients with CLBP. Variables such as pain catastrophizing, pain-related fears, anxiety and depression have been associated with more severe pain, and greater disability [13], [16], [48]. These psychological factors have also been shown to contribute to temporal summation of pain [9], [15], [34]. The relation between psychological variables and changes in pain in response to repeated physical activity has yet to be investigated.
Section snippets
Participants
The study sample consisted of 90 participants (44 women and 46 men) with CLBP. Participants were recruited through local pain treatment centres and newspaper advertisements in Montreal, Quebec. At the time of the assessment, all the participants were work-disabled due to their CLBP and were receiving disability benefits. The mean age of the sample was 40.6 years, with a range of 20–60 years. The mean number of years in pain was 7.3 years (SD = 6.9 years). The majority of participants were married
Sample characteristics
Mean scores on measures of condition-related pain severity (MPQ), mean activity-related pain (MARP), the index of repetition-induced summation of activity-related pain (IRISP), fear of movement/re-injury (TSK), catastrophizing (PCS), and depression (BDI-II) are presented in Table 1. Scores on MPQ, PCS, TSK, PCS and BDI-II are comparable to those that have been reported in previous research with CLBP patients [6], [49].
Correlations among measures
Correlations among the different pain measures, namely the MPQ-PRI, MARP, and
Discussion
Consistent with previous research, analyses revealed that pain catastrophizing, fear of movement and depression were significantly correlated with the MPQ-PRI [14], [45], [50]. Psychological measures were also correlated with mean activity-related pain. Pain catastrophizing emerged as the strongest predictor of condition-related pain (i.e., MPQ-PRI) and activity-related pain (i.e., MARP). Of interest was that the MPQ-PRI was not correlated with the IRISP. The IRISP was correlated with MARP, but
Acknowledgements
The authors thank Danica Layton, Nicole Davidson, and Beatrice Garfinkel for their assistance in data coding and data entry. This research was supported by grants from the Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST) and the Canadian Institutes of Health Research. None of the authors has any financial interests associated with the results of this study.
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