Home Medicine Functional disability and depression symptoms in a paediatric persistent pain sample
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Functional disability and depression symptoms in a paediatric persistent pain sample

  • Jaclyn Broadbent EMAIL logo , Melanie D. Bertino , Leah Brooke , Matthew Fuller-Tyszkiewicz and George Chalkiadis
Published/Copyright: July 1, 2017
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 16 Issue 1

Abstract

Background and Aims

Clinicians treating paediatric chronic pain conditions understand that persistent pain, functional ability, and symptoms of depression often co-exist, yet these relationships have only been described to a limited extent by research. This paper more closely examines the relationship between symptoms of depression and subtypes of functional disability.

Methods

Participants included a clinical sample of children and adolescents (N = 239) referred to a paediatric multidisciplinary pain clinic for treatment of persistent or recurrent (chronic) pain in Australia. The majority of participants were female, (76.6%), and were aged 7–17 years (mean age at the time of presentation was 13.8 years). Data from standardized instruments and interview data were collected from a clinical file audit. The Pediatric Outcomes Data Collection Instrument (PODCI) was used as a measure of functional difficulties performing activities of daily living, and the Children’s Depression Inventory (CDI) was used to measure depressive symptoms.

Results

High rates of depression and functional disability were observed, but were not associated with one another beyond relatively weak associations. Contrary to prior studies using different measures of physical functioning, depression symptoms were not associated with PODCI functional disability beyond a minor association with anhedonia symptoms (primarily driven by the pain/comfort subscale of the PODCI).

Conclusions and Implications

We argue that prior research has measured physical functional limitations in paediatric pain sufferers in a way that is heavily influenced by psychosocial factors, in particular by the symptoms of clinical depression. In contrast, using a measure of physical functioning (PODCI) less influenced by psychosocial factors suggests that the relationship between physical functioning during activities of daily living (e.g., use of upper limbs, basic gross and fine motor skills, basic mobility) and depression is weaker, despite both being heightened in this sample. Unlike other functional disability measures, the Pediatric Outcomes Data Collection Instrument (PODCI) may allow researchers to assess functional limitations somewhat independently of depression symptoms. This conclusion requires replication in further studies, but if confirmed, then the PODCI could be advocated as a useful measure to obtain a more ‘pure’ measure of functional difficulties due to pain, relatively independent of depression.

Keywords: Depression; Mental health; Chronic pain; Paediatric; Physical functioning

1 Introduction

Chronic pain is a common and apparently growing problem in child and adolescent populations. Up to 38% of children and adolescents are affected by chronic pain and there is also evidence to suggest that these prevalence rates have risen over recent decades [1,2,3]. Chronic pain is more often reported by girls [2,4], seems to have onset most commonly between the ages of 12 and 14 years [2,5], and impairs children’s ability to participate optimally at home, school, sport, and during other hobbies [3,4,5].

According to the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (pedIMMPACT) taskforce (established to recommend standard measures of paediatric pain), there are three primary types of functioning likely to be impacted by chronic pain. These include role functioning (includes being a student, friend, employee, and family member), emotional functioning (mental health), and physical functioning (for example, walking or playing sports) [6]. Both depression (a type of emotional dysfunction) and other types of functional limitations have been found to occur in high rates in paediatric pain sufferers [7]. Prior research has linked global functional difficulties and emotional distress in paediatric pain samples (e.g., 8).

A common measure used in paediatric pain to measure physical functioning is the Functional Disability Inventory (FDI) [9]. The FDI assesses patients on a global functioning score, but does not produce scores for subtypes of functioning. Examining the subtypes of functioning such as physical functioning during activities of daily living (e.g., use of upper limbs, basic gross and fine motor skills, basic mobility), may help us to further understand the complexity of the relationship between different types of impaired functioning and depression. However, much, if not all, of the prior paediatric pain research has measured functional disability using global functional scores, and has not examined how subtypes of functioning interact with depression symptoms on different depression subscales. Further, measures that do include subtypes of functioning, such as The Pediatric Outcomes Data Collection Instrument (PODCI) [10], are not often used with paediatric chronic pain patients.

The purpose of this paper is to explore the inter-relationships between functional disability and depression symptoms in a sample of paediatric pain patients. In order to allow a more in-depth exploration of the relationship between depression and functional disability, this paper aims to investigate subtypes of functioning and their relationship with depression symptoms. Based on the existing literature, it is hypothesized that the depression symptoms (both globally and all subscales of depression) will be strongly and positively associated with PODCI disability (both globally and all subscales of functioning). No specific predictions beyond this were made given this is an exploratory study.

2 Material and methods

2.1 Ethics

Ethics approval was obtained from the Deakin University and Royal Children’s Hospital Human Research Ethics Committees. Patients and their parents attending the clinic signed a consent form indicating that their de-identified data may be used for research purposes in the future.

2.2 Participants

Clinical sample data were obtained by auditing the medical files of 239 children and adolescents (aged 7–17 years) who attended the Children’s Pain Management Clinic at Royal Children’s Hospital, Australia between 2002 and 2011, and who had completed the questionnaires outlined below. Of the 239 cases presenting for treatment of chronic pain, 76.6% (N =183) were female, the mean age at the time of presentation was 13.8 years. This is consistent with the findings of previous research that adolescent girls are at greater risk for chronic pain disorders [2,4,5]. The most common presenting pain locations included lower limb pain (43.8%), head, face or mouth pain (37.2%), and lower back, lumbar spine, sacrum, or coccyx (see Table 1). These pain areas commonly present in children and adolescents, although the relative frequencies of reports may differ across individual studies [2,3,4-5]. Approximately half presented with a single pain location, a quarter with two pain areas, and the remainder 3 or more (see Table 1).

Table 1

Paediatric pain locations (N = 239).

Pain location N %
Limb pain 120 50.2
 Lower limb 105 43.9
 Shoulder and upper limbs 30 12.6
Head, face, mouth 89 37.2
Lumbar region, lower back, sacrum, or coccyx 49 20.5
Abdominal region 33 13.8
Thoracic region, upper back 20 8.4
Widespread (more than 3 major sites) 20 8.4
Pelvic region 17 7.1
Cervical region, neck 13 5.4
Anal, perineal, and genital region 2 .8

  1. Note: Cumulative percentages exceed 100% due to multiple diagnoses per patient.

2.3 Materials

2.3.1 Demographics

Included child’s date of birth and gender.

2.3.2 Pain locations

Information on pain locations was obtained both from referral information and from a questionnaire item. The following categories were then created based on common anatomical sites in prior literature: head/face/mouth, cervical/neck, shoulder/upper limbs, thoracic/upper back, abdominal, lumbar/lower back/sacrum/coccyx, pelvic, anal/perineal/genital, lower limb, and widespread (more than 3 major pain sites).

2.3.3 Depression symptoms

Data were collected using the Children’s Depression Inventory (CDI) [11] to assess participant’s levels of depression for the past 2 weeks. This screening tool is a 27-item self-rated symptom oriented scale suitable for children and adolescents aged 7–17 years. The CDI yields five subscales: Negative mood (irritability or anger) (reliability in current study α = .79), Interpersonal problems (difficulty making and keeping close relationships) (reliability in current study α = .47), Ineffectiveness (lack of motivation or inability to complete tasks) (reliability in current study α = .66), Anhedonia (inability or decreased ability to experience joy) (reliability in current study α = .72), and Negative Self-Esteem (belief that one is not good at anything) (reliability in current study α = .70). It is a standardized measure that incorporates specific scoring criteria in order to rate each item on a 3-point scale according to the extent to which it applies to each individual (i.e., 0 = Absence of symptom, 1 = Mild symptom, 2 = Definite symptom). The scores obtained from the five subscales are used to derive an overall indicator of depression (i.e., Total CDI), with higher scores indicating increasing severity. The scores on each item are summed to get a raw total score, which is standardized by age and gender to obtain a T-score, ranging from 34 to 100. The CDI demonstrates good validity, predicting depressive disorders and discriminating between depressive disorders and other psychological mood disorders [12,13], and has been used in mixed pain populations [14,15]. The CDI also demonstrates moderate to high test-retest reliability [12]. The Total CDI scale demonstrated high internal consistency in the current study (α = .90), with the subscales ranging from α = .66 to .79, with the exception of Interpersonal problems which had a low reliability (α = .47).

2.3.4 Pain-related functional disability

The PODCI [10], also known as the Pediatric Orthopaedic Society of North America (POSNA) questionnaire, assesses patients under 19 years of age on their overall health, pain, and ability to participate in normal daily activities, as well as in more vigorous activities associated with young people. The POSNA includes five subscales and a global scale made up of a total of 117 items, on a five point Likert-type scale ranging from “Not at all” to “Extremely”. The Global Functioning Scale measures general disruptions to daily and student activities, and is calculated by summing the scores of all the subscales (reliability in current study α = .94). The four primary subscales include: the Upper Extremity and Physical Function Subscale, which measures difficulty encountered in performing daily personal care and student activities (reliability in current study α = .85), the Transfer and Basic Mobility Subscale measuring difficulty experienced in performing routine motion and motor activities in daily activities (reliability in current study α = .86), the Sports/Physical Functioning Subscale measuring difficulty or limitations encountered in participating in more active activities or sports (reliability in current study α = .94), and the Pain/Comfort Subscale which measures the level of pain experienced during the past week (reliability in current study α = .80).

Developed by the American Academy of Orthopedic Surgeons (AAOS), there are three versions: the parent–child (parent completing for children <11 years of age), parent–adolescent (parent completing for adolescent), and the adolescent format (adolescent completing for themselves). The PODCI scales have a normative scoring system, which allows for direct comparison of outcome scores across all three versions (both self- and parent-rated adolescent versions, and a parent-rated child version). In the current study, the parent–child and parent–adolescent versions were used. Normative outcome scores are produced for the global functioning scale and the subscales. Normative data for the PODCI scale has been provided in a large study by Hunsaker and colleagues [16]. While the PODCI has not been used extensively in the paediatric pain literature, it has been found to be reliable in pain conditions such as juvenile idiopathic arthritis [17,18], pain related injury [19], and complex regional pain syndrome [20]. The global functioning scale demonstrated high internal consistency in the current study (α = .94), with the subscales ranging from α = .80 to .94.

2.4 Procedure

A random, representative sample of medical files of patients who were assessed and treated in the Children’s Pain Management Clinic at the Royal Children’s Hospital between 2002 and 2011 were audited. The total number of files entered was based on a power calculation of the number needed to test the a priori hypotheses with t-tests or correlations, as appropriate. Assuming power =.8, alpha = .05, equal group sizes (relevant for the t-tests only), and a small effect size (r =.2 or Cohen’s d = .35, depending on the analysis), the minimum required sample size was estimated at 200. These effect sizes were chosen on the basis of prior findings and clinical experience suggesting effects smaller than this would be of negligible benefit in clinical contexts.

Children attended the clinic with their parent(s) and were assessed on initial presentation by a multi-disciplinary team and with standardized questionnaires (see materials section). All patients were required to complete the battery of questionnaires as part of their initial assessment and intake procedure into the clinic. Parents completed questionnaires on behalf of their child. PODCI scales have a normative scoring system, which allows for direct comparison of outcome scores for both the parent–child and parent–adolescent versions.

3 Results

3.1 Data analyses

All analyses were conducted using SPSS version 21. The CDI had 10 cases (4.2%) with more than 10% missing data (3 or more data points), the PODCI had 11 cases (4.6%) with more than 10% missing data (11 or more data points), all which were deleted listwise. Missing values analysis was then conducted, and revealed there was less than 5% missing data overall. Missing values were imputed using expectation maximization [21]. Several outliers were found, and appeared to be influential for normality. Once these cases were brought closer to the mean (3.29 SD form the mean), all variables were normally distributed. No further transformations were necessary.

3.2 Functional disability

With regards to the functional scales of the PODCI, this clinical sample reported statistically and clinically significantly poorer functioning than the general population on all subscales of the PODCI (see Table 2), with moderate to large effect sizes according to Cohen’s criteria [22]. On the global functioning scale, 88.2% of participants were at least 10 points (1 full Standard Deviation [SD]) below their peers without chronic pain, and 76.9% of these children were at least 20 points (2 SDs) below the normative mean. Further details are included in Table 2.

Table 2

PODCI Pediatric Functional Disability.

Clinical sample, M(SD) Normative sample, M (SD) Mean difference t-test Effect size, d
Global functioning 10.42(21.22) 50(10) t(237) = 28.77[*] 2.39
Upper extremity and physical function 38.56(22.90) 50(10) t(237) = 7.70[*] 0.65
Transfer and basic mobility 21.59 (32.74) 50(10) t(237) = 13.39[*] 1.17
Sports and physical functioning 12.94(26.40) 50(10) t(237) = 21.66[*] 1.86
Pain comfort 17.22(13.84) 50(10) t(237) = 36.55[*] 2.72

  1. Notes: PODCI, Pediatric Outcomes Data Collection Instrument. N = 238; Scores we converted to normative scores against the general population, with a mean of 50 and SD of 10. Lower scores indicate poorer functioning.

3.3 Depression and functional disability

Table 3 presents data on mean differences between the clinical sample and a normative sample (general population means) on the standardized depression scale. All scales and total scores on the depression inventory were significantly higher for the group with chronic pain than for the normative sample, and 97% of the clinical sample fell within the clinical range for depression symptoms [11]. Effect sizes were large by Cohen’s criteria [22].

Table 3

Scores on the CDI: chronic pain versus normative sample.

Pain (N = 226) Normative Score Mean Effect Size
M (SD) M (SD) Difference d
t-test
Depression (Total) 73.77 (5.26) 50(10) t(225) = 67.92[*] 2.98
Negative Mood 74.88 (6.77) 50(10) t(225) = 55.25[*] 2.91
Interpersonal Problems 65.30 (7.23) 50(10) t(225) = 31.79[*] 1.75
Ineffectiveness 60.90 (6.35) 50(10) t(225) = 25.80[*] 1.30
Anhedonia 64.21 (5.67) 50(10) t(225) = 37.67[*] 1.75
Negative Self-Esteem 74.30 (5.68) 50(10) t(225) = 64.27[*] 2.99

  1. Notes. CDI = Children’s Depression Inventory.

To determine the relationship between functional disability and depression, bivariate correlations were performed (see Table 4). Depression was not found to be correlated with functional disability on the PODCI in contrast to previous findings using the FDI [7,16]. One exception was that the anhedonia subscale showed a weak positive relationship with Global PODCI Functioning (r = .13, P > .05); this is likely driven by the PODCI Pain/Comfort subscale association with Anhedonia (r = .13, P > .05).

Table 4

Bivariate correlations between PODCI functioning and CDI depression.

1 2 3 4 5 6 7 8 9 10 11
1 1
2 .53 [***] 1
3 .80 [***] .36[**] 1
4 .87 [***] .27 [***] .77 [***] 1
5 .74 [***] .20 [**] .48 [***] .58 [***] 1
6 .06 .04 .04 −.01 .11 [*] 1
7 .01 .06 −.01 −.04 .07 .43 [***] 1
8 .01 −.03 −.03 −.05 .05 .40 [***] −.21[**] 1
9 −.08 −.02 −.07 −.08 −.01 .46 [***] .12[*] .13 [*] 1
10 .13 [*] .01 .06 .09 .13 [*] .45 [***] −.07 .24 [***] −.02 1
11 −.03 .02 .01 −.06 −.04 .40 [***] .16 [**] −.02 .17 [**] −.11[*] 1

  1. Notes: PODCI, Pediatric Outcomes Data Collection Instrument; CDI, Children’s Depression Inventory; 1, Global Functioning; 2, Upper Extremity & Physical Functioning; 3, Transfer & Basic Mobility; 4, Sports & Physical Functioning; 5, Pain/Comfort; 6, Total CDI; 7, Negative Mood; 8, Interpersonal Problems; 9, Ineffectiveness; 10, Anhedonia; 11, Negative Self-Esteem.

    N =225.

4 Discussion

It is clear that chronic pain often permeates many aspects of the sufferer’s physical and psychological functioning. By exploring functional disability and depression global scores, as well as their subscales, we aimed to provide a more detailed picture of how emotional and physical functioning inter-relate in this population. As in prior research, high rates of both depressive symptoms and physical functional limitations were observed in this sample. This is not a particularly novel finding. However, perhaps of greater interest was the finding that contrary to prior studies using measures of physical functioning other than the PODCI, and contrary to the study hypotheses, depression symptoms were not associated with PODCI functional disability beyond a relatively weak association between pain/comfort and anhedonia symptoms. This was unexpected and warrants further consideration.

4.1 Depression and functional disability (as measured by the PODCI)

In contemplating these findings, a clear difference was identified in the measures that we used, and those used in much of the prior research on which our hypotheses were based (e.g. [8,23,24,25-26]). Whilst the majority of studies demonstrating the relationship between depression and physical functional disability have used the CDI or a similar instrument to measure depression, consistent with our sample; the majority did not use the PODCI to measure both broad and specific functional disability domains. Instead, many prior studies have used the Functional Disability Inventory (FDI) or a similar instrument. On inspecting the items included in the FDI compared with the items of the PODCI, the FDI items appear to include mostly broader and more general activities of daily living (ADL) descriptions than the PODCI. Examples of FDI items include doing chores, eating regular meals, and going shopping. Examples of PODCI items include using a fork and spoon, bending over from standing to pick up something off the floor, and walking three blocks. Given this, it is possible that FDI items are more likely to be influenced by depression; as during a depressive episode, a person may be more likely to continue to perform tasks like picking something off the floor, but may have more difficulty eating regular meals or going shopping (e.g. due to anhedonia, loss of motivation, and fatigue). To illustrate this idea, Supplementary File 1 compares the items of the CDI depression measure, with those items the authors have deemed to demonstrate a reasonable degree of similarity on either the FDI or PODCI. Supplementary File 2 summarizes the total number of items on each functional scale and subscales identified in Supplementary File 1, and gives the percentage of the total functional scale or subscale overlapping with CDI depression items.

The tables within the supplementary files suggest that the FDI items show similarity with 7 of the 27 CDI items (representing approximately 25.9% of the CDI scale), whereas the PODCI Global Functioning Scale items only overlap with 2 of the 27 CDI items (representing approximately 7.4% of the CDI scale). This is despite the FDI having a total of 15 items, whereas the PODCI Global Functioning Scale has a total of 34 items. The upper extremity and transfer and basic mobility subscales have no items that were judged to be reasonably similar to the CDI items. The Sports and Physical Functioning and Pain/Comfort subscales, each had one similar CDI item. In judging the items, 4 CDI items and 5 functional items produced some uncertainty in classification (Table 5).

Table 5

CDI items that produced uncertainty in classification.

CDI Item Possible matches
CDI item 20: “I do/not feel alone…” PODCI SPF item 57: “How often do things with friends”
CDI item 27: “I get along with people/get into fights many/all times…” PODCI SPF items 36, 43, 50: “Participate in recreation/sports/comp. sports with children same age”
CDI item 12: “I do/not like being with people/many/all times…” FDI item 3: “Doing something with a friend”
“CDI item 19:1 do/not worry about aches and pains…” PODCI P/C items 17, 73: Pain/Discomfort interferes with activities/normal activities” PODCI P/C item 72: Amount. of pain in the last week (from ‘none’ to ‘severe’)

After consulting with an independent rater, it was decided that CDI item 19 and PODCIP/C items 17, 73, and 72 were similar enough to be paired, given they were likely to assess a similar underlying construct (i.e., a focus and concern about pain and its impact). Also, the PODCI SPF items 57, 36, 43, and 50, and FDI item 3 were deemed to be similar enough to be paired with CDI items 20, 27, and 12 given they likely assess similar constructs of feeling connected to friends/peers. However, even in the most conservative of cases, there would still have remained a discrepancy between the FDI and the PODCI, in that the FDI would have more similar items to the CDI than the PODCI.

In considering this apparent discrepancy between the measures, we note that it is difficult to assess limitations to physical functioning that may be a consequence of chronic pain or other health conditions without also measuring the impact of mental health difficulties, particularly depression. This is because the symptoms of depression include depleted functioning in daily activities and tasks such as participating in enjoyable activities, eating well, sleeping well, and lack of energy. However, the FDI apparently includes more of such items than the PODCI. Therefore, if this is true, the PODCI may provide a more ‘pure’ measure of limitations to physical functioning that are a direct consequence of the pain condition (or other health condition under study). The FDI, on the other hand, might provide more information about disruptions to psychosocial, emotional, and role functioning. The following paragraphs list limitations that should be considered alongside these findings.

4.2 Limitations

The study was cross-sectional with retrospective analysis, and requires replication and verification with other methodologies and samples. The lack of a significant relationship between depression and functional disability may instead be attributable to the truncated variability on the depression measure, given that 97% of the sample was considered to fall within the clinical range for depression symptoms. Participants came from a specialist pain clinic and may therefore be unrepresentative of all children with chronic pain. Further, while aligning with cohorts used in previous studies [27,28], there was a predominance of females with chronic pain used in this study. Both of these factors mean that generalizing findings to the general population should be done with caution. Lastly, the CDI subscale ‘Interpersonal Problems’ had a low reliability (α = .47). While this subscale had the smallest number of items (n = 4), this substandard reliability may mean that relationships involving this variable are under estimated, and thus should be interpreted with caution.

4.3 Conclusions and implications

In summary, clinicians treating paediatric chronic pain conditions understand the importance and inter-dependencies of chronic pain, physical and other functional abilities, and symptoms of depression [29]. However, these relationships have only been described to a limited extent by prior research. This report described a large clinical sample of children and adolescents seeking treatment for chronic pain, and analyzed the associations between their pain complaint and reported physical functional impairments, and symptoms and subscales of depression. The characteristics of the overall sample were consistent with previous research. While functional disability and depression were elevated in the population (as expected), depression was not found to correlate with functional disability on the PODCI, other than a smaller than expected relationship between pain/comfort and anhedonia.

The existing research base examining the associations between these functional disability and depression symptoms in paediatric chronic pain patients is limited. Given the sample size and the clinical nature of the population in the present study, further investigation into different measures of functional disability and their relationship with depression is warranted. This will assist in confirming or denying whether the PODCI measures a type of functional disability that is somewhat independent of the symptoms of clinical depression, such that activities of daily living (e.g., use of upper limbs, basic gross and fine motor skills, basic mobility) may be less affected by depression in paediatric pain sufferers compared with broader social and role functioning tasks. If this were confirmed, then the PODCI could be advocated as a useful measure to obtain a more ‘pure’ measure of functional difficulties due to pain, relatively independent of depression.

Highlights

  • High rates of depression and functional disability were observed.

  • Depression and functional disability had a weak association.

  • PODCI may assess functional limitations independently of depression symptoms.

Deakin University, School of Psychology, 221 Burwood Hwy, Burwood, Victoria 3125, Australia.

  1. Ethical issues: Research was approved by Children’s Pain Management Clinic at the Royal Children’s Hospital and at Deakin University. This study collected data retrospectively from a database of previous patients at the pain clinic who had given their consent for their data to be used in future research.

  2. Conflicts of interest: The author(s) have no competing or potential conflicts of interest.

  3. Funding: No funding sources were provided.

Acknowledgements

For assistance with data collection we would like to acknowledge: Emma Thompson, Ye Sul Kim, and Alexandra Gough.

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Appendix A. Supplementary data

Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.sjpain.2017.05.006.
Received: 2017-01-25
Revised: 2017-05-05
Accepted: 2017-05-19
Published Online: 2017-07-01
Published in Print: 2017-07-01

© 2017 Scandinavian Association for the Study of Pain

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  2. Scandinavian Journal of Pain
  3. Editorial comment
  4. Glucocorticoids – Efficient analgesics against postherpetic neuralgia?
  5. Original experimental
  6. Effect of intrathecal glucocorticoids on the central glucocorticoid receptor in a rat nerve ligation model
  7. Editorial comment
  8. Important new insight in pain and pain treatment induced changes in functional connectivity between the Pain Matrix and the Salience, Central Executive, and Sensorimotor networks
  9. Original experimental
  10. Salience, central executive, and sensorimotor network functional connectivity alterations in failed back surgery syndrome
  11. Editorial comment
  12. Education and support strategies improve assessment and management of pain by nurses
  13. Clinical pain research
  14. Using education and support strategies to improve the way nurses assess regular and transient pain – A quality improvement study of three hospitals
  15. Editorial comment
  16. The interference of pain with task performance: Increasing ecological validity in research
  17. Original experimental
  18. The disruptive effects of pain on multitasking in a virtual errands task
  19. Editorial comment
  20. Analyzing transition from acute back pain to chronic pain with linear mixed models reveals a continuous chronification of acute back pain
  21. Observational study
  22. From acute to chronic back pain: Using linear mixed models to explore changes in pain intensity, disability, and depression
  23. Editorial comment
  24. NSAIDs relieve osteoarthritis (OA) pain, but cardiovascular safety in question even for diclofenac, ibuprofen, naproxen, and celecoxib: what are the alternatives?
  25. Clinical pain research
  26. Efficacy and safety of diclofenac in osteoarthritis: Results of a network meta-analysis of unpublished legacy studies
  27. Editorial comment
  28. Editorial comment on Nina Kreddig’s and Monika Hasenbring’s study on pain anxiety and fear of (re) injury in patients with chronic back pain: Sex as a moderator
  29. Clinical pain research
  30. Pain anxiety and fear of (re) injury in patients with chronic back pain: Sex as a moderator
  31. Editorial comment
  32. Intraoral QST – Mission impossible or not?
  33. Clinical pain research
  34. Multifactorial assessment of measurement errors affecting intraoral quantitative sensory testing reliability
  35. Editorial comment
  36. Objective measurement of subjective pain-experience: Real nociceptive stimuli versus pain expectation
  37. Clinical pain research
  38. Cerebral oxygenation for pain monitoring in adults is ineffective: A sequence-randomized, sham controlled study in volunteers
  39. Editorial comment
  40. Association between adolescent and parental use of analgesics
  41. Observational study
  42. The association between adolescent and parental use of non-prescription analgesics for headache and other somatic pain – A cross-sectional study
  43. Editorial comment
  44. Cancer-pain intractable to high-doses systemic opioids can be relieved by intraspinal local anaesthetic plus an opioid and an alfa2-adrenoceptor agonist
  45. Clinical pain research
  46. Spinal analgesia for severe cancer pain: A retrospective analysis of 60 patients
  47. Editorial comment
  48. Specific symptoms and signs of unstable back segments and curative surgery?
  49. Clinical pain research
  50. Symptoms and signs possibly indicating segmental, discogenic pain. A fusion study with 18 years of follow-up
  51. Editorial comment
  52. Local anaesthesia methods for analgesia after total hip replacement: Problems of anatomy, methodology and interpretation?
  53. Clinical pain research
  54. Local infiltration analgesia or femoral nerve block for postoperative pain management in patients undergoing total hip arthroplasty. A randomized, double-blind study
  55. Editorial
  56. Scientific presentations at the 2017 annual meeting of the Scandinavian Association for the Study of Pain (SASP)
  57. Abstracts
  58. Correlation between quality of pain and depression: A post-operative assessment of pain after caesarian section among women in Ghana
  59. Abstracts
  60. Dynamic and static mechanical pain sensitivity is associated in women with migraine
  61. Abstracts
  62. The number of active trigger points is associated with sensory and emotional aspects of health-related quality of life in tension type headache
  63. Abstracts
  64. Chronic neuropathic pain following oxaliplatin and docetaxel: A 5-year follow-up questionnaire study
  65. Abstracts
  66. Expression of α1 adrenergic receptor subtypes by afferent fibers that innervate rat masseter muscle
  67. Abstracts
  68. Buprenorphine alleviation of pain does not compromise the rat monoarthritic pain model
  69. Abstracts
  70. Association between pain, disability, widespread pressure pain hypersensitivity and trigger points in subjects with neck pain
  71. Abstracts
  72. Association between widespread pressure pain hypersensitivity, health history, and trigger points in subjects with neck pain
  73. Abstracts
  74. Neuromas in patients with peripheral nerve injury and amputation - An ongoing study
  75. Abstracts
  76. The link between chronic musculoskeletal pain and sperm quality in overweight orthopedic patients
  77. Abstracts
  78. Several days of muscle hyperalgesia facilitates cortical somatosensory excitability
  79. Abstracts
  80. Social stress, epigenetic changes and pain
  81. Abstracts
  82. Characterization of released exosomes from satellite glial cells under normal and inflammatory conditions
  83. Abstracts
  84. Cell-based platform for studying trigeminal satellite glial cells under normal and inflammatory conditions
  85. Abstracts
  86. Tramadol in postoperative pain – 1 mg/ml IV gave no pain reduction but more side effects in third molar surgery
  87. Abstracts
  88. Tempo-spatial discrimination to non-noxious stimuli is better than for noxious stimuli
  89. Abstracts
  90. The encoding of the thermal grill illusion in the human spinal cord
  91. Abstracts
  92. Effect of cocoa on endorphin levels and craniofacial muscle sensitivity in healthy individuals
  93. Abstracts
  94. The impact of naloxegol treatment on gastrointestinal transit and colonic volume
  95. Abstracts
  96. Preoperative downregulation of long-noncoding RNA Meg3 in serum of patients with chronic postoperative pain after total knee replacement
  97. Abstracts
  98. Painful diabetic polyneuropathy and quality of life in Danish type 2 diabetic patients
  99. Abstracts
  100. “What about me?”: A qualitative explorative study on perspectives of spouses living with complex chronic pain patients
  101. Abstracts
  102. Increased postural stiffness in patients with knee osteoarthritis who are highly sensitized
  103. Abstracts
  104. Efficacy of dry needling on latent myofascial trigger points in male subjects with neck/shoulders musculoskeletal pain. A case series
  105. Abstracts
  106. Identification of pre-operative of risk factors associated with persistent post-operative pain by self-reporting tools in lower limb amputee patients – A feasibility study
  107. Abstracts
  108. Renal function estimations and dose recommendations for Gabapentin, Ibuprofen and Morphine in acute hip fracture patients
  109. Abstracts
  110. Evaluating the ability of non-rectangular electrical pulse forms to preferentially activate nociceptive fibers by comparing perception thresholds
  111. Abstracts
  112. Detection of systemic inflammation in severely impaired chronic pain patients, and effects of a CBT-ACT-based multi-modal pain rehabilitation program
  113. Abstracts
  114. Fixed or adapted conditioning intensity for repeated conditioned pain modulation
  115. Abstracts
  116. Combined treatment (Norspan, Gabapentin and Oxynorm) was found superior in pain management after total knee arthroplasty
  117. Abstracts
  118. Effects of conditioned pain modulation on the withdrawal pattern to nociceptive stimulation in humans – Preliminary results
  119. Abstracts
  120. Application of miR-223 onto the dorsal nerve roots in rats induces hypoexcitability in the pain pathways
  121. Abstracts
  122. Acute muscle pain alters corticomotor output of the affected muscle stronger than a synergistic, ipsilateral muscle
  123. Abstracts
  124. The subjective sensation induced by various thermal pulse stimulation in healthy volunteers
  125. Abstracts
  126. Assessing Offset Analgesia through electrical stimulations in healthy volunteers
  127. Abstracts
  128. Metastatic lung cancer in patient with non-malignant neck pain: A case report
  129. Abstracts
  130. The size of pain referral patterns from a tonic painful mechanical stimulus is increased in women
  131. Abstracts
  132. Oxycodone and macrogol 3350 treatment reduces anal sphincter relaxation compared to combined oxycodone and naloxone tablets
  133. Abstracts
  134. The effect of UVB-induced skin inflammation on histaminergic and non-histaminergic evoked itch and pain
  135. Abstracts
  136. Topical allyl-isothiocyanate (mustard oil) as a TRPA1-dependent human surrogate model of pain, hyperalgesia, and neurogenic inflammation – A dose response study
  137. Abstracts
  138. Dissatisfaction and persistent post-operative pain following total knee replacement – A 5 year follow-up of all patients from a whole region
  139. Abstracts
  140. Paradoxical differences in pain ratings of the same stimulus intensity
  141. Abstracts
  142. Pain assessment and post-operative pain management in orthopedic patients
  143. Abstracts
  144. Combined electric and pressure cuff pain stimuli for assessing conditioning pain modulation (CPM)
  145. Abstracts
  146. The effect of facilitated temporal summation of pain, widespread pressure hyperalgesia and pain intensity in patients with knee osteoarthritis on the responds to Non-Steroidal Anti-Inflammatory Drugs – A preliminary analysis
  147. Abstracts
  148. How to obtain the biopsychosocial record in multidisciplinary pain clinic? An action research study
  149. Abstracts
  150. Experimental neck muscle pain increase pressure pain threshold over cervical facet joints
  151. Abstracts
  152. Are we using Placebo effects in specialized Palliative Care?
  153. Abstracts
  154. Prevalence and pattern of helmet-induced headache among Danish military personnel
  155. Abstracts
  156. Aquaporin 4 expression on trigeminal satellite glial cells under normal and inflammatory conditions
  157. Abstracts
  158. Preoperative synovitis in knee osteoarthritis is predictive for pain 1 year after total knee arthroplasty
  159. Abstracts
  160. Biomarkers alterations in trapezius muscle after an acute tissue trauma: A human microdialysis study
  161. Abstracts
  162. PainData: A clinical pain registry in Denmark
  163. Abstracts
  164. A novel method for investigating the importance of visual feedback on somatosensation and bodily-self perception
  165. Abstracts
  166. Drugs that can cause respiratory depression with concomitant use of opioids
  167. Abstracts
  168. The potential use of a serious game to help patients learn about post-operative pain management – An evaluation study
  169. Abstracts
  170. Modelling activity-dependent changes of velocity in C-fibers
  171. Abstracts
  172. Choice of rat strain in pre-clinical pain-research – Does it make a difference for translation from animal model to human condition?
  173. Abstracts
  174. Omics as a potential tool to identify biomarkers and to clarify the mechanism of chronic pain development
  175. Abstracts
  176. Evaluation of the benefits from the introduction meeting for patients with chronic non-malignant pain and their relatives in interdisciplinary pain center
  177. Observational study
  178. The changing face of acute pain services
  179. Observational study
  180. Chronic pain in multiple sclerosis: A10-year longitudinal study
  181. Clinical pain research
  182. Functional disability and depression symptoms in a paediatric persistent pain sample
  183. Observational study
  184. Pain provocation following sagittal plane repeated movements in people with chronic low back pain: Associations with pain sensitivity and psychological profiles
  185. Observational study
  186. A longitudinal exploration of pain tolerance and participation in contact sports
  187. Original experimental
  188. Taking a break in response to pain. An experimental investigation of the effects of interruptions by pain on subsequent activity resumption
  189. Clinical pain research
  190. Sex moderates the effects of positive and negative affect on clinical pain in patients with knee osteoarthritis
  191. Original experimental
  192. The effects of a brief educational intervention on medical students’ knowledge, attitudes and beliefs towards low back pain
  193. Observational study
  194. The association between pain characteristics, pain catastrophizing and health care use – Baseline results from the SWEPAIN cohort
  195. Topical review
  196. Couples coping with chronic pain: How do intercouple interactions relate to pain coping?
  197. Narrative review
  198. The wit and wisdom of Wilbert (Bill) Fordyce (1923 - 2009)
  199. Letter to the Editor
  200. Unjustified extrapolation
  201. Letter to the Editor
  202. Response to: “Letter to the Editor entitled: Unjustified extrapolation” [by authors: Supp G., Rosedale R., Werneke M.]
https://doi.org/10.1016/j.sjpain.2017.05.006
Keywords for this article
Depression; Mental health; Chronic pain; Paediatric; Physical functioning

Articles in the same Issue

  2. Scandinavian Journal of Pain
  3. Editorial comment
  4. Glucocorticoids – Efficient analgesics against postherpetic neuralgia?
  5. Original experimental
  6. Effect of intrathecal glucocorticoids on the central glucocorticoid receptor in a rat nerve ligation model
  7. Editorial comment
  8. Important new insight in pain and pain treatment induced changes in functional connectivity between the Pain Matrix and the Salience, Central Executive, and Sensorimotor networks
  9. Original experimental
  10. Salience, central executive, and sensorimotor network functional connectivity alterations in failed back surgery syndrome
  11. Editorial comment
  12. Education and support strategies improve assessment and management of pain by nurses
  13. Clinical pain research
  14. Using education and support strategies to improve the way nurses assess regular and transient pain – A quality improvement study of three hospitals
  15. Editorial comment
  16. The interference of pain with task performance: Increasing ecological validity in research
  17. Original experimental
  18. The disruptive effects of pain on multitasking in a virtual errands task
  19. Editorial comment
  20. Analyzing transition from acute back pain to chronic pain with linear mixed models reveals a continuous chronification of acute back pain
  21. Observational study
  22. From acute to chronic back pain: Using linear mixed models to explore changes in pain intensity, disability, and depression
  23. Editorial comment
  24. NSAIDs relieve osteoarthritis (OA) pain, but cardiovascular safety in question even for diclofenac, ibuprofen, naproxen, and celecoxib: what are the alternatives?
  25. Clinical pain research
  26. Efficacy and safety of diclofenac in osteoarthritis: Results of a network meta-analysis of unpublished legacy studies
  27. Editorial comment
  28. Editorial comment on Nina Kreddig’s and Monika Hasenbring’s study on pain anxiety and fear of (re) injury in patients with chronic back pain: Sex as a moderator
  29. Clinical pain research
  30. Pain anxiety and fear of (re) injury in patients with chronic back pain: Sex as a moderator
  31. Editorial comment
  32. Intraoral QST – Mission impossible or not?
  33. Clinical pain research
  34. Multifactorial assessment of measurement errors affecting intraoral quantitative sensory testing reliability
  35. Editorial comment
  36. Objective measurement of subjective pain-experience: Real nociceptive stimuli versus pain expectation
  37. Clinical pain research
  38. Cerebral oxygenation for pain monitoring in adults is ineffective: A sequence-randomized, sham controlled study in volunteers
  39. Editorial comment
  40. Association between adolescent and parental use of analgesics
  41. Observational study
  42. The association between adolescent and parental use of non-prescription analgesics for headache and other somatic pain – A cross-sectional study
  43. Editorial comment
  44. Cancer-pain intractable to high-doses systemic opioids can be relieved by intraspinal local anaesthetic plus an opioid and an alfa2-adrenoceptor agonist
  45. Clinical pain research
  46. Spinal analgesia for severe cancer pain: A retrospective analysis of 60 patients
  47. Editorial comment
  48. Specific symptoms and signs of unstable back segments and curative surgery?
  49. Clinical pain research
  50. Symptoms and signs possibly indicating segmental, discogenic pain. A fusion study with 18 years of follow-up
  51. Editorial comment
  52. Local anaesthesia methods for analgesia after total hip replacement: Problems of anatomy, methodology and interpretation?
  53. Clinical pain research
  54. Local infiltration analgesia or femoral nerve block for postoperative pain management in patients undergoing total hip arthroplasty. A randomized, double-blind study
  55. Editorial
  56. Scientific presentations at the 2017 annual meeting of the Scandinavian Association for the Study of Pain (SASP)
  57. Abstracts
  58. Correlation between quality of pain and depression: A post-operative assessment of pain after caesarian section among women in Ghana
  59. Abstracts
  60. Dynamic and static mechanical pain sensitivity is associated in women with migraine
  61. Abstracts
  62. The number of active trigger points is associated with sensory and emotional aspects of health-related quality of life in tension type headache
  63. Abstracts
  64. Chronic neuropathic pain following oxaliplatin and docetaxel: A 5-year follow-up questionnaire study
  65. Abstracts
  66. Expression of α1 adrenergic receptor subtypes by afferent fibers that innervate rat masseter muscle
  67. Abstracts
  68. Buprenorphine alleviation of pain does not compromise the rat monoarthritic pain model
  69. Abstracts
  70. Association between pain, disability, widespread pressure pain hypersensitivity and trigger points in subjects with neck pain
  71. Abstracts
  72. Association between widespread pressure pain hypersensitivity, health history, and trigger points in subjects with neck pain
  73. Abstracts
  74. Neuromas in patients with peripheral nerve injury and amputation - An ongoing study
  75. Abstracts
  76. The link between chronic musculoskeletal pain and sperm quality in overweight orthopedic patients
  77. Abstracts
  78. Several days of muscle hyperalgesia facilitates cortical somatosensory excitability
  79. Abstracts
  80. Social stress, epigenetic changes and pain
  81. Abstracts
  82. Characterization of released exosomes from satellite glial cells under normal and inflammatory conditions
  83. Abstracts
  84. Cell-based platform for studying trigeminal satellite glial cells under normal and inflammatory conditions
  85. Abstracts
  86. Tramadol in postoperative pain – 1 mg/ml IV gave no pain reduction but more side effects in third molar surgery
  87. Abstracts
  88. Tempo-spatial discrimination to non-noxious stimuli is better than for noxious stimuli
  89. Abstracts
  90. The encoding of the thermal grill illusion in the human spinal cord
  91. Abstracts
  92. Effect of cocoa on endorphin levels and craniofacial muscle sensitivity in healthy individuals
  93. Abstracts
  94. The impact of naloxegol treatment on gastrointestinal transit and colonic volume
  95. Abstracts
  96. Preoperative downregulation of long-noncoding RNA Meg3 in serum of patients with chronic postoperative pain after total knee replacement
  97. Abstracts
  98. Painful diabetic polyneuropathy and quality of life in Danish type 2 diabetic patients
  99. Abstracts
  100. “What about me?”: A qualitative explorative study on perspectives of spouses living with complex chronic pain patients
  101. Abstracts
  102. Increased postural stiffness in patients with knee osteoarthritis who are highly sensitized
  103. Abstracts
  104. Efficacy of dry needling on latent myofascial trigger points in male subjects with neck/shoulders musculoskeletal pain. A case series
  105. Abstracts
  106. Identification of pre-operative of risk factors associated with persistent post-operative pain by self-reporting tools in lower limb amputee patients – A feasibility study
  107. Abstracts
  108. Renal function estimations and dose recommendations for Gabapentin, Ibuprofen and Morphine in acute hip fracture patients
  109. Abstracts
  110. Evaluating the ability of non-rectangular electrical pulse forms to preferentially activate nociceptive fibers by comparing perception thresholds
  111. Abstracts
  112. Detection of systemic inflammation in severely impaired chronic pain patients, and effects of a CBT-ACT-based multi-modal pain rehabilitation program
  113. Abstracts
  114. Fixed or adapted conditioning intensity for repeated conditioned pain modulation
  115. Abstracts
  116. Combined treatment (Norspan, Gabapentin and Oxynorm) was found superior in pain management after total knee arthroplasty
  117. Abstracts
  118. Effects of conditioned pain modulation on the withdrawal pattern to nociceptive stimulation in humans – Preliminary results
  119. Abstracts
  120. Application of miR-223 onto the dorsal nerve roots in rats induces hypoexcitability in the pain pathways
  121. Abstracts
  122. Acute muscle pain alters corticomotor output of the affected muscle stronger than a synergistic, ipsilateral muscle
  123. Abstracts
  124. The subjective sensation induced by various thermal pulse stimulation in healthy volunteers
  125. Abstracts
  126. Assessing Offset Analgesia through electrical stimulations in healthy volunteers
  127. Abstracts
  128. Metastatic lung cancer in patient with non-malignant neck pain: A case report
  129. Abstracts
  130. The size of pain referral patterns from a tonic painful mechanical stimulus is increased in women
  131. Abstracts
  132. Oxycodone and macrogol 3350 treatment reduces anal sphincter relaxation compared to combined oxycodone and naloxone tablets
  133. Abstracts
  134. The effect of UVB-induced skin inflammation on histaminergic and non-histaminergic evoked itch and pain
  135. Abstracts
  136. Topical allyl-isothiocyanate (mustard oil) as a TRPA1-dependent human surrogate model of pain, hyperalgesia, and neurogenic inflammation – A dose response study
  137. Abstracts
  138. Dissatisfaction and persistent post-operative pain following total knee replacement – A 5 year follow-up of all patients from a whole region
  139. Abstracts
  140. Paradoxical differences in pain ratings of the same stimulus intensity
  141. Abstracts
  142. Pain assessment and post-operative pain management in orthopedic patients
  143. Abstracts
  144. Combined electric and pressure cuff pain stimuli for assessing conditioning pain modulation (CPM)
  145. Abstracts
  146. The effect of facilitated temporal summation of pain, widespread pressure hyperalgesia and pain intensity in patients with knee osteoarthritis on the responds to Non-Steroidal Anti-Inflammatory Drugs – A preliminary analysis
  147. Abstracts
  148. How to obtain the biopsychosocial record in multidisciplinary pain clinic? An action research study
  149. Abstracts
  150. Experimental neck muscle pain increase pressure pain threshold over cervical facet joints
  151. Abstracts
  152. Are we using Placebo effects in specialized Palliative Care?
  153. Abstracts
  154. Prevalence and pattern of helmet-induced headache among Danish military personnel
  155. Abstracts
  156. Aquaporin 4 expression on trigeminal satellite glial cells under normal and inflammatory conditions
  157. Abstracts
  158. Preoperative synovitis in knee osteoarthritis is predictive for pain 1 year after total knee arthroplasty
  159. Abstracts
  160. Biomarkers alterations in trapezius muscle after an acute tissue trauma: A human microdialysis study
  161. Abstracts
  162. PainData: A clinical pain registry in Denmark
  163. Abstracts
  164. A novel method for investigating the importance of visual feedback on somatosensation and bodily-self perception
  165. Abstracts
  166. Drugs that can cause respiratory depression with concomitant use of opioids
  167. Abstracts
  168. The potential use of a serious game to help patients learn about post-operative pain management – An evaluation study
  169. Abstracts
  170. Modelling activity-dependent changes of velocity in C-fibers
  171. Abstracts
  172. Choice of rat strain in pre-clinical pain-research – Does it make a difference for translation from animal model to human condition?
  173. Abstracts
  174. Omics as a potential tool to identify biomarkers and to clarify the mechanism of chronic pain development
  175. Abstracts
  176. Evaluation of the benefits from the introduction meeting for patients with chronic non-malignant pain and their relatives in interdisciplinary pain center
  177. Observational study
  178. The changing face of acute pain services
  179. Observational study
  180. Chronic pain in multiple sclerosis: A10-year longitudinal study
  181. Clinical pain research
  182. Functional disability and depression symptoms in a paediatric persistent pain sample
  183. Observational study
  184. Pain provocation following sagittal plane repeated movements in people with chronic low back pain: Associations with pain sensitivity and psychological profiles
  185. Observational study
  186. A longitudinal exploration of pain tolerance and participation in contact sports
  187. Original experimental
  188. Taking a break in response to pain. An experimental investigation of the effects of interruptions by pain on subsequent activity resumption
  189. Clinical pain research
  190. Sex moderates the effects of positive and negative affect on clinical pain in patients with knee osteoarthritis
  191. Original experimental
  192. The effects of a brief educational intervention on medical students’ knowledge, attitudes and beliefs towards low back pain
  193. Observational study
  194. The association between pain characteristics, pain catastrophizing and health care use – Baseline results from the SWEPAIN cohort
  195. Topical review
  196. Couples coping with chronic pain: How do intercouple interactions relate to pain coping?
  197. Narrative review
  198. The wit and wisdom of Wilbert (Bill) Fordyce (1923 - 2009)
  199. Letter to the Editor
  200. Unjustified extrapolation
  201. Letter to the Editor
  202. Response to: “Letter to the Editor entitled: Unjustified extrapolation” [by authors: Supp G., Rosedale R., Werneke M.]
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