35 SCIENTIFIC PUBLICATIONS International Journal of Psychology: Biopsychosocial Approach 2016 / 19 ISSN 1941-7233 (Print), ISSN 2345-024X (Online) http://dx.doi.org/10.7220/2345-024X.19.2 C ATASTROPHIZING OF PAIN AS A PREDIC TOR OF PRE- AND ACUTE POSTOPER ATIVE PAIN IN PATIENTS WITH C ARPAL TUNNEL SYNDROME Aistė Pranckevičienė1, Neuroscience Institute, Lithuanian University of Health Sciences, Lithuania Justina Dimšaitė Medical Academy of the Lithuanian University of Health Sciences, Lithuania Antanas Budėnas Medical Academy of the Lithuanian University of Health Sciences, Lithuania Andrius Radžiūnas, Neuroscience Institute, Lithuanian University of Health Sciences, Lithuania Abstract. Background and purpose. Research shows that pain catastrophizing might be an important predictor of pain related outcomes in patients with various health conditions despite of objective severity of the illness. This study aimed to evaluate prognostic value of catastrophizing the pain in predicting pain intensity before and one day after the surgery for median nerve decompression in a sample of patients with carpal tunnel syndrome (CTS). Methods. 53 patients with electrodiagnostically proven CTS participated in this study. Patients were assessed before and one day after the surgery for median nerve decompression using the Pain Catastrophizing Scale (PCS), and the Short Form of the McGill Pain Questionnaire (SF-MPQ). Intensity of pre- and acute postoperative pain was evaluated using visual analogue scales. Results. Level of reported pain decreased significantly one day after the surgery. No significant correlations were observed between pain catastrophizing and average level of pain during a week before and one day after the surgery. Correlation was observed be- tween highest experienced level of pain after the surgery and preoperative total PCS 1 Address for correspondence: Aistė Pranckevičienė, Neuroscience Institute, Laboratory of Clinical Research, Lithuanian University of Health Sciences, Eiveniu st. 4, LT-50009 Kaunas, Lithuania. E-mail: aiste.pranckeviciene@lsmuni.lt Aistė Pranckevičienė, Justina Dimšaitė, Antanas Budėnas, Andrius Radžiūnas 36 score. However, pain catastrophizing did not predict neither preoperative nor acute postoperative pain one day after the surgery in multivariate analyses when other study variables were taken into account. Sensory dimension of SF-MPQ was a better predictor of preoperative pain. None of pain and demographic variables predicted acute postoperative pain. Conclusions. Pain catastrophizing was not found to be a significant predictor of pre- or acute postoperative pain in CTS patients. Keywords: carpal tunnel syndrome, pain catastrophizing, pain intensity, surgery, predic- tive validity. INTRODUC TION Carpal tunnel syndrome (CTS), that is, the idiopathic median nerve neuropathy at the carpal tunnel, is the most common mono neuropa- thy of the upper extremity (Makanji et al., 2012), affecting up to 5% of the general population (Dale et al., 2013). The condition occurs when the median nerve, one of the hand’s major nerves, becomes squeezed or compressed in the wrist area. The most frequent symptoms of CTS include numbness, tingling, burning, and pain in the first three fingers of the hand; the symptoms usually become more intensive during the night (Tamburin et al., 2008; Bhatt, Sheth, Vyas, 2015). About 50% of the patients also report motor symptoms such as hand weakness and diffi- culties in grasping small objects (Tamburin et al., 2008). Early symptoms of CTS can often be relieved by giving the wrist enough rest, avoiding certain activities that intensify pain, wrist splinting, nonsteroidal anti- inflammatory drugs or injections of corticosteroids. However, if the pres- sure on the median nerve continues, it can lead to serious nerve damage and worsen symptoms. In this case, surgery to release the pressure of the median nerve is recommended (Lane et al., 2014). Although damage of median nerve might be confirmed and evalu- ated by means of objective electrophysiological measures, Makanji et al. (2012) showed that objective clinical data does not directly predict the level of pain and disability in CTS patients. Some patients have no symptoms despite the presence of severe electrophysiological find- ings as opposed to patients with severe symptoms despite objectively measured mild electrophysiological dysfunction (Sonahata et al., 2013). According to Nunez, Vranceanu and Ring (2010), illness behavior and ill- ness related emotions such as depression or a tendency to exaggerate 2016, 19, 35–47 p.International Journal of Psychology: A Biopsychosocial Approach 37 noxious stimuli are better predictors of pain intensity than demographic factors and objective pathophysiological measures in CTS patients. Thus, psychological characteristics of patients, and especially illness related reactions such as depression or a tendency to catastrophize, might serve as important predictors of treatment outcomes (Lozano, Calderón, Paiva, Ring, 2008). Sullivan, Bishop and Pivic (1995) studied the role of pain cata- strophizing which might be defined as a negative cognitive-affective response to anticipated or actual pain. Magnification (the propensity to amplify pain), rumination (the tendency to relive painful experience) and feelings of helplessness in pain situation are considered as main components of pain catastrophizing (Sullivan, Bishop, Pivik, 1995). Special attention is given to the prognostic value of catastrophiz- ing as it is believed that patients with a tendency to exaggerate pain might be susceptible to a higher distress response to aversive medical procedures (Sullivan, Bishop, Pivik, 1995). Correlation between pain cat- astrophizing and array of clinical pain-related outcomes, such as pain intensity, pain-related activity interference, disability, more frequent seeking of medical care and narcotic usage, postsurgical pain, and de- creased mental health, in various pain patients have been found (Quar- tana, Campbell, Edwards, 2009; Kim et al., 2015; Vranceanu et al., 2010; Kremer et al., 2013). Quartana, Campbell and Edwards (2009) indicated that a high level of pain catastrophizing should be considered as a risk factor for adverse acute and long-term pain-related outcomes. Further- more, pain catastrophizing and pain behavior have been found to pre- dict days lost from work and failure to return to work in subacute and chronic low back pain patients (Fernandes et al., 2012). The growing need for multidisciplinary approach orientated towards the early detec- tion and treatment of risk factors of a subjective pain and disability when providing medical care for patients with CTS is acknowledged (Das De, Vranceanu, Ring, 2013; Yang et al., 2016, Teunis et al., 2015). Therefore, this study evaluated the prognostic value of pain catastrophizing in predicting pain intensity before and one day after the surgery used for median nerve decompression. Aistė Pranckevičienė, Justina Dimšaitė, Antanas Budėnas, Andrius Radžiūnas 38 ME THODS Sample and procedure Ethical approval for this study was obtained from the Lithuanian Uni- versity of Health Sciences Bioethical Center, on October 2015. All eligible subjects read and sign an informed consent form prior to participating in the study. To ensure anonymity, a unique study identification number was allocated to each subject on recruitment. Patients admitted to Neurosurgery Clinic at Hospital of Lithuanian University of Health Sciences from November 2015 to March 2016 for carpal tunnel release surgery who had clinical symptoms of CTS which was electrodiagnostically proven were invited to participate in this study. Patient agreement along with decreased median nerve conduc- tion velocity (≤35 m/s) at the level of carpal tunnel, proven by electro- diagnostic testing, were the main inclusion criteria in the present study. The final study sample consisted of 53 patients, 12 (22.6%) males and 41 (77.4%) females, mean aged 60.5 years, SD – 13.0, ranging from 36 to 88 years. Altogether, 23 (43.4%) of the patients had CTS in their left, and 30 (56.6%) in their right hand. The electrodiagnostical assessments were performed by two expe- rienced neurologists using a standard nerve conduction test method for CTS (described in Svilpauskaitė et al., 2006) with decrease in median nerve sensory or motor conduction being the key criterion. Question- naires were introduced to patients upon their arrival to the hospital before the surgery by two fifth year medical students participating in the study. Patients were asked to answer questionnaires before the surgery and to mark average and highest pain after the surgery on a visual analog scale next morning. Participants were required to fill out the question- naires themselves, but in some cases, when patients were incapable to read or write on their own, the questions were read out loud and/or their answers were marked for them by the same medical students. Measures Pain catastrophizing was assessed using the Pain Catastrophizing Scale (PCS, Sullivan, Bishop, Pivik, 1995). The PCS is a public domain and can be freely used for research purposes (Sullivan, 2009). Permission 2016, 19, 35–47 p.International Journal of Psychology: A Biopsychosocial Approach 39 to translate the PCS was obtained from M. J. L. Sullivan. The Lithuanian version of this scale was prepared by authors of this article according to the recommendations for the translation and adaptation of psycho- logical questionnaires (Sousa & Rojjanasrirat, 2011). Steps of forward and back translation by two independent translators, review of the transla- tions by a field expert, and a pilot testing with several patients were used to develop final Lithuanian version of the scale. The PCS contains thir- teen items rated in 5-point scale ranging from 0 – not at all, to 4 – all the time. Three subscales representing main components of catastrophiz- ing, rumination, magnification and helplessness were calculated besides the total scale score. PCS demonstrated adequate reliability, Cronbach alpha ranging from .74 to .90. A short form version of the McGill Pain Questionnaire (SF-MPQ, R.Melzack, 1987, contact for information and permission to use: Mapi Research Trust, Lyon, France – Internet: https://eprovide.mapi-trust.org/) was used as an additional measure of pain. The questionnaire contains 15 descriptions of pain which are rated on a 4 item-intensity scale rang- ing from 0 – none, to 3 – severe. Three pain scores were derived from SF-MPQ: affective dimension of pain (4 items), sensory dimension of pain (11 items) and total pain score. Lithuanian version of SF-MPQ dem- onstrated good reliability in previous research (Juozapavičienė, 2015). In current study, Cronbach alpha ranged from .76 for an affective sub- scale to .87 for a total pain score. Intensity of pre- and acute postoperative pain was evaluated using visual analogue scales (VAS). Preoperatively patients were asked to eval- uate average intensity of their pain during the past week and to indicate the highest intensity of experienced pain during the past week. One day after the surgery, patients were asked to evaluate average as well as highest pain during the last 12 hours. Descriptive statistics were used to describe study sample and illus- trate intensity of the pain. Nonparametric Wilcoxon signed ranks test was used to evaluate changes in pain intensity after the surgery. Correla- tion analysis was used to clarify relationship between pain catastrophiz- ing and pain intensity. Finally, linear regression analysis was employed to evaluate relationship between pain catastrophizing and pain intensity in the context of other study variables. Data was analyzed using the SPSS for Windows. Aistė Pranckevičienė, Justina Dimšaitė, Antanas Budėnas, Andrius Radžiūnas 40 RESULTS The reported pain decreased significantly one day after the surgery. Highest reported pain decreased from 6.4 (SD 2.7) to 3.3 (SD 2.4) points (Wilcoxon Signed Ranks Test Z = -5.3, p < .01); average pain decreased from 5.9 (SD 2.7) to 2.6 (SD 2.0) points (Wilcoxon Signed Ranks Test Z = -5.1, p < .01) (Table 1). Table 1. Descriptive statistic of study variables Study variable Mean SD Minimum Maximum Age 60.47 13.03 36 88 Highest level of pain before the surgery 6.42 2.66 0 10 Average level of pain before the surgery 5.89 2.74 0 10 Highest level of pain intensity one day after the surgery 3.32 2.41 0 9 Average level of pain one day after the surgery 2.60 1.99 0 7 PCS Totala 23.77 11.74 2 49 PCS Rumination 9.25 4.15 0 16 PCS Magnification 4.21 3.45 0 12 PCS Helplessness 10.32 5.67 0 23 SF-MPQ Totalb 15.11 9.73 0 42 SF-MPQ Sensory Score 12.23 7.46 0 33 SF-MPQ Affective Score 2.89 3.11 0 11 a Pain Catastrophizing Scale; b McGill Pain Questionnaire, Short Form. Total score of PCS ranged from 2 to 49; mean – 23.8, SD – 11.7. Scores did not deviate significantly from a normal distribution (Shapiro-Wilk Test, p = .41). PCS scores did not differ significantly between gender 2016, 19, 35–47 p.International Journal of Psychology: A Biopsychosocial Approach 41 (females: mean (SD) 25.2 (12.0); and males: 18.8 (9.5), t = -1.7, p = .10). No correlation with age was observed (Pearson r = -.02). No correlations were observed between total PCS score and average level of pain during a week before the surgery (Table 2). Mild correla- tions were observed between helplessness and reported highest levels of pain before the surgery. Average reported pain one day after the sur- gery did not significantly correlate with preoperative catastrophizing of pain. However, weak but significant correlation was observed between the highest experienced level of pain after the surgery and preoperative total PCS score. Moderate correlations were observed between PCS and SF-MPQ scores. Table 2. Relationship between PCS and other measures of pain. Pearson r Rumination Magnification Helplessness Total PCS score Highest level of pain before the surgery .20 .15 .28* .25 Average level of pain during a week before the surgery .08 .06 .11 .10 Highest level of pain one day after the surgery .26 .23 .25 .28* Average level of pain one day after the surgery .18 .15 .19 .20 SF-MPQ Sensory dimension .37** .31* .40** .41** SF-MPQ Affective dimension .34** .53** .44** .49** SF-MPQ Total pain score .39** .40** .45** .47** p < .05, **p < .01. To evaluate prognostic value of PCS for the prediction of pre- and acute postoperative pain in CTS patients, linear regression analysis was employed. Levels of pre- and postoperative pain were predicted by the total score of preoperative PCS, age, gender, SF-MPQ sensory and affec- tive dimensions. Aistė Pranckevičienė, Justina Dimšaitė, Antanas Budėnas, Andrius Radžiūnas 42 Pain catastrophizing predicted neither preoperative nor acute post- operative pain one day after the surgery. Higher levels of preoperative pain were predicted by the sensory dimension of SF-MPQ. Analyzed vari- ables failed to predict levels of acute postoperative pain, model of re- gression for average and highest postoperative pain was non-significant. Table 3. Summar y of regression models for the prediction of pre- and acute postoperative pain in CTS patients Highest preoperative pain Average preoperative pain Average pain one day after the surgery Highest pain one day after the surgery Regression models statistics Adj.R2 .16 .22 .01 .10 F 2.92 2.61 1.05 2.14 p .02 .04 .40 .08 Regression coefficients Std.ß p Std.ß p Std.ß p Std.ß p PCS Total .01 .96 -.08 .60 .11 .50 .11 .49 Gender .20 .14 .01 .93 -.01 .97 .05 .40 Age -.07 .60 .19 .17 .11 .46 .11 .43 SF-MPQ Affective dimension .11 .54 .04 .84 .31 .11 .37 .06 SF-MPQ Sensory dimension .35 .05 .39 .03 -.15 .44 -.01 .94 DISCUSSION This study aimed to evaluate the prognostic value of catastrophizing the pain in predicting pain intensity before and one day after the surgery for median nerve decompression in carpal tunnel syndrome. Fifty-three patients with CTS with an objectively proven decreased median nerve conduction velocity participated in this study. Patients’ selection based on the objective electrodiagnostic data is one of the major strengths 2016, 19, 35–47 p.International Journal of Psychology: A Biopsychosocial Approach 43 of this study. Although some surgeons still base their surgery decisions on patients’ complaints and clinical examination only, Makanji et al. (2012) stressed that absence of objectively verifiable pathophysiology represents either an inaccurate diagnosis or a very mild disease. Thus, objectified patients’ selection in this study resulted in a more homo- geneous sample; patients with possible complaints of psychological nature were excluded. To our knowledge, this was the first study analyzing the predictive value of Lithuanian version of PCS. Lithuanian version demonstrated ad- equate internal consistency and that was close to that reported by the scale author (Sullivan, 2009). Level of pain catastrophizing in our sample was somewhat higher than reported by the scale author: in our sample, mean for the total score of PCS was 23.8, SD – 11.7; while Sullivan (2009) reported mean to be 20.9, SD – 12.5 in a sample of 851 injured workers. This difference might have been expected as our sample consisted of pa- tients with chronic conditions pain being one of the primary complaints. Scores of the PCS correlated significantly with other measures of pain. Correlation analysis revealed that pain catastrophizing is closely re- lated both to affective and sensory aspects of pain measured by SF-MPQ. Although correlations with other similar measures might be interpreted as indicators of questionnaire validity, relatively strong correlations also increase the risk of possible constructs redundancy (Leung, 2012), which is not desirable when applying questionnaires in clinical practice. Thus, evaluation of prognostic value of pain catastrophizing in the context of other possible pain predictors is important while investigating utility of PCS in clinical practice. Contrary to our expectations, pain catastrophizing did not predict neither preoperative nor acute postoperative pain on the following day after the surgery in our study. Kim et al. (2015) did not find relationship between preoperative catastrophizing of pain and surgery outcomes in a sample of 138 patients with lumbar spinal stenosis as well. On the other hand, in a study by London et al. (2014), patients scoring high on depression or pain catastrophizing reported clinically worse hand function before and after the treatment regardless of the type of treat- ment received. In another study of 120 patients who underwent minor hand surgery, the intensity of the pain at the time of suture removal was Aistė Pranckevičienė, Justina Dimšaitė, Antanas Budėnas, Andrius Radžiūnas 44 related to depression, pain catastrophizing, pain anxiety and self-effi- cacy (Vrancianu et al., 2010). Pain catastrophizing was related to greater perceived disability after a limited incision open carpal tunnel release in a sample of 82 electrodiagnostically confirmed CTS patients (Lozano, Calderón, Paiva, Ring, 2008). Our results might have the following limitations: only patients with objectively confirmed and relatively severe CTS were included in the study. It is possible that in these circumstances, PCS reflected not psychological overreaction to pain but objective reaction to CTS related symptoms which were persistent and uncontrollable. Thus, one of the hypotheses might be that in our sample, the meaning of PCS was changed and validity of this scale for pain prediction was lost. How- ever, this hypothesis should be confirmed by a qualitative study asking CTS patients to share their reactions and thoughts by answering PCS questions. None of the recorded variables predicted pain intensity one day after the surgery. These results might be influenced by the short assessment period and possible effect of analgesic medication used during and after the surgery. Although we expected that patients with a tendency to exaggerate pain would experience more pain immediately after the sur- gery, this prediction was not confirmed. A longer follow-up time might be needed to eliminate possible effect of pain sedation. The Lithuanian version of PCS still lacks appropriate cultural adap- tation and validation of the construct and norms. Our sample size did not allow us to investigate PCS factor structure, thus we used only total PCS score for pain intensity predictions. Future studies investigating construct validity of Lithuanian PCS version as well as prognostic value of individual PCS scales are suggested. To conclude, our results do not confirm that pain catastrophizing constitutes a significant predictor of pre- or acute postoperative pain in CTS patients. Sensory dimension of SF-MPQ was a better predictor of preoperative pain. None of the demographic or pain related variables predicted acute postoperative pain. Qualitative and quantitative studies investigating PCS validity are vital to justify the use of this psychological instrument in clinical practice. 2016, 19, 35–47 p.International Journal of Psychology: A Biopsychosocial Approach 45 References Bhatt, N. G., Sheth, M. S., Vyas, N. J. (2015). 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DOI: 10.3109/09638288.2015.1107635. 2016, 19, 35–47 p.International Journal of Psychology: A Biopsychosocial Approach 47 SK AUSMO K ATASTROFIZ AVIMO SĄSA JOS SU PRIEŠOPER ACINIO IR ŪMAUS POOPER ACINIO SK AUSMO INTENSY VUMU RIEŠO K ANALO SINDROMU SERGANČIŲ PACIENTŲ IMT YJE Aistė Pranckevičienė Lietuvos sveikatos mokslų universitetas, Neuromokslų institutas, Lietuva Justina Dimšaitė, Antanas Budėnas Lietuvos sveikatos mokslų universitetas, Medicinos akademija, Lietuva Andrius R adžiūnas Lietuvos sveikatos mokslų universitetas, Neuromokslų institutas, Lietuva Santrauka. Problema. Moksliniai tyrimai rodo, jog polinkis katastrofizuoti skausmą prognozuoja įvairių su skausmu susijusių būklių gydymo išeitis nepriklausomai nuo objektyvaus sutrikimo ar negalios sunkumo. Šiuo tyrimu siekiama įvertinti dėl riešo kanalo sindromo patiriamo skausmo ir skausmo katastrofizavimo sąsajas prieš medialinio nervo dekompresijos operaciją ir praėjus vienai dienai po jos. Metodika. Tyrime dalyvavo 53 pacientai, kuriems riešo kanalo sindromas patvirtintas elektrodiagnostiškai. Pacientai atsakė į Skausmo katastrofizavimo skalės (Pain Cata- strophizing Scale (PCS)) ir Trumposios McGill skausmo klausimyno formos (A Short Form of the McGill Pain Questionnaire (SF-MPQ)) klausimus prieš operaciją ir pagal vizualinės analogijos skales įvertino patiriamo skausmo intensyvumą prieš operaciją ir praėjus vienai dienai po jos. Rezultatai. Praėjus vienai dienai po medialinio nervo dekompresijos operacijos skausmo intensyvumas reikšmingai sumažėjo. Polinkis katastrofizuoti skausmą nekoreliavo su vidutiniu patirto skausmo intensyvu savaitę prieš operaciją ar praėjus dienai po jos. Silpna, bet statistiškai reikšminga koreliacija nustatyta tarp suminio PCS skalės įverčio ir didžiausio skausmo intensyvumo po operacijos. Visgi skausmo katastrofizavimas neprognozavo skausmo intensyvumo prieš operaciją ar po jos, kai analizėje buvo atsižvelgta į kitus veiksnius. SF-MPQ sensorinis skausmo rodiklis buvo stipriau susiję su priešoperaciniu skausmu nei polinkis katastrofizuoti skausmą. Nė vienas iš analizuotų demografinių ar skausmo rodiklių neprognozavo pooperacinio skausmo intensyvumo. Išvados. Tyrimo rezul- tatai nepatvirtino prielaidos, kad polinkis katastrofizuoti skausmą leidžia prognozuoti riešo kanalo sindromu sergančių pacientų prieš operaciją ir po jos patiriamo skausmo intensyvumą. Pagrindiniai žodžiai: riešo kanalo sindromas, skausmo katastrofizavimas, skausmo inten- syvumas, chirurginis gydymas, prognostinis validumas. Received: 2016-11-09 Accepted: 2017-02-17