The Clinical Journal of Pain

The Prevalence and Potential Role of Pain Beliefs When Managing Later-Life Pain Objectives: In this study of 154 community-dwelling older adults with chronic non-cancer pain, we sought to assess participants' beliefs about pain as well as pain management treatments and determined the influence of those beliefs on participants' willingness to undertake three physician-recommended pain treatments, i.e., a pharmacologic, physical, and psychological therapy. Methods: A 16-item questionnaire was employed to ascertain participants' pain beliefs, divided into four subscales representing (1) negative beliefs about pharmacological treatments, (2) positive beliefs about physical treatment approaches, e.g., exercise; (3) positive beliefs about psychological treatments, and (4) fatalistic beliefs about pain. Participants were asked to rate their willingness to undertake a pharmacologic, physical, or psychological therapy if their physician recommended that they do so. Agreement with each belief was measured, and we examined willingness to undertake each treatment as a function of pain belief subscale scores after controlling for relevant covariates. Results: Positive beliefs about physical treatments (e.g., benefits of exercise) were the most strongly endorsed items on the pain beliefs questionnaire. All three treatment-focused pain beliefs subscales were significantly associated with willingness to undertake that form of treatment (e.g., negative beliefs about pain medication use were associated with decreased willingness to take pain medication). Fatalistic attitudes were significantly associated with a decreased willingness to undertake physical treatments. Discussion: These results support the notion that patients' beliefs about pain and pain treatments can have important effects on treatment engagement and, if assessed, can help guide clinical management of chronic pain in older adults. There are no conflicts of interest. Reprints: M. Carrington Reid, MD, PhD, Division of Geriatrics & Palliative Medicine, Weill Cornell Medical Center, New York, NY 10065, USA (e-mail: mcr2004@med.cornell.edu). Received June 22, 2020 Received in revised form November 22, 2020 Accepted November 25, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Brief Psychological Interventions for Reducing Prescription Opioid Use, Related Harm and Pain Intensity in Patients with Chronic Pain: A Systematic Review and Assessment of Patient Interest Objectives: Brief psychological interventions (BPIs) have demonstrated effectiveness in reducing substance use and related harm. No systematic review has examined their potential to reduce or prevent prescription opioid use or related harm, and/or pain intensity in opioid-using patients with chronic non-cancer pain (CNCP). Recognizing the importance of patient preferences in evidence-based practice, we also sought to assess patient interest in BPIs. Methods: A systematic review of studies published between 1980-2020 was conducted using five databases. Eligible treatment studies included patients ≥18 years old, with CNCP, and who were using prescription opioids. An adjunctive study independent of our review was also undertaken in 188 prescription opioid-using patients (77% female; Mage=49▒y) diagnosed with CNCP. Patients completed pain-related questionnaires online and indicated if they would consider BPI treatment options. Results: The review identified six studies. Given the heterogeneity across studies, a meta-analysis was not conducted. A narrative review found all of the six studies demonstrated some evidence for BPI effectiveness for reducing opioid use or related harms; these were assessed as having mostly low methodological quality. Mixed support for the effect on pain intensity was found in one study. Despite the inconclusive findings and heterogenous studies identified in the review, 92% of patients in our survey reported interest in receiving a BPI. Discussion: In combination, these findings highlight the inconsistency between patient demand and the availability of evidence for BPIs targeting opioid use, related harm and/or pain intensity. Future work should examine the effectiveness of BPIs in higher quality studies. Submission category: Review. Funding sources: No funding sources were provided. Significance: Our findings highlight the inconsistency between patient demand and the availability of evidence for brief psychological interventions (BPIs) in reducing prescription opioid use and related harm, and pain intensity. Based on the success of BPIs in reducing substance-related harm and patient preferences identified in this study, more higher quality research is needed to determine whether BPIs should be a treatment option for improving outcomes for opioid-using patients with chronic non-cancer pain. PROSPERO Pre-registration number: CRD42020149423. Author contributions: RE, JC, MS, and JL were involved in the conceptualization and design of the study. RE, JL, and SSR were involved in the design and execution of the searches with guidance from a librarian. RE and SSR conducted the screening and quality review of studies. All members of the research team were involved in the final selection of included studies. All authors discussed the results and were involved in interpretation. RE drafted the manuscript, and all authors provided critical revisions. All authors approved the final manuscript for submission. Conflict of interest: The authors have no conflicts of interest to declare. Reprints: Rachel Elphinston, PhD, Recover Injury Research Centre, Level 7, 288 Herston Road, Herston, Brisbane, Queensland, Australia 4006 (e-mail: rachelel@uq.edu.au). Received June 17, 2020 Received in revised form November 23, 2020 Accepted November 29, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Pre- versus Postoperative Scalp Block Combined with Incision Line Infiltration for Pain Control after Supratentorial Craniotomy Objective: Postoperative pain after craniotomy is a significant clinical problem which is sometimes underestimated, although moderate or severe pain in early postoperative period complicates up to 60% of cases. The purpose of this prospective randomized multicenter trial is to determine the optimal timing for selective scalp block in patients undergoing general anesthesia for supratentorial craniotomy. Methods: After ethics committee approval and informed consent, 56 adult patients were enrolled, and randomly assigned to receive a selective scalp block combined with incision line infiltration preoperatively or postoperatively. Results: Postoperative pain at 24 hours after the procedure was recorded in all 56 enrolled patients. In patients assigned to receive a scalp block preoperatively, median VAS score at 24 hours after surgery was 0 (0-2), and in patients assigned to receive a scalp block postoperatively it was 0 (0-3) (P>0,05). There was no difference in severity of pain at 24, 12, 6, and 2 hours after surgery between the two study groups, but the amount of fentanyl administered intraoperatively was lower in patients assigned to the preoperative scalp block group (1.6±0.7▒mkg/kg/h vs. 2.4±0.7▒mkg/kg/h (P=0.01)). Discussion: This study confirms and extends available clinical evidence on the safety and efficacy of selective scalp blocks for the prevention of postoperative pain. Recorded data suggest that there is no difference in terms of occurrence and severity of postoperative pain regardless of whether the scalp block is performed preoperatively (after general anesthesia induction) or postoperatively (before extubation). Patients assigned to receive a scalp block combined with incision line infiltration preoperatively needed less intraoperative opioids than those assigned to postoperative scalp block. Financial Disclosures: None Conflicts of interest: None Reprints: Alexander Kulikov, MD, PhD, 125047, 4th Tverskaya-Yamskaya St., 16, Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia (e-mail: akulikov@nsi.ru). Received April 25, 2019 Received in revised form August 28, 2020 Accepted November 6, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Video-based Pain Education in Schools: A Study with Adolescents Objective: School-based educational programs have shown positive changes in health-related behaviors among adolescents. The aim of this study was to analyze the changes in pain-related knowledge among adolescents and in the use of positive responses to their peers' pain behaviors after watching a brief educational video. Methods: One hundred and thirty-five adolescents (mean age=13.27; SD=1.17) participated and provided demographic and pain-related information. They also responded to a pain-related knowledge questionnaire before (T1), after (T2) and one month after (T3) watching a brief pain educational video, and to a modified version of the Inventory of Parent/Caregiver Responses to the Children's Pain Experience at T1 and at T3. Results: There was a significant increase in pain knowledge for all participants between T1 and T2 (η2p=0.73) and between T1 and T3 (η2p=0.62). An increase in responses considered to be positive to peers' pain behaviors (i.e., the promotion of well-behaviors and coping responses) one month after watching the educational video was also found. Interestingly, these results were not associated with the chronic pain status of the participant. Discussion: The findings showed that a brief and inexpensive educational video-based intervention in schools helps to increase pain-related knowledge and change responses to students with chronic pain. This has the potential to prevent chronic pain and related disability among students, and decrease bullying-like behaviors towards students with chronic pain. Conflict of interests: The authors declare no conflicts of interest in relation to this study. Reprints: Jordi Miró, PhD, Departament de Psicologia; Universitat Rovira i Virgili; Carretera de Valls, s/n; 43007 Tarragona; Spain (e-mail: jordi.miro@urv.cat). Received July 17, 2020 Received in revised form November 9, 2020 Accepted November 11, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Patients with High Chronic Postoperative Knee Pain 5 years after Total Knee Replacement Demonstrate Low-grad Inflammation, Impairment of Function and High Levels of Pain Catastrophizing Objectives: Total knee replacement (TKR) normally provides improvements of physical function and reduces pain. However, approximately 20% of the patients report chronic postoperative knee pain. The aims of the present study were to assess the pain, physical function, and physiological characteristics 5 years after TKR surgery. Methods: Eighty patients were recruited 5 years after TKR and divided into two groups based on their average 24-hour knee pain intensity assessed on a visual analog scale (VAS 0-10) ("High Pain Group": VAS≥3; "Low Pain Group": VAS<3). The patients completed the painDETECT (PD-Q), Oxford Knee Score (OKS), Pain Catastrophizing Scale (PCS), and Forgotten Joint Score (FJS-12). Furthermore, the patients underwent a clinical examination of the knees and high sensitivity serum C-reactive protein (hs-CRP) was measured as an inflammatory marker. Results: 53% of the patients in the High Pain Group was not satisfied with the outcome, while only 11% of the patients in the Low Pain Group was not satisfied, and the pain intensities in the two groups were 5.1 (4.6-5-6) and 1.1 (0.6-1.5), (P<0.001), respectively. Furthermore, the High Pain Group demonstrates worse scores in: FJS-12 (P=0.001), OKS function (P<0.001), OKS pain (P<0.001), and PCS (P<0.001). The High Pain Group demonstrated increased level of hs-CRP (4.3▒mg/L (3.2-5.5) vs. 1.7▒mg/L (1.2-2.2), P<0.001), and decreased range of motion in the knee (110-degrees ROM vs. 119-degrees ROM, P=0.013). Discussion: Patients with high chronic postoperative knee pain 5 years after TKR demonstrate decreased physical function, higher levels of catastrophizing thoughts, and increased levels of inflammation. Original paper for: Clinical Journal of Pain Article Type: Original Research Conflicts of Interest and Source of Funding: The authors declare no conflict of interest. Reprints: Peter Skrejborg, MSc, PhD-fellow, SMI, Department of Health Science and Technology, School of Medicine, Aalborg University, Fredrik Bajers Vej 7 D3, DK-9220 Aalborg, Denmark (e-mail: peter@skrejborg.dk). Received May 18, 2020 Received in revised form November 19, 2020 Accepted November 23, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Physical Activity as a Predictor of Chronic Pain Following Pediatric Spinal Surgery Objectives: (1) Characterize objective physical activity patterns via actigraphy over 4 months post-spinal fusion surgery, and (2) examine associations between activity patterns at 2-weeks and chronic post-surgical pain (CPSP) status at 4-months. Methods: Data from 109 youth (10-18▒y) who underwent spinal fusion surgery at a children's hospital in the northwestern United States were analyzed. Youth completed questionnaires and actigraphic assessment of physical activity pre-surgery, and 2-weeks and 4-months post-surgery. Results: 18% of youth developed CPSP at 4-months. Pre-surgery physical activity was similar for youth with and without CPSP. At 2-weeks post-surgery, daily activity levels were lower for youth who developed CPSP as compared to those who did not, including lower mean activity (168 vs. 212 counts/minute, P=0.01), fewer activity bouts (n=1.7 vs. 2.6, P=0.02), and shorter bout duration (27 vs. 40▒min, P=0.02). Differences in activity were maintained at 4-months such that youth with CPSP had lower mean activity (284 vs. 334 counts/min, P=0.03), as well as greater proportion time spent sedentary and lower proportion time in light activity than youth without CPSP. In adjusted models examining 2-week actigraphy as a predictor of 4-month pain status, mean activity (OR=0.99, P=0.04) and number of activity bouts (OR=0.79, P=0.02) were associated with subsequent CPSP status. Discussion: Lower activity engagement during the initial weeks following spinal fusion surgery was associated with development of CPSP, suggesting early physical activity limitations as a risk factor for CPSP in youth. Understanding recovery patterns is critical for identifying those at risk for chronic pain and implementing early interventions. https://www.seattlechildrens.org/rabbitts-lab/ Funding Source: This research was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, at the National Institutes of Health under Grant No. K23HD078239 (P.I.: J.A. Rabbitts). Abbreviations: CPSP, chronic postsurgical pain; MVPA, Moderate to vigorous activity; NRS, Numeric Rating Scale; REDCap, Research Electronic Data Capture System. Conflict of Interest: The authors have no conflicts of interest to disclose. Reprints: Jennifer A. Rabbitts, MB, ChB, Seattle Children's Hospital, 4800 Sand Point Way NE MB.11.500.3, Seattle WA 98105 (e-mail: jennifer.rabbitts@seattlechildrens.org). Received April 9, 2020 Received in revised form October 9, 2020 Accepted November 11, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

The Impact of Parental Pain- and Non-pain-attending Responses upon Child Pain Behavior in the Context of Cancer-related Painful Procedures: The Moderating Role of Parental Self-oriented Distress Objectives: Literature has demonstrated inconsistent findings regarding the impact of parental responses upon child pain-related outcomes. Yet, research into factors that may underlie inconsistent findings regarding the variable impact of parental responses is lacking. The current study investigated the moderating role of parental distress in understanding the impact of parental pain-attending (e.g., reassuring the child) and non-pain-attending (e.g., distracting the child with humor) responses upon child pain behavior (e.g., crying). Methods: Children (≤18▒y) suffering from leukemia, undergoing a lumbar puncture (LP) and/or bone marrow aspiration (BMA) procedure, and one of their parents, were recruited from the Pediatric Ghent University Hospital. Parent-child interactions were videotaped after the procedure allowing coding of parental responses and child pain behavior. Parents self-reported on experienced personal distress. Results: Participants consisted of 42 children (24 boys, 18 girls) with leukemia and one of their parents. Children were 0.6-15 (7.08±4.39) years old. Findings indicated a positive association between parental pain-attending and child pain behavior, but only when parents reported high levels of distress (β=0.56, P=0.001). No association was observed for parents reporting low levels of distress (β=-0.09, ns). Parental non-pain-attending responses contributed to lower child pain behavior (β=-0.24, P=0.045), independently from parental distress (β=-0.07, ns). Discussion: The current findings point to the moderating role of parental distress in understanding the impact of parental responses upon child pain behavior and highlight the importance of interventions targeting parental emotion regulation to promote more optimal child pain outcomes. Disclosures: Grant support for Emma Rheel was provided by a Chair funded by the Berekuyl Academy / European College for Decongestive Lymphatic Therapy, the Netherlands and awarded to the Vrije Universiteit Brussel, Belgium. Kelly Ickmans is a postdoctoral research fellow, partly funded by the Research Foundation – Flanders (FWO). Line Caes was funded by the Research Foundation – Flanders (FWO). None of these sponsors played a role in the (1) study design, (2) collection, analysis and interpretation of data, (3) writing of the report, (4) decision to submit the paper for publication. The authors report no conflicts of interest. Reprints: Emma Rheel, MSc, Address of correspondence and reprints requests to Emma Rheel, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium (e-mail: emma.rheel@vub.be). Received June 5, 2020 Received in revised form November 4, 2020 Accepted November 11, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

What Mediates Treatment Effects in a Pre-surgery Physiotherapy Treatment in Surgical Candidates with Degenerative Lumbar Spine Disorders? A Mediation and Conditional Process Analysis of the PREPARE Randomized Controlled Trial Objectives: Treatment guidelines recommend targeting both physical and psychological factors in interventions for degenerative lumbar spine disorders. Studying treatment mechanisms gives information on key factors explaining outcome improvement which can refine treatments for future research. This study explores treatment mediators in a physiotherapy treatment on disability, pain intensity and health related quality of life (HRQoL) in surgical candidates with degenerative lumbar spine disorders compared to waiting-list controls. An additional aim was to evaluate patients´ expectation as a moderator of treatment outcome. Methods: Data collected from 197 patients in a single blinded randomized controlled trial comparing 9 weeks of multifaceted physiotherapy to waiting-list were used in this conditional process analysis. Analysis was carried out on group differences for change in Oswestry Disability Index (ODI), Pain Visual Analog Scale (VAS) back pain, EuroQol-5D (EQ-5D) and EQ-VAS. The putative moderation role of expectations and mediation role of change in physical variables and psychosocial variables were tested. Results: Change in self-efficacy mediated improvement in all outcomes. Improvement in ODI was also mediated by change in depression, VAS was mediated by change in fear avoidance beliefs and EQ-VAS was mediated by change in activity level and fear avoidance beliefs. Improvements were moderated by patients´ treatment expectations. Discussion: Self-efficacy, fear avoidance beliefs, physical activity level and patients´ treatment expectations were found to be important factors explaining treatment effects. Self-efficacy was the consistent mediator for effects of the pre-surgical physiotherapy on disability, back pain intensity and HRQoL. Sources of grant support: Research Council in Southeast Sweden (grant number: FORSS*660371), the Swedish Research Council (grant number:2017*01444) and Region Östergötland (LIO-921021). Approved by the Regional Ethics Committee in Linköping (dnr 2012/167-31). Trial registration: NCT02454400. Trail registration date: August 31st, 2015, retrospectively registered. The authors declare no conflict of interest. Reprints: Maria Fors, RPT, MSc, Linkopings universitet Medicinska Fakulteten Linköping, SWEDEN (e-mail: maria.fors@liu.se). Received March 31, 2020 Received in revised form October 28, 2020 Accepted November 3, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Deep Cervical Plexus Block for Neck and Shoulder Pain Due to Myofascial Pain: A Randomized Clinical Trial Objectives: Myofascial pain is one of the most common causes of regional pain yet with no definitive treatment modality. This randomized clinical trial was conducted to assess the efficacy of deep cervical plexus block versus placebo injection (sham block) for the treatment of myofascial neck and shoulder pain in terms of analgesic consumption and pain during a follow up period of two weeks after performing the block. Methods: Patients were randomly divided into two groups. Group I (Block) received deep cervical plexus block and group II (Placebo) received normal saline. A total of 66 patients were included in the study, 34 patients in the block group and 32 patients in the placebo group. Results: Two weeks after the intervention, average pain duration was significantly lower in the block group (1.38±1.39 vs. 5.25±1.72) for the block and placebo groups respectively (P-value<0.0001). Pain intensity was significantly less in the block group such that 2.9% of patients in the block group had severe pain compared to 53.1% of patients in the placebo group (P-value<0.0001). Two weeks after receiving the block, the mean opioid consumption calculated as tramadol equivalent was 21.1±44.2▒mg compared to 166.1±118.8▒mg for the block and placebo groups respectively. Multivariate analysis revealed that patients with a longer history of pain had a higher pain score after two weeks. The possibility of recovery is affected by pain duration since patients with chronic history of pain were least affected by the block. Discussion: This technique could be an alternative to pharmacological and non-pharmacological treatments for myofascial pain. Disclosures: Funding: none Conflict of interest: none declared Reprints: Zoher Naja, MD, PhD, Anesthesia and Pain Management Department - Makassed General Hospital, P.O. Box: 11-6301 Riad EI-Solh 11072210, Beirut – Lebanon (e-mail: zouhnaja@yahoo.com). Received September 18, 2019 Received in revised form November 10, 2020 Accepted November 17, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

The Effect of Perioperative Lidocaine Infusion on Postoperative Pain and Postsurgical Recovery Parameters in Gynecological Cancer Surgery Objectives: The primary objective of this prospective non-blinded randomized study was to investigate the effect of perioperative systemic lidocaine infusion on pain control after major gynecologic oncology surgery. Patient-reported outcomes, postoperative recovery parameters, and complications were secondary endpoints of the study. Methods: Seventy-five patients with ASA I-III was divided into three groups based on perioperative analgesia methods: The opioid group: patient-controlled analgesia (PCA) with morphine, The lidocaine group: perioperative intravenous lidocaine infusion, plus PCA with morphine, and the epidural group: PCA with bupivacaine. The Visual Analog Scale (VAS) was recorded postoperatively. In addition, nausea-vomiting, time to first oral intake, time to first ambulation, time to first flatus, and length of hospital stay were recorded. Results: VAS scores (rest) at 24 hours at rest and VAS scores (cough) at 12 and 24 hours were significantly lower in the epidural group than in the opioid group (P<0.05). VAS scores were found to be similar between the lidocaine and epidural group. The nausea-vomiting incidence was lower in the lidocaine group than in the opioid group(P<0.05). Compared to the other two groups, first flatus time was shorter in the lidocaine group (P<0.05). Discussion: Perioperative lidocaine infusion is effective as epidural analgesia, which is often advocated as the gold-standard analgesic technique for abdominal surgery and is superior to the others in terms of time to first flatus, and the incidence of nausea-vomiting. Conflicts of Interest: The authors declare that they have no conflicts of interest. Reprints: Menşure Kaya, MD, Associate Professor, Department of Anesthesiology and Reanimation, University of Health Sciences Dr. AY Oncology Training and Research Hospital, Demetevler 13. Cad. 06180, Ankara, Turkey (e-mail: mensurekaya@yahoo.com). Received April 3, 2020 Received in revised form October 28, 2020 Accepted November 3, 2020 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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