Secondary and Tertiary Prevention of Chronic Pain

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疼痛的二级预防
Secondary and Tertiary Prevention of Chronic Pain

Introduction
Prevention of pain and its chronic forms will reduce the burden of suffering for individuals and society,respectively. Secondary prevention aims to detect disease in the early stages and limits its progression[1, 2], whereby tertiary prevention aims to reduce or avoid complications or limiting consequences ofthe disease already present [1]. For pain, the definitions state to prevent individuals from developingchronic pain after initial onset of acute pain (secondary prevention), or to reduce ongoing disability,disuse or loss of social contacts and occupation, once pain has become chronic (tertiary prevention).Even though the research body for secondary pain prevention has grown during the past years, thefocus remains on treating chronic pain

The Global Year for the Prevention of Pain is a chance to raise awareness on strategies and interventionsfor the primary and secondary stages of disease development, supporting sufferers in maintaining dailyphysical, personal and social activities the best way possible to reduce the development of chronic pain.Recommendations in designing prevention trials have been published [3], which will hopefully generatereliable evidence.

Secondary Prevention of Pain: Preventing Chronicity

The secondary prevention of pain was first described by Fordyce in the 1970s [4], when distinguishingbetween pain and pain behaviour (disabling behaviour). A prevention regime was applied to reduce painbehaviour, leading to preliminary promising results in terms of prevention strategies [2, 4] includingtime-contingent training and medication. Secondary prevention requires an understanding of the factorsinvolved in chronification, validated instruments to detect patients at risk, and validated clinicalstrategies addressing these risk factors with specific interventions [5]. Several reviews report risk factorsfor maintaining different forms of pain; red (biological) and yellow (psychosocial) flags formusculoskeletal pain is the most common construct, followed by blue (occupational), black(compensation) and white (socio-cultural) [6] flags, where evidence is still pending regarding theirimpact in secondary prevention of pain. Specific mechanism-based risk factors would help designingpreventive strategies providing future base of tailored interventions [5, 7]. Such risk factors have beenidentified in catastrophizing/maladaptive cognitions and depressive mood for developing chronic knee[8] or low back pain [9] as yellow flags, or joint damage as red flag for knee pain [8]. Others reportedseveral risk factors for developing chronic pain after surgery (e.g. [10-12]) with sound evidence for age,gender, type of surgery, genetic factors, preceding pain or history of chronic pain of other origin and avariety of psychosocial factors. Screening instruments are available especially for back pain withpreliminary evidence for their prognostic value [13]. Preliminary evidence is also provided thatsubgrouping patients regarding their risk for chronification and specifically tailored treatment is

effective in the short and middle terms [14]. Education and exercise in preventing back pain frombecoming chronic seems to be of best evidence at the moment [5, 7], primarily in the short and middleterms.In contrast, iatrogenic factors (factors lying in the health care system) seem to contribute tochronification of pain, especially when solely focusing on somatic factors, ignoring multi-causal genesisof pain, overestimating the impact of somatic or radiologic findings on wellbeing of the patient andoveruse of diagnostic procedures and rather passively oriented interventions in long term (e.g. massage)[15]. In light of these findings, responsibility of health care providers in treating pain in an evidencebased manner should not be underestimated and should be included into research activities.Intensified effort in establishing models [3] such as the avoidance-endurance model [16] or, from basicscience, deriving tailored treatments and generating evidence by pain researchers is needed.Incorporating spontaneous recovery from initial pain, saluto-genetic models and patient preferences forspecific interventions [17] should be taken into future considerations.

Tertiary Prevention of Pain: Reducing Disability, Work Loss, Negative Emotionality and Social Isolationfor Sufferers with Chronic Pain

Tertiary prevention aims to reduce secondary effects of those suffering from chronic pain. Models suchas the fear avoidance model [18, 19] or the avoidance and endurance model [16, 20-23] incorporate thefunctional, psychological and social impairment in leading a satisfying life by the affected individuals.The biopsychosocial model of pain [24-26] led to the development of biopsychosocial (synonymouslymultidisciplinary, interdisciplinary, multi component) treatment approaches. A corresponding definitionwas devised by an IASP Task Force in 2017 and published at IASP homepage (https://www.iasppain.org/Education/Content.aspx?ItemNumber=1698).Mayer and Gatchel [27]

introduced the biopsychosocial treatment approach in the 1980s. Its main aimis the restoration of physical, psychological and social functioning, involving a core team of multidisciplinary healthcare professionals (physicians, physiotherapists, occupational therapists, psychologistsand nurses)working in an integrated team setting [27].

Interdisciplinary treatment has been acknowledged as an appropriate answer to the comprehensivesuffering of patients with chronic pain worldwide [28], but evidence is controversially discussed [29].The heterogeneity of involved professions, providing interventions and the treatment composition, doseand duration of treatment, and the outcome assessment tools in clinical trials hampers considerablycomparative effectiveness research and valid meta analyses [30]. Conceptual frameworks andmechanism based treatment designs, harmonized outcome assessment (considering comprehensivemultidimensional outcomes [31]), carefully reported studies and carefully performed systematicresearch is needed to distinguish beneficial treatment from non-beneficial and, finally, to identify besttreatment to specific groups of patients regarding their characteristics [32].

REFERENCES
[1] Loisel P. Developing a new paradigm: Work disability prevention. Occupational Health Southern Africa 2009;15(2):56-60.
[2] Linton SJ, Chronic pain: the case for prevention. Behaviour research and therapy 1987;25(4):313-317.

[3] Gewandter JS, Dworkin RH, Turk DC, Farrar JT, Fillingim RB, Gilron I, Markman JD, Oaklander AL, Polydefkis MJ, Raja SN,Robinson JP, Woolf CJ, Ziegler D, Ashburn MA, Burke LB, Cowan P, George SZ, Goli V, Graff OX, Iyengar S, Jay GW, Katz J, KehletH, Kitt RA, Kopecky EA, Malamut R, McDermott MP, Palmer P, Rappaport BA, Rauschkolb C, Steigerwal I, Tobias J, Walco GA.Research design considerations for chronic pain prevention clinical trials: IMMPACT recommendations. Pain 2015;156(7):1184-1197.[4] Fordyce WE, Brockway JA, Bergman JA, Spengler D. Acute back pain: a control-group comparison of behavioral vs traditionalmanagement methods. Journal of Behavioral Medicine 1986;9(2):127-140.[5] Meyer C, Denis CM, Berquin AD. Secondary prevention of chronic musculoskeletal pain: A systematic review of clinical trials.Ann Phys Rehabil Med 2018;61(5):323-338.[6] Winkelmann C and Schreiber T. Using ’White Flags’ to categorize socio-cultural aspects in chronic pain. European Journal ofPublic Health 2019;29(Supplement_4):ckz186-196.[7] Sowah D, Boyko R, Antle D, Miller L, Zakhary M, Straube S. Occupational interventions for the prevention of back pain:Overview of systematic reviews. J Safety Res 2018;66:39-59.[8] Sarmanova A, Fernandes GS, Richardson H, Valdes AM, Walsh DA, Zhang W, Doherty M. Contribution of central andperipheral risk factors to prevalence, incidence and progression of knee pain: a community-based cohort study. OsteoarthritisCartilage 2018;26(11):1461-1473.[9] Melloh M, Elfering, Egli Presland C, Röder C, Hendrick P, Darlow B, Theis J-C. Predicting the transition from acute topersistent low back pain. Occup Med (Lond) 2011;61(2):127-31.[10] Johannsen M, Frederiksen Y, Jensen AB, Zacharie R. Psychosocial predictors of posttreatment pain after nonmetastaticbreast cancer treatment: a systematic review and meta-analysis of prospective studies. J Pain Res 2018;11:23-36.[11] Kehlet H, Jensen TS, Woolf CJ, Persistent postsurgical pain: risk factors and prevention. The Lancet 2006;367(9522):1618-1625.[12] Reinpold W. Risk factors of chronic pain after inguinal hernia repair: a systematic review. Innov Surg Sci 2017;2(2):61-68.[13] Hill JC, Dunn KM, Main CJ, Hay EM. Subgrouping low back pain: a comparison of the STarT Back Tool with the OrebroMusculoskeletal Pain Screening Questionnaire. Eur J Pain 2010;14(1):83-89.[14] Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, Hay EM. A primary care back pain screening tool: identifyingpatient subgroups for initial treatment. Arthritis Rheum 2008;59(5):632-641.[15] Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The association between health care professional attitudesand beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematicreview. Eur J Pain 2012;16(1):3-17.[16] Hasenbring MI, Chehadi O, Titze C, Kreddig N. Fear and anxiety in the transition from acute to chronic pain: there isevidence for endurance besides avoidance. Pain manage 2014;4(5):363-374.[17] Aboagye E, Hagber J, Axén I, Kwak L, Lohela-Karlsson, M, Skillgate E, Dahlgren G, Jensen I. Individual preferences forphysical exercise as secondary prevention for non-specific low back pain: A discrete choice experiment. PLoS One2017;12(12):e0187709.[18] Crombez G, Eccleston C, Van Damme S, Vlaeyen JWS, Karoly P. Fear-avoidance model of chronic pain: the next generation.Clin J Pain 2012;28(6):475-483.[19] Vlaeyen JW and Linton SJ. Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain 2012; 153(6):1144-1147.[20] Hasenbring MI, Hallner D, Klasen B, Streitlein-Böhme I, Willburger R, Rusche H. Pain-related avoidance versus endurance inprimary care patients with subacute back pain: psychological characteristics and outcome at a 6-month follow-up. Pain2012;153(1):211-217.[21] Hasenbring MI and Verbunt JA. Fear-avoidance and endurance-related responses to pain: new models of behavior andtheir consequences for clinical practice. Clin J Pain 2010;26(9):747-753.[22] Plaas H, Sudhaus S, Willburger R, Hasenbring MI. Physical activity and low back pain: the role of subgroups based on theavoidance-endurance model. Disabil Rehabil 2014;36(9):749-755.[23] Sudhaus S, Held S, Schoofs D, Bültmann J, Dück, I, Wolf OT, Hasenbring MI. Associations between fear-avoidance andendurance responses to pain and salivary cortisol in the context of experimental pain induction. Psychoneuroendocrinology2015; 52:195-199.[24] Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977; 196(4286):129-136.[25] Engel GL. The clinical application of the biopsychosocial model. J Med Philos 1981;6(2):101-124.[26] Williams ACC and Craig KD. Updating the definition of pain. Pain 2016;157(11):2420-2423.[27] Mayer TG and Gatchel RJ. Functional restoration in spinal disorders: The Sports Medicine Approach. Philadelphia: Lea andFebiger; 1988.[28] Schatman M. Interdisciplinary chronic pain management: international perspectives. Pain: Clinical Updates 2012;20(7): 1-5.

[29] Dragioti E, Evangelou E, Larsson B, Gerdle B. Effectiveness of multidisciplinary programmes for clinical pain conditions: Anumbrella review. J Rehabil Med 2018;50(9):779-791.[30] Kaiser U, Treede R-D, Sabatowski R. Multimodal pain therapy in chronic noncancer pain—gold standard or need for furtherclarification? Pain 2017;158(10):1853-1859.[31] Deckert S, Kaiser U, Kopkow C, Trautmann F, Sabatowski R, Schmitt J. A systematic review of the outcomes reported inmultimodal pain therapy for chronic pain. Eur J Pain 2016;20(1):51-63.[32] Turk DC. Chronic pain and whiplash associated disorders: rehabilitation and secondary prevention. Pain Res Manag2003;8(1):40-3.AUTHORDr. Ulrike KaiserLead. Clinical psychologistComprehensive Pain CenterUniversity Hospital Carl Gustav Carus DresdenDresden, GermanyREVIEWERSBrona M. Fullen, PhDAssociate ProfessorUCD School of Public HealthPhysiotherapy and Sports ScienceDublin, IrelandProfessor Esther Pogatzki-Zahn, MD, PhDDepartment of Anesthesiology, Intensive Care and Pain MedicineUniversity Hospital MuensterMuenster, Germany