Page 56 Acute Pain Management

people with persisting pain (Leeuw et al, 2007). Negative appraisals of internal and external
stimuli (eg catastrophising), negative affectivity and anxiety sensitivity could contribute to the
development of pain‐related fear and, in turn, lead to escape and avoidance behaviours, as
well as hypervigilance to internal and external illness information, muscular reactivity, and
physical disuse and behavioural changes.

1.2.2 Acute pain settings
The contribution of psychosocial factors to the pain experience is important in acute and
chronic pain settings as well as in the transition from acute to chronic pain (Linton, 2000
Level IV; Pincus et al, 2002 Level IV).
Preoperative anxiety has been shown to be associated with higher pain intensities in the first
CHAPTER 1 (Caumo et al, 2002 Level IV; Granot & Ferber, 2005 Level IV), coronary artery bypass (Nelson et al,
hour after a variety of different operations (Kalkman et al, 2003 Level IV), including abdominal
1998 Level IV), gynaecological (Hsu et al, 2005 Level IV; Carr et al, 2006 Level IV) and varicose vein
(Terry et al, 2007 Level IV) surgery, and after laparoscopic tubal ligation (Rudin et al, 2008 Level IV).
Preoperative anxiety was also associated with increased pain and reduced function 1 year
after total knee replacement (Brander et al, 2003 Level IV), but not 5 years after the surgery
(Brander et al, 2007 Level IV). Similarly, preoperative psychological distress was shown to predict
pain up to 2 years after knee arthroplasty (Lingard & Riddle, 2007 Level IV). Pain from 2 to
30 days after breast surgery was also predicted by preoperative anxiety (Katz et al, 2005
Level IV). After elective Caesarean section, preoperative anxiety did not predict analgesic use,
but was negatively associated with maternal satisfaction and speed of recovery (Hobson et al,
2006 Level IV).
In patients who underwent repair of their anterior cruciate ligament, those with high Pain
Catastrophising Scale (PCS) scores, assessed prior to surgery, reported more pain immediately
after surgery and when walking at 24 hours compared with those with low scores, but there
was no difference in analgesic consumption (Pavlin et al, 2005 Level IV). After breast surgery,
catastrophising was associated with increased pain intensity and analgesic use (Jacobsen &
Butler, 1996 Level IV) and with higher pain scores after abdominal surgery (Granot & Ferber, 2005
Level IV) and Caesarean section (Strulov et al, 2007 Level IV). Preoperative PCS scores also predicted
pain after knee arthroplasty on the second postoperative day (Roth et al, 2007 Level IV) and at 6
weeks (Sullivan et al, 2009 Level IV) and 2 years after surgery (Forsythe et al, 2008 Level IV).
Preoperative depression (Caumo et al, 2002 Level IV; Kudoh et al, 2002 Level III‐2; Katz et al, 2005
Level IV; Rudin et al, 2008 Level IV) and neuroticism (Bisgaard et al, 2001 Level IV) were predictors of
postoperative pain early after surgery; preoperative depression was also associated with pain
1 year after total knee replacement (Brander et al, 2003 Level IV) and reduced function at both
1 year (Brander et al, 2003 Level IV) and 5 years later (Brander et al, 2007 Level IV). Strong
information‐seeking behaviour was associated with a reduction in the incidence of severe pain
(Kalkman et al, 2003 Level IV).
Preoperative anxiety and moderate to severe postoperative pain are, in turn, predictors of
postoperative anxiety (Caumo et al, 2001 Level IV; Carr et al, 2006 Level IV).
In opioid‐tolerant patients, the anxiety and autonomic arousal associated with withdrawal
(Tetrault & O'Connor, 2008) may also impact on acute pain experience and report (see Section
11.7 for further details). Behavioural problems were more common in methadone‐maintained
patients who required inpatient acute pain management (Hines et al, 2008 Level III‐2).

8 Acute Pain Management: Scientific Evidence