Background 

Among people with musculoskeletal disorders, much of the variation in magnitude of incapability and pain intensity is accounted for by mental and social health opportunities rather than severity of pathology. Current questionnaires seem to combine distinct aspects of mental health such as unhelpful thoughts and distress regarding symptoms, and they can be long and burdensome. To identify personalized health strategies, it would be helpful to measure unhelpful thoughts and distress regarding symptoms at the point of care with just a few questions in a way that feels relevant to a person’s health.

Questions/purposes 

(1) Do questions that address unhelpful thoughts and distress regarding symptoms independently account for variation in accommodation of pain? (2) Which questions best measure unhelpful thoughts and distress regarding symptoms?

Methods 

This is a cross-sectional questionnaire study of people seeking care regarding upper and lower extremity conditions from one of eight specialist clinicians (one upper extremity, one arthroplasty, and one sports surgeon and their three nurse practitioners and two physician assistants) in one urban office. Between June 2020 and September 2020, 171 new and returning patients were approached and agreed to participate, and 89% (153) of patients completed all questionnaires. The most common reason for noncompletion was the use of a pandemic strategy allowing people to use their phone to finish the questionnaire, with more people leaving before completion. Women and divorced, separated, or widowed people were more likely to not complete the survey, and we specifically account for sex and marital status as potential confounders in our multivariable analysis. Forty-eight percent (73 of 153) of participants were women, with a mean age 48 ± 16 years. Participants completed demographics and the validated questionnaires: Pain Catastrophizing Scale, Negative Pain Thoughts Questionnaire, Tampa Scale of Kinesiophobia, Intolerance of Uncertainty Scale, and Pain Self-Efficacy Questionnaire (a measure of accommodation to pain). In an exploratory factor analysis, we found that questions group together on four topics: (1) distress about symptoms (unhelpful feelings of worry and despair), (2) unhelpful thoughts about symptoms (such as worst-case thinking and pain indicating harm), (3) being able to plan, and (4) discomfort with uncertainty. We used a multivariable analysis, accounting for potential confounding demographics, to determine whether the identified question groupings account for variation in accommodation of pain—and thus are clinically relevant. Then, we used a confirmatory factor analysis to determine which questions best represent clinically relevant groupings of questions.

Results 

After accounting for sex, marital status, work, and income, we found that distress and unhelpful thoughts about symptoms were independently associated with accommodation of pain, and together, they explained 60% of its variation (compared with 52% for distress alone and 40% for unhelpful thoughts alone). Variation in symptoms of distress was best measured by the question “I feel I can’t stand it anymore” (76%). Variation in unhelpful thoughts was best addressed by the question “I wouldn’t have this much pain if there wasn’t something potentially dangerous going on in my body” (64%).

Conclusion 

We found that distress (unhelpful feelings) and unhelpful thoughts about symptoms are separate factors with important and comparable associations with accommodation to pain. It also appears that these two factors can be measured with just a few questions. Being attentive to the language people use and the language of influential questions might improve clinician identification of mental health opportunities in the form of distress and unhelpful thoughts about symptoms, which in turn might contribute to better accommodation and alleviation of symptoms.

Level of Evidence 

Level II, prognostic study.

中文翻译：

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对症状的无益想法和痛苦限制了肌肉骨骼疼痛的调节

背景 

在肌肉骨骼疾病患者中，丧失能力程度和疼痛强度的差异很大程度上是由心理和社会健康机会而不是病理严重程度造成的。目前的调查问卷似乎结合了心理健康的不同方面，例如无益的想法和对症状的困扰，而且调查问卷可能很长且繁重。为了确定个性化的健康策略，只需以与个人健康相关的方式提出几个问题，就可以在护理时测量有关症状的无益想法和痛苦，这将很有帮助。

问题/目的 

(1) 解决有关症状的无益想法和痛苦的问题是否可以独立解释疼痛调节的变化？(2) 哪些问题最能衡量有关症状的无益想法和痛苦？

方法 

这是一项横断面问卷调查，研究对象是在一个城市办公室向八名专科临床医生（一名上肢医生、一名关节置换医生、一名运动外科医生及其三名执业护士和两名医师助理）中的一名寻求上肢和下肢疾病护理的人。2020 年 6 月至 2020 年 9 月期间，我们联系了 171 名新患者和回访患者并同意参与，89% (153) 的患者完成了所有问卷。未完成的最常见原因是使用流行病策略，允许人们使用手机完成调查问卷，更多的人在完成之前离开。女性和离婚、分居或丧偶的人更有可能无法完成调查，我们在多变量分析中特别将性别和婚姻状况视为潜在的混杂因素。48% 的参与者（153 人中的 73 人）是女性，平均年龄为 48 ± 16 岁。参与者完成了人口统计数据和经过验证的问卷：疼痛灾难化量表、消极疼痛想法问卷、坦帕运动恐惧量表、不确定性不耐受量表和疼痛自我效能问卷（一种适应疼痛的措施）。在探索性因素分析中，我们发现问题集中在四个主题上：（1）对症状的困扰（担心和绝望的无益感），（2）对症状无益的想法（例如最坏情况的想法和表明伤害的疼痛） ，(3) 能够制定计划，以及 (4) 对不确定性感到不适。我们使用多变量分析，考虑了潜在的令人困惑的人口统计数据，以确定所确定的问题分组是否解释了疼痛调节的变化，从而具有临床相关性。然后，我们使用验证性因素分析来确定哪些问题最能代表临床相关的问题组。

结果 

在考虑了性别、婚姻状况、工作和收入之后，我们发现痛苦和对症状的无益想法与疼痛调节独立相关，并且它们共同解释了 60% 的变化（相比之下，单独痛苦的解释为 52%，而单独的痛苦想法解释了 40%）。 ％仅用于无益的想法）。痛苦症状的变化最好通过“我觉得我再也无法忍受了”这个问题来衡量（76%）。无益想法的变化最好通过以下问题来解决：“如果我的身体里没有发生潜在危险的事情，我就不会这么痛苦”（64%）。

结论 

我们发现，痛苦（无益的感觉）和对症状无益的想法是独立的因素，与疼痛调节具有重要且可比的关联。似乎只需几个问题就可以衡量这两个因素。关注人们使用的语言和有影响力的问题的语言可能会提高临床医生对心理健康机会的识别，这些机会以痛苦和对症状的无益想法的形式出现，这反过来又可能有助于更好地适应和缓解症状。

证据水平 

II级，预后研究。