Victims of Abuse Have Worse Pain Outcomes
Interview with Andrea L. Nicol, MD
Physical and sexual abuse is often reported by patients who have chronic pain conditions. However, physicians did not fully understand the relationship between trauma and pain. It now appears that co-occurring mental health issues play a significant role in the development of chronic pain later in life.
In a new study published in The Journal of Pain,1 researchers found that chronic pain patients with a history of abuse commonly suffer from various mental health problems, greater pain severity, and compromised physical functioning. The researchers now believe that traumatic events may be a trigger to affective distress and centralized pain in these patients, something that could lead to chronic pain later in life.
Patients who have suffered abuse, whether as a child or as an adult, often report a wide range of chronic pain issues,2 including low back pain,3 pelvic pain,4 musculoskeletal pain,5 and fibromyalgia.6 Lead author of the new study Andrea L. Nicol, MD, has witnessed this phenomenon in her own practice, which prompted her to start her own investigation.
“I was inspired to do this study after seeing trends for increased prevalence of abuse and traumas in my chronic pain/centralized pain patients and after reading preclinical and clinical data that reported these associations,” Dr. Nicol, from the department of anesthesiology at the University of Kansas School of Medicine in Kansas City, Kansas, told Practical Pain Management.
Unfortunately, Dr. Nicol was never instructed about how or why to assess pain patients’ possible traumatic histories. Once Dr. Nicol started to do this in her own practice, she started to dive deeper into having critical discussions with her patients, and oftentimes, recommended them behavioral, psychological, and medical treatments for their pain.
Within this biopsychosocial framework, doctors are beginning to find that central nervous system (CNS) mechanisms could be a primary factor in the development of centralized pain, something that actually could be more important than nociceptive input, itself.7-8 In this new study, Dr. Nicol and her colleagues took one step further: could a prototypical centralized pain syndrome, like fibromyalgia, mediate the relationship between a patient’s history of abuse and their levels of affective disease, pain severity, and physical functioning?
Mapping the Mediators of Abuse and Chronic Pain
To try to answer this question, Dr. Nicol and her colleagues put together a cross-sectional study deriving data from 3,081 adult patients from a research initiative based at the University of Michigan’s Back and Pain Center. As part of routine clinical care, patients were assessed about their history of abuse, their chronic pain condition, pain severity and interference, anxiety, depression, catastrophizing, functional status, as well as survey criteria for fibromyalgia, or “fibromyalgianess,” which could serve as an estimate of the degree of centralized pain.7,9
Researchers found 15.25% of patients (n=470) reported a history of abuse. These patients appeared to have greater depression and anxiety, worse physical functioning, greater pain severity, more pain interference, worse catastrophizing, and higher scores for FM Survey Criteria, compared to patients who did not have histories of abuse (P < 0.001 for all factors).
But Dr. Nicol and her colleagues wanted to investigate further, so they created mediation models designed to assess whether depression, anxiety, or fibromyalgianess possibly could mediate the relationship between abuse and pain severity or physical functioning. The models provided 4 different assessments:
- Fibromyalgianess and depression as mediators of pain severity
- Fibromyalgianess and depression as mediators of physical function
- Fibromyalgianess and anxiety as mediators of pain severity
- Fibromyalgianess and anxiety as mediators of physical function
“All mediation models showed that depression, anxiety, and FM score are mediators” between having a history of abuse and pain outcomes, which included child abuse, adult abuse, and child/adult abuse, said Dr. Nicol.
However, when researchers assessed patients who were only abused as children, not as adults, the relationship between abuse and physical function could not be fully accounted for just by the increased fibromyalgianess, depression, or anxiety. It may be possible that other factors not included in the study may have played a role, Dr. Nicol explained.
“Obviously, all one can do is hypothesize what these factors may be, but my best guess is it is likely a combination of behavioral, physical, and environmental factors as these all influence one’s physical functioning. Myself and my colleagues will continue to investigate these themes related to trauma in our current ongoing and future research projects,” Dr. Nicol told Practical Pain Management.
The study also is limited by its cross-sectional design, which makes it implausible the results prove a “true directional relationship,” but given the prevalence of fibromyalgianess, depression, and anxiety in victims of abuse, exploring how these factors lead to chronic pain is a significant area of future study. “We believe the more likely hypothesis is that depression or anxiety after abuse could lead to symptoms of chronic pain,” said Dr. Nicol.
The study also serves as a stark reminder of the prevalence and clinical significance of a pain patient’s history, which shouldn’t be limited to past medical diagnoses. History of abuse, while a personal and sensitive topic, could be a vital piece of information to ensure informed, effective clinical decisions.
“I hope that the results of this study will inspire pain practitioners and general medical practitioners to not only screen their chronic pain patients for abuse or traumatic events, but to understand that patients who do screen positive for these events will need a highly integrative approach to treatment – meaning they need to offer treatments to the patient which will work to heal the body and the mind,” said Dr. Nicol.
This research was funded by the Department of Anesthesiology of the University of Michigan Medical School. All additional funding information, as well as full disclosure of the study authors’ financial interests and affiliations can be found by reading the official study here.