The Role of Pain Catastrophizing in the Prediction of Acute Procedure Related Pain

Background: Aim of this study was to assess preoperative pain catastrophizing scale (PCS) scores and its predictive value regarding acute access-site pain after percutaneous coronary intervention (PCI). Methods: Patients who received PCI via radial artery enrolled in a prospective observational study. Patients filled out PCS questionnaire prior to procedure. Pain intensity was assessed using numeric rating scale during PCI and 2 hours, 12 hours, 24 hours, 48 hours, 1 week and 1 month after PCI. Results: Median PCS score was 15 (8.0-22.0), female score (18.0 (10.0-29.5)) was higher than male (14.0 (6.5-20.0) (P = 0.030). Magnification scores were higher among females P = 0.018). Patients aged 75 and older had highest PCS scores (20.0) and rumination scores (P = 0.04 and P = 0.006 respectively). Female pain scores during procedure (2.5 (0.0-5.0) and 2 hours after procedure (4.0 (2.0-5.0) were higher than male (P = 0.024 and P = 0.013 respectively). Significant correlation was found between gender and pain during PCI (r = 0.219, P = 0.022), 2 hours after PCI (r=0.233, P = 0.015). We didn’t find any correlation or predictive value of PCS for acute pain. Female sex predicted pain 1 month after PCI ((OR = 3.143 95% CI (1.063-9.296), P = 0.038). Conclusion: PCS had no significant associations with pain after PCI. Females were more likely to report higher PCS and pain scores than males. Patients aged 75 and over reported higher PCS scores. Further research is needed to evaluate the importance of psychological factors regarding acute postprocedural pain. The Role of Pain Catastrophizing in the Prediction of Acute Procedure Related Pain. Biomed


Introduction
Myocardial revascularization by either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) combined with pharmacotherapy remains the main approach in coronary artery disease treatment, PCI being a more preferred revascularization method in most cases [1][2][3]. Radial artery approach is generally favored over femoral artery approach, for the reason that transradial PCI has a lower incidence of access site complications, bleeding, lower risk of all-cause mortality and higher patient satisfaction compared to approach via femoral artery [4,5]. Despite numerous transradial approach benefits, patients undergoing PCI via radial artery experience pain during and after the procedure. There are several risk factors contributing to pain intensity during transradial access PCI, such as female sex, diabetes, smoking, low body mass index [6]. None of them have a direct connection to mental state and there are very limited data regarding the psychological risk factors for higher pain levels during and after PCI.
Nevertheless, various studies have shown the important role of depression, anxiety and pain catastrophizing as relevant independent risk factors of pain intensity experienced by patients in multiple surgical procedures [7,8]. Catastrophizing is described as a tendency to aggravate possible outcomes when subjected to painrelated stimuli. It is considered a result of dysfunctional cognitive and emotional adaptation mechanism and consists of three main components: rumination, helplessness and magnification [9].
Pain catastrophizing causes higher pain intensity, which in turn requires a more aggressive approach to postsurgical analgesia.
Furthermore, it can lead to the development of chronic postsurgical pain, contribute to anxiety, depression or other negative emotional dysfunctions, overall, negatively affecting patient's quality of life.
Pain catastrophizing scale (PCS) is widely used for objectifying rather abstract components of catastrophizing and is considered a standard measuring tool, as it is proven to be accurate, consistent and reliable [8,10].
The primary aim of this study is to evaluate the relationship between pain catastrophizing and acute access site pain intensity after percutaneous coronary intervention via radial artery and determination whether pain catastrophizing scale score can be used as a predictive factor of acute pain after transradial PCI. Secondary aims include evaluating gender and age differences regarding PCS scores as well as pain scores up to 1 month after the procedure.

Methods
The Regional Ethics Committee approved the trial (approval number BE-2-7, 2018-02-26). 137 patients who underwent percutaneous coronary intervention via radial artery were enrolled in a prospective observational study (between 2018 and 2020).  The preoperative PCS scores were not normally distributed, as well as pain scores at all time points were not normally distributed and therefore results are presented as medians (with quartiles). A

Inclusion Criteria
Mann-Whitney U test was run to determine if there were differences in overall PCS score and in pain scores between males and females.
The Kruskal-Wallis H test was used to evaluate the distribution of PCS scores between age groups. Pearson correlations test was used to examine the associations between catastrophizing, pain and age and to study the associations between pain scores and age.
Point-Biserial correlation test was used to examine the correlation between gender and pain scores. To investigate the association between preprocedural pain catastrophizing and postprocedural pain intensity and to determine whether PCS could be used as a predictive factor for pain intensity after the procedure, we used a linear regression test with postoperative pain intensity as the dependent variable. Univariate logistic regression analysis was carried out to examine PCS, sex and age as prognostic factors for acute pain. The results were considered statistically significant at P < 0.05. 3. It's terrible and I think it's never going to get any better.
4. It's awful and I feel that it overwhelms me.
5. I feel I can't stand it anymore.
6. I become afraid that the pain will get worse.
7. I keep thinking of other painful events.
8. I anxiously want the pain to go away.
9. I can't seem to keep it out of my mind. 10. I keep thinking about how much it hurts. 11. I keep thinking about how badly I want the pain to stop.
12. There's nothing I can do to reduce the intensity of the pain.
13. I wonder whether something serious may happen.

Results
In total 109 patients were included in the statistical analysis: 73 men (67%) and 36 women (33%). Baseline and demographic characteristics are presented in (Table 2). The overall median preoperative PCS score was 15.0 (8.0-22.0). The median for females was 18.0 (10.0-29.5) and for males 14.0 (6.5-20.0). Overall PCS scores for females were statistically significantly higher than for males (P = 0.030). In addition to that, females had a statistically significantly higher magnification score in PCS than males (P = 0.018). Distributions of PCS scores were similar for all age groups, as assessed by visual inspection of a boxplot. Median PCS scores were statistically significantly different between groups, with the highest median score (20.0) being in the ≥75 years old group and the lowest (9.0) among patients younger than 55 years old (P = 0.04). Rumination score was also higher among patients older than 75 years (P = 0.006). PCS values are presented in (Table 3). The median pain score during the procedure was 1.0 (0.0-4.0).    A linear regression analysis revealed that PCS score had no statistically significant effect on the postprocedural pain score. The results are shown in (Table 4). Univariate regression analysis didn't reveal any statistically significant results regarding higher pain catastrophizing scores and acute access-site pain development.
However, our results showed that females had a 3.143 times greater possibility to report access-site pain 1 month after the procedure (P = 0.038) ( Table 5).

Discussion
Our study evaluated the gender differences regarding PCS scores and pain scores during and up to 1 month after the intervention. We found that females had a statistically significantly higher PCS score than males, as well as statistically significantly higher pain scores at 2 hours after the procedure. The tests also revealed that females are more likely to have a 1.064-point higher pain score than males 2 hours after the procedure. Differences between genders regarding pain and catastrophizing have been explored in earlier studies, which often reported higher pain and catastrophizing ratings in females 13. According to literature, women may be more sensitive and less tolerant to painful stimuli due to differences in sex hormones and immunity [12][13][14]. Further study is needed to explore benefit of intervention approach based on gender. Considering age and PCS scores, we found that PCS scores were statistically significantly different between age groups and the highest among those older than 75 years.
Older adults often struggle with medical comorbidities, disability, depression and anxiety and an overall impaired quality of life, and all of these factors could influence catastrophizing thoughts [15,16]. Suren  level with a median rating of 9.0 (0.0-28.5) on the 100 mm long visual analogue scale 3 h after the procedure [25,26], which is in accordance to our results.
Determining which patients could be more prone to catastrophizing could come of use when deciding whether certain interventions would be of clinical value, as it has been shown that pain catastrophizing can be modified in various surgical settings 26. Importance of such interventions can be highlighted by relationship between higher PCS scores and greater need for postoperative opioids, as found by Sacks, et al. [27]. This study has a few limitations. First, patients filled PCS only prior to the procedure, thus data was not available to examine possible correlation between pain and PCS at all time points. This approach could have been important as it is known that PCS tend to vary depending on recovery [28]. Furthermore, no other possible psychological factors, such as anxiety, were evaluated. Some authors found a significant positive correlation between preoperative anxiety and PCS scores.
These psychological factors could potentially add to the prediction of acute pain intensity. Further studies should be considered to specify our findings.

Conclusion
This study found no significant associations between pain catastrophizing and pain intensity after percutaneous coronary intervention. In addition, we found that females are more likely to report higher pain catastrophizing scores and higher pain scores than males and adults aged 75 and over were found to have higher PCS scores. Further study is needed to evaluate the importance of psychological factors regarding acute postprocedural pain.