Introduction
Postoperative pain is a common phenomenon among patients of the surgery. This is a phenomenon that has remained relatively unchanged over the last three decades where such scholars as Small and Laycock (2020) have established that approximately 20% of patients experience acute postoperative pain within 24 hours after surgery. Additionally, the postoperative pain can take up to three months, after which it is labeled persistent or chronic. Therefore, there is a serious concern among practitioners regarding the most effective means of addressing this problem for patients. According to Horn and Kramer (2020), less than half of the surgery patients report adequate pain relief despite the availability of multiple interventions and pain management strategies. Research has also indicated that poorly managed postoperative pain contributes significantly towards the low quality of life, high morbidity, delayed recovery time, longer periods of opioid use, and high costs of healthcare (Gan, 2017). Therefore, it can be argued that postoperative pain is a serious challenge for practitioners.
The focus of this literature review is on pain catastrophizing and its effects on postoperative pain. With the critical nature of this problem, it is deemed prudent that an examination of all factors affecting postoperative pain should inform the pain management decisions and interventions. A brief background to the concept of pain catastrophizing is presented, after which the current literature on the relationship between these variables is explored.
Pain Catastrophizing
The concept of pain catastrophizing has been studied in different contexts, including clinical settings, physical therapy, and psychology. Regardless of the context, the definition and the basic idea behind pain catastrophizing have remained relatively standard. According to Coronando et al. (2020), pain catastrophizing has been described as the tendency by patients to magnify, focus on, or exaggerate the seriousness of the threat of pain. The basic idea is that the patients have their own perception of pain, a mental and psychological phenomenon that may create greater sensations of the pain. In simpler terms, the above description of pain catastrophizing is that the pain perceived by patients is more than it is normally. The main observation with this description is that the phenomenon is a state of mind of the patient as opposed to reality. Such sentiments have been upheld by Horn et al. (2020), who define catastrophizing as an exaggerated negative mental state of the patient during anticipated or actual pain experiences. Therefore, the level of pain described by patients could be determined by how much exaggeration there is by the patient.
Another key aspect of pain catastrophizing is that it is one of the psychological determinants of pain among patients, alongside anxiety and fear of pain. In the context of surgery, many scholars have expressed that the psychological determinants tend to affect the amount of pain felt by patients after operations. Such a condition begins before the surgery, where the fear of pain may cause the patients to feel more pain than reality. Perioperative anxiety and catastrophizing have been used to predict postsurgical pain, as explained by Chow et al. (2020). Pain catastrophizing is closely related to anxiety, and it has been defined by Chow et al. (2020) as the tendency to dwell on the negative associations of pain or to magnify the threat of pain. Therefore, understanding the relationship between pain catastrophizing and postoperative pain should help practitioners determine the surgical methods and strategies to use for specific patients. However, the focus of this review is on how pain catastrophizing affects postoperative pain. As such, a selection of previous studies will be examined in terms of their purpose, approaches, and general conclusions regarding this subject.
Effects of Pain Catastrophizing on Postoperative Pain
Literature on pain catastrophizing is diverse, and multiple studies have yielded different results. A prospective cohort study conducted by Hovik et al. (2016) was aimed at exploring the associations between pain catastrophizing and postoperative pain where the scholars observed no relationship between these variables. The cohort study comprised 71 total knee arthroplasty patients in a period of six months. The pain was measured using a brief pain inventory (BPI), and the pain catastrophizing scale (PCS) was the tool used to measure pain catastrophizing. The quantitative analysis revealed that the association between pain catastrophizing and postoperative pain is inconclusive. Additionally, Hovik et al. (2016) express that their study supports several others that found no association between pain catastrophizing and postsurgical pain. Therefore, it can be argued that this study is one of those where scholars believe that pain catastrophizing has no effect on postoperative pain.
However, some studies find that there is a relationship between pain catastrophizing and postoperative pain. According to Horn et al. (2020), there is a significant relationship between a patient’s catastrophic thinking, and the intensity of pain felt during post-surgery. As a systemic review, the study by Horn et al. (2020) focuses on the previous studies conducted by other researchers, which should help express the differences in findings and opinions regarding the subject. However, the vast majority of the studies explored in their review reveal that patients with pain catastrophizing tendencies recorded higher pain scores after operations. It is difficult to explore the reasoning behind the different outcomes, especially because systematic reviews do not offer ample information regarding the methodologies used. However, the fact that primary data is used in most of the experiments reveals that some scholars prefer to use the lived experiences of the patients. Therefore, it can be argued that the efficacy of the measurements, tools, methods, and approaches can be critically examined to establish whether they are the reason behind the differences in the research outcomes.
As expressed above, many studies have presented evidence of the existence of a positive correlation between pain catastrophizing and postoperative pain. Research by Birch et al. (2019) aimed to explore how pain catastrophizing affects postoperative pain and physical function. A cohort study of patients of knee arthroplasty was conducted where the scholars established that the patients with a PCS score greater than 21 had a higher pain score than those with a PCS less than 11 both before and 4 and 12 months after the operation. Additionally, low physical function was also observed for patients with PCS scores greater than 21, which means that pain catastrophizing has a significant effect on postoperative pain. The study by Birch et al. (2019) is an apparent contrast to that of Hovik et al. (2016) due to the differences in research outcomes despite similar methods, approaches, and measurement tools being used. Therefore, it can be argued that it is unnecessary to explore the differences in methodologies as potential causes of the different research outcomes. The key point is that more studies support the relationship between the variables.
As expressed earlier, pain catastrophizing is among the psychological predictors of postsurgical pain, an observation that has been the basis for psychological pain management practices. A study by Scarone et al. (2020) is founded on the notion that pain catastrophizing is the strongest psychological predictor of acute and chronic pain after surgery and that the modifiable nature of these psychological variables makes it possible to target them for pain interventions. The study by Scarone et al. (2020) is a randomized controlled trial comparing pain outcomes between two cohorts. Adult patients undergoing lumbar fusion surgery are selected for the research, which extends for 12 months. The key measurements include quality of life, pain, depression, and disability. Regarding postoperative pain, the study established that there is a possibility of using cognitive behavioral therapy (CBT) to treat postsurgical pain due to the past that pain catastrophizing is a key predictor of postoperative pain. It is important to appreciate that even the study focused on approving the use of CBT, the association between pain catastrophizing and postoperative pain has been established.
Literature available on pain management after surgeries suggests that CBT is becoming increasingly appreciated as an effective pain management approach. Another randomized controlled trial for patients of lumbar fusion surgery is conducted by Lotzke et al. (2019) to assess how CBT can help developed person-centered prehabilitation programs. Similar to the research by Scarone et al. (2020), this study is founded on the observation that pain catastrophizing significantly affects the pain scores expressed by patients after surgeries. Additionally, similar outcomes are observed in these two studies in that pan catastrophizing also adversely affects physical activity and other aspects of the quality of life. The main contrast in the two experiments is that while Scarone et al. (2020) do not express the findings of their research, Lotzke et al. (2019) find that CBT has clinically important outcomes to postoperative pain experienced by researchers. However, Lotzke et al. (2019) also express that it is not clear what prehabilitation programs are the most effective. Therefore, the fact that CBT has produced positive results indicates that modifying pain catastrophizing is associated with the level of preoperative pain.
Many studies on CBT have proven the hypothesis that pain catastrophizing is a key predictor of postoperative pain. However, a randomized controlled trial by Buvanendran et al. (2021) has hypothesized that there was a significant difference between patient subjected to preoperative CBT and those without such treatment. Additionally, their study proved this hypothesis by showing that the PCS measurements were lower in the CBT-treated group as compared to the control group. CBT has majorly been described as a potential approach to reduce postoperative pain. However, it remains largely an underexplored subject, especially regarding the specific methods and approaches that should be used for patients. In other words, only a general application has been shown across multiple studies reviewed in this paper. It can be argued that the search criteria adopted simply yields materials that address the relationship between pain catastrophizing and postoperative pain. Therefore, it would not be justifiable to criticize the research used without first establishing the presence or absence of specific CBT activities. At this point, it can only be appreciated that all the materials on CBT have illustrated the relationship between catastrophizing and postsurgical pain.
While some scholars find no significant link between pain catastrophizing and postoperative pain, some find that preoperative pain catastrophizing affects the behavioral responses to postoperative pain. Such studies include Coronando et al. (2020), who find that pain catastrophizing and other psychological elements affect how patients interact with and how they respond behaviorally to the pain. Some individuals prefer to avoid the pain, while others prefer to engage in activities that help avert the pain. Additionally, pain catastrophizing affects the self-efficacy in dealing with the pain, which has been used by therapists in the design of pain management programs. A study by Suffeda et al. (2016) supports both positions regarding the effects of pain catastrophizing: that it affects and influences the behavioral responses to postoperative pain, including the consumption of analgesic. As mentioned earlier, pain catastrophizing takes place before surgeries, and the pain perceptions created preoperatively affect the postoperative pain outcomes, as explained by Suffeda et al. (2016). The survey by the researchers has helped reach the general conclusion that such somatic, psychological parameters as pain catastrophizing make it possible to predict patients with a greater risk of postoperative pain.
The psychological nature of pain catastrophizing has also been studied by some scholars. For example, Grosen et al. (2016) explore the possibility of past pain experiences determining the pain scores for a current surgery. Their experimental study gathered data from patients undergoing corrective surgery for funnel chest. The adjusted analysis for preoperative psychological elements, including situational clinical pain catastrophizing yielded a positive correlation between these variables and postoperative pain and unpleasantness. Therefore, it can be proven that pain catastrophizing can be the result of past experiences. This means that if the patient felt pain during surgery, they will show the same sensations in a concurrent operation even where there is no actual pain in the second surgery. However, it is important to acknowledge that the study by Grosen et al. (2016) focuses on early postoperative pain, which means that the same results have not been generalized for persistent and chronic postsurgical pain. However, the basic idea is that the scholars have been able to find a positive correlation between pain catastrophizing and postoperative pain.
Pain management is often concerned with both early and chronic pain. Different approaches can be used for each of these two categories, depending on what the clinicians establish as the predictor of pain. Another study focusing on the early postsurgical pain has been presented by Mimic et al. (2018), who explore the psychological predictors of early postsurgical pain for patients of open nephrectomy. Their research was a prospective observational cohort study comprising 196 patients where the key finding was that pain catastrophizing was the most important predictor of postoperative pain. Additionally, this study can be described as also focusing on the responses to pain, where the scores in the PCS determine such behaviors as analgesic consumption among patients. Therefore, different studies use different or similar approaches and methodologies, and all seem to support the existence of an association between pain catastrophizing and the level of postoperative pain and the behavioral responses.
As expressed earlier, some studies have focused on the behavioral responses to postoperative pain. Among the most notable behaviors include the level of physical activity and intention for pain medication. Additionally, the consumption of pain relievers, most importantly opioids, also reflects how the patients perceive their pain. Therefore, while such studies are aiming to show responses, it can be argued that their basic assumption is that there exists a relationship between pain catastrophizing and postoperative pain. A closer examination of such studies as that conducted by Dunn et al. (2018) reveals that the researchers have based their efforts on previous scholarly work. Additionally, their arguments reveal that they agree with the findings regarding the role of pain catastrophizing in the scores of postsurgical pain. According to Dunn et al. (2018), pain catastrophizing tends to modulate postoperative pain. This observation also supports the position taken by studies on the application of CBT by Scarone et al. (2020) and Lotzke et al. (2019) that pain catastrophizing and other elements help identify high-risk patients. Therefore, there is a consensus by researchers that pain catastrophizing determines several postsurgical outcomes.
The consumption of analgesics and opioids after major surgeries can be described as a behavioral response to pain catastrophizing, while the studies on CBT focus on predicting pain and intervening through therapy, such scholars as Onishi et al. (2018) are concerned with the prediction of opioid use among patients after surgery. The one-time survey conducted across a diverse demographic in the United States has shown a connection between pain catastrophizing and opioid consumption. A vast majority of patients (71%) expected opioid prescription in the pain scenarios studied. Therefore, the scholars could effectively conclude that the patients with higher pain catastrophizing scores had more than three times the probability of expecting opioid subscriptions from the physician. While this study shown the link between pain catastrophizing and opioid expectations, it has not expressed how the same patients consume the drugs after surgery or reveal whether the prescription expectations were matched by the actual prescriptions given. Additionally, the actual behavior in opioid and analgesic consumption is not studied, which means that only an assumption can be made if the efforts to make inferences regarding how patients consume drugs after surgery.
Pain catastrophizing is a phenomenon that can help to illustrate the link between physical and mental wellbeing. Such sentiment has been expressed by Gudmundsson et al. (2021), who illustrate the link between pain catastrophizing and negative post-treatment outcomes, including pain. Pain catastrophizing has been described as a mental condition or a state of mind where patients perceive pain to be greater than it is in reality. The results from a hip clinic and focusing on several types of hip surgeries reveal that the functional levels changed with the levels of pain catastrophizing. Other psychological variables were studied alongside pain catastrophizing, including depression and anxiety. The findings have expressed that mental wellbeing has a direct impact on the physical health of an individual. In this case, the relationship is in terms of both the postoperative pain and other health outcomes, including the physical functioning of the patients.
Surgeries often tend to affect multiple functional outcomes, including physical abilities or disabilities. Another study on functional outcomes has been presented by Miller et al. (2018), whose focus is on children suffering from chronic pain. The meta-analytic review has been founded on the basic idea that theoretical developments have made it possible to measure pain catastrophizing and other health outcomes. However, it is important to acknowledge that review does not involve postoperative pain or any notion of surgery. However, the materials used in the study support the idea that mental wellbeing has a direct impact on physical health. For the children, those recording higher pain catastrophizing scores have been shown to display poor physical health outcomes, including disability poor quality of life.
Hospitalization often follows from surgeries, and the period of hospitalization involves pain management and other clinical support. It is also a period that can be categorized as early postoperative pain. A survey on total knee arthroplasty patients conducted by Lindberg et al. (2016) revealed that those patients recording high preoperative pain intensities also expressed higher postoperative pain. Therefore, hospitalization serves as an excellent research setting involving post-surgical patients. However, the setting and context of the research do not have any influence on how patients respond. The argument is that despite the type of surgery, there is consistency across all studies, which makes it possible to make the relevant generalizations.
Postoperative pain is often classified as one of the major postsurgical outcomes and determinants of the quality of life after surgeries. According to Dismore et al. (2020), pain catastrophizing is associated with all domains of quality of life, including more pain, patient dissatisfaction, and declined physical function. The systematic review focuses on eight previous studies on the subject and the qualitative synthesis supports the position that pain catastrophizing is a useful prognostic indicator for patients with a higher risk of poorer postoperative outcome. Additionally, the results also support the argument that understanding the patients’ tendency to catastrophize pain can help implement measures to improve the postoperative results. The basic idea is that these scholars find that pain catastrophizing affects postsurgical recovery and offer a framework for the development of effective interventions.
Some studies explored so far have presented an argument that pain catastrophizing can be used to develop interventions for improving surgical outcomes. Such arguments, it should be emphasized, are founded on the knowledge that pain catastrophizing devastates postoperative outcomes and its mitigation should have the opposite effects. A scoping review presented by Gibson and Sabo (2018) acknowledged that pain catastrophizing adversely affects postsurgical outcomes. In other words, the researchers stated that high levels of preoperative pain catastrophizing results in higher scores of postoperative pain and poorer overall patient outcomes. Their study seeks to answer the basic question of whether pain catastrophizing can be changed in patients. The answer from the studies explored in the review was that the modifiable nature of this variable makes it possible to change it. Additionally, the review led to the observation some interventions produced better results than others, which should call for additional research focusing primarily on the development of appropriate interventions.
The literature on the relationship between pain catastrophizing and postoperative pain has also been presented in terms of pain prediction. Such scholars as Horn-Hofmann et al. (2018) have explored the pain-specific psychological variables and compared them with the acute postsurgical pain and general psychological variables. The findings from the experiment measurements indicated that it was possible to use psychological factors can be used to predict the outcomes of surgery. Pain catastrophizing was the major variable studied, where the experiment highlighted that those patients with higher preoperative PCS scores also expressed higher postoperative pain intensity and other pain-related disabilities. Therefore, the study support two claims: that pain catastrophizing affects postoperative pain and that pain catastrophizing can be used as a predictor of postoperative outcomes. The only downside of this study and many others with the same focus is that the use of this knowledge in the development of interventions is inadequate. As concluded by Gibson and Sabo (2018), the relevant interventions and their outcomes are a subject for future research. Therefore, the current studies seem to only explore and validate the links between pain catastrophizing and postoperative outcomes.
Even with inadequate focus on the interventions, some researchers have recommended a shift from medical to biopsychosocial approaches. Research by Dismore et al. (2021) expresses that with pain catastrophizing being a key moderator of postoperative outcomes, behavioral interventions should be used to optimize the postsurgical outcomes. these scholars have also acknowledged the lack of focus on the actual interventions by expressing that less is known regarding the experience of surgeons offering the behavioral interventions. A thematic analysis by these researchers sought to evaluate several themes related to postoperative pain. Their findings indicate that the physicians have a hard time establishing how to achieve the best results. However, they also acknowledge that using pain catastrophizing as a predictor of postoperative outcomes is possible. most importantly, the thematic analysis has allowed the researchers to conclude that a screening tool should be developed to aid in the efforts of developing behavioral and psychological interventions. Such a tool should help to identify at-risk patient and potentially the right approaches interventions for different patients.
One of the key observations from many previous studies is that they express the existence of a link between pain catastrophizing and postoperative pain. According to Terrandas-Monllor et al. (2020), many have not specified whether the relationship is causal, which means that this is a question for future research. However, such sentiments do not negate or express doubt regarding the fact that pain catastrophising is associated with greater postoperative pain scores. Indeed, their study also indicated that patients with higher PCS ratings recorded higher pain outcomes after the knee arthroplasty. The prospective, observational, and hypothesis-generating cohort study design used by the researchers may indicate that their main focus was to develop and prove various hypotheses regarding this subject. Findings indicated that there existed a consistency across all follow-up measurements throughout the study regarding pain intensity and other health outcomes. However, it is important to acknowledge that these researchers are justified in expressing the need to establish examine the nature of the relationship between catastrophizing and pain intensity. The rationale for this position is that causal relationships show the root cause of a problem, which makes it easier to address.
Lastly, pain catastrophizing has been associated with the resilience of patients after major surgeries. The argument is that the ability to withstand and persevere through the pain will depend on how patients perceived pain before the operation. Both pre- and postoperative pain catastrophizing studied by Nwankwo et al. (2021) are associated with negative or poor function after surgery. Similar to pain catastrophizing, resilience is a psychological construct that can be defined as the ability of a person to adapt to adversity. Therefore, the patients with higher PCS scores can be categorized as having low resilience. As such, pain catastrophizing reduces the resilience of patients, and it is these resilience levels that determine the rest of the health outcomes, including physical and mental health. While this cohort study shows a positive relationship between pain catastrophizing and postsurgical outcomes, it should be noted that the concept of resilience offers an alternative stream of research. In other words, the factors determining the resilience levels of patients need to be studied and potentially used alongside the CBT literature to help find means of improving resilience as an intervention for postoperative pain.
Conclusion
The purpose of this literature review was to explore how pain catastrophizing affects postoperative pain. A brief description of this concept has been presented, where the definition adopted is that pain catastrophizing involved exaggerating or magnifying the level of pain. Additionally, pain catastrophizing has been described as a mental or psychological state different from reality. The materials reviewed have adopted different mythological approaches, including prospective cohort studies and randomized controlled trials, as well as systematic and meta-analytic reviews. In summary, only one of the studies has failed to express an association between pain catastrophizing and postoperative pain.
Most of the scholarly work has illustrated that pain catastrophizing positively correlated with the level of postoperative pain experienced by the patients. In other words, those patients that perceive the pain to be greater before surgeries will express that they feel more pain after the operation. Additionally, other studies have explored the behavioral responses and physical health outcomes and functions of the patients. The basic conclusion from the materials reviewed is that the mental wellbeing of the patients directly affects physical health, which means that pain catastrophizing affects postoperative physical functioning of the body. Lastly, psychological theories, including CBT, have been used to express that psychological pain management interventions can be developed for patients with higher risks of postoperative pain by assessing their PCS scores.
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