Neuropathic pain is caused by a lesion or disease of the somatosensory system, including peripheral fibres (Aβ, Aδ and C fibres) and central neurons, and affects 7–10% of the general population. Multiple causes of neuropathic pain have been described and its incidence is likely to increase owing to the ageing global population, increased incidence of diabetes mellitus and improved survival from cancer after chemotherapy. Indeed, imbalances between excitatory and inhibitory somatosensory signalling, alterations in ion channels and variability in the way that pain messages are modulated in the central nervous system all have been implicated in neuropathic pain. The burden of chronic neuropathic pain seems to be related to the complexity of neuropathic symptoms, poor outcomes and difficult treatment decisions. Importantly, quality of life is impaired in patients with neuropathic pain owing to increased drug prescriptions and visits to health care providers, as well as the morbidity from the pain itself and the inciting disease. Despite challenges, progress in the understanding of the pathophysiology of neuropathic pain is spurring the development of new diagnostic procedures and personalized interventions, which emphasize the need for a multidisciplinary approach to the management of neuropathic pain.

Pain interrupts and demands attention. The authors review evidence for how and why this interruption of attention is achieved. The interruptive function of pain depends on the relationship between pain-related characteristics (e.g., the threat value of pain) and the characteristics of the environmental demands (e.g., emotional arousal). A model of the interruptive function of pain is developed that holds that pain is selected for action from within complex affective and motivational environments to urge escape. The implications of this model for research and therapy are outlined with an emphasis on the redefinition of chronic pain as chronic interruption.

Acceptance of chronic pain entails that an individual reduce unsuccessful attempts to avoid or control pain and focus instead on participation in valued activities and the pursuit of personally relevant goals. Recent research suggests that pain-related acceptance leads to enhanced emotional and physical functioning in chronic pain patients above and beyond the influence of depression, pain intensity, and coping. In these studies, acceptance was measured using the Chronic Pain Acceptance Questionnaire (CPAQ). Preliminary analyses of the CPAQ have supported its psychometric properties. The present study sought to further refine the CPAQ by examining its factor structure and evaluating the relations of these factors to other indices of pain-related distress and disability. Although a previously demonstrated factor structure of the CPAQ was generally supported, only factors assessing (a) the degree to which one engaged in life activities regardless of the pain and (b) willingness to experience pain had adequate reliability and validity and were significantly related to the other measures of patient functioning. A revised version of the CPAQ is suggested. q

A computer and a hand search of the literature recovered 33 papers from which 25 trials suitable for meta-analysis were identified. We compared the effectiveness of cognitive-behavioural treatments with the waiting list control and alternative treatment control conditions. There was a great diversity of measurements which we grouped into domains representing major facets of pain. Effect sizes, corrected for measurement unreliability, were estimated for each domain. When compared with the waiting list control conditions cognitive-behavioural treatments were associated with significant effect sizes on all domains of measurement (median effect size across domains = 0.5). Comparison with alternative active treatments revealed that cognitive-behavioural treatments produced significantly greater changes for the domains of pain experience, cognitive coping and appraisal (positive coping measures), and reduced behavioural expression of pain. Differences on the following domains were not significant; mood/affect (depression and other, non-depression, measures), cognitive coping and appraisal (negative, e.g. catastrophization), and social role functioning. We conclude that active psychological treatments based on the principle of cognitive behavioural therapy are effective. We discuss the results with reference to the complexity and quality of the trials.

Objective: The fear-avoidance (FA) model of chronic pain describes how individuals experiencing acute pain may become trapped into a vicious circle of chronic disability and suffering. We propose to extend the FA model by adopting a motivational perspective on chronic pain and disability. Methods: A narrative reviewResults: There is ample evidence to support the validity of the FA model as originally formulated. There are, however, some key challenges that call for a next generation of the FA model. First, the FA model has its roots in psychopathology, and investigators will have to find a way to account for findings that do not easily fit within such framework. Second, the FA model needs to address the dynamics and complexities of disability and functional recovery. Third, the FA model should incorporate the idea that pain-related fear and avoidance occurs in a context of multiple and often competing personal goals. Discussion:To address these three key challenges, we argue that the next generation of the FA model needs to more explicitly adopt a motivational perspective, one that is built around the organizing powers of goals and self-regulatory processes.Using this framework, the FA model is recast as capturing the persistent but futile attempts to solve pain-related problems in order to protect and restore life goals.

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Benefits of CBT emerged almost entirely from comparisons with treatment as usual/waiting list, not with active controls. CBT but not behaviour therapy has weak effects in improving pain, but only immediately post-treatment and when compared with treatment as usual/waiting list. CBT but not behaviour therapy has small effects on disability associated with chronic pain, with some maintenance at six months. CBT is effective in altering mood and catastrophising outcomes, when compared with treatment as usual/waiting list, with some evidence that this is maintained at six months. Behaviour therapy has no effects on mood, but showed an effect on catastrophising immediately post-treatment. CBT is a useful approach to the management of chronic pain. There is no need for more general RCTs reporting group means: rather, different types of studies and analyses are needed to identify which components of CBT work for which type of patient on which outcome/s, and to try to understand why.

Catastrophizing about pain has emerged as a critical variable in how we understand adjustment to pain in both adults and children. In children, however, current methods of measuring catastrophizing about pain rely on brief subscales of larger coping inventories. Therefore, we adapted the Pain Catastrophizing Scale (Sullivan et al., 1995) for use in children, and investigated its construct and predictive validity in two studies. Study 1 revealed that in a community sample (400 boys, 414 girls; age range between 8 years 9 months and 16 years 5 months) the Pain Catastrophizing Scale for Children (PCS-C) assesses the independent but strongly related dimensions of rumination, magnification and helplessness that are subsumed under the higher-order construct of pain catastrophizing. This three factor structure is invariant across age groups and gender. Study 2 revealed in a clinical sample of children with chronic or recurrent pain (23 girls, 20 boys; age range between 8 years 3 months and 16 years 6 months) that catastrophizing about pain had a unique contribution in predicting pain intensity beyond gender and age, and in predicting disability, beyond gender, age and pain intensity. The function of pain catastrophizing is discussed in terms of the facilitation of escape from pain, and of the communication of distress to significant others.