Cortisol Awakening Response and Pain-Related Fear-Avoidance Versus Endurance in Patients Six Months After Lumbar Disc Surgery

Abstract

Recent research indicates that stress-induced, prolonged deviations in basal adrenocortical activity might contribute to ongoing/recurrent pain following lumbar disc surgery. Further, fear-avoidance and endurance responses to pain (FAR and ER) are regarded as important risk factors for pain after surgery. In patients with non-specific low back pain, FAR appear to possibly increase pain-related arousal, whereas ER may have an arousal-lowering effect, indicated by adrenocortical activity. The current study explores the relationship between basal adrenocortical activity and FAR and ER. Thirty-six patients 6 months after lumbar disc surgery participated. Basal adrenocortical activity was assessed through the cortisol awakening response (CAR), using salivary samples collected on two consecutive days. FAR and ER were estimated using questionnaires. While the ER variables pain-persistence behavior and positive mood despite pain showed negative associations with the CAR, the FAR variables fear-avoidance beliefs and avoidance of social activity were positively correlated with it. Additionally, higher CAR levels were found in patients with high versus patients with low fear-avoidance beliefs and, conversely, in patients with low versus high positive mood and pain persistence. These results indicate that FAR may increase the individuals' level of pain-related stress among patients after disc surgery, while ER may lower it.

Risk Factors for Postoperative Pain Intensity in Patients Undergoing Lumbar Disc Surgery: A Systematic Review

“…Moreover, persisting pain after surgery may be due to an association between psychological factors and pain that was already existent before surgery. Therefore, various authors suggested to introduce psychological screenings to identify patients at risk for pain chronification [15,36,38,39,42,48] and expand preventative approaches [55], as well as psychological interventions, in addition to routine surgical treatment [21,22,38,39,42,48]. A strong association between coping behavior and depressive symptoms was found by three independent studies [39,41,48].…”

Physiological Stress Response Based on Salivary α-Amylase Activity and Secretory Immunoglobulin A Levels in Female Care Workers and General Workers

“…Although there are various kinds of substances indicating a physiological stress response, the s-IgA and α-amylase activity in the saliva have been used in many studies as useful indicators of physiological stress because they can be easily collected and impose little burden on subjects [13,[15][16][17]23,29]. The s-IgA in saliva is an indicator of the level of activity of the sympathetic nervous system, parasympathetic nervous system and immune system.…”

“…Different from blood, collection of saliva to investigate physiological stress can be performed non-invasively, without causing pain or burden to the subjects and by non-medical people; hence, many studies have been performed using saliva [15][16][17][18][19][20].…”

Early multimodal rehabilitation following lumbar disc surgery: a randomised clinical trial comparing the effects of two exercise programmes on clinical outcome and lumbar multifidus muscle function

“…After lumbar discectomy, patients express little understanding of the surgical procedure, confusion regarding activity limitations and develop a fear of movement and reinjury 41. Elevated fear-avoidance responses following lumbar disc surgery are associated with higher pain-related stress42 and worse clinical outcomes 43. It has been suggested that high-intensity postdiscectomy exercise programmes allow patients to confront their fears and insecurities and that this process may in part explain the effect of postoperative exercise programmes 44.…”