Purpose: The Avoidance-Endurance Model postulates fear-avoidance responses and endurance responses as important psychological mechanisms in the development and maintenance of chronic pain. The present study aims to investigate potential differences in avoidance and endurance responses to pain before and with advanced chronification. Patients and Methods: Two samples of adults with non-cancer pain at two different stages of chronicity were compared: One with pain and risk factors for chronicity (n=26, part of the PAIN2020 project) and one with chronic pain (n=33 from a pain day care clinic). The German Pain Questionnaire, the Graded Chronic Pain Scale (GCPS) and medical reports were used to measure duration and severity of pain. Responses to pain were assessed with the Avoidance-Endurance Questionnaire (AEQ) and psychological strain with the Depression, Anxiety and Stress Scales (DASS). Results: Both groups were primarily affected by musculoskeletal pain. Although not yet chronified, the risk group reported comparable GCPS levels of pain intensity and disability. Depression and stress ratings were also similar, except for anxiety, which was significantly elevated in the chronic pain sample (p< .001). The AEQ scales did not differ between groups, neither on any of the fear-avoidance- nor endurance-related dimensions. A post-hoc regression analysis revealed a significant prediction of fear-avoidance by pain-related disability (p< .001). The regression model for endurance responses was not significant. Conclusion: Patients with risk factors of chronification experience substantial pain-related burden. Responses to pain in the realm of the Avoidance-Endurance model do not appear to vary as a function of chronification. While fear-avoidance and pain-related disability correlate positively, endurance could not be associated to any of our variables.

Introduction: Complex regional pain syndrome (CRPS) is a rare complication after limb injuries. Early recognition of the symptomatology and interdisciplinary interventions are essential to prevent long-term disability and pain. Objective: This article presents results on the incidence of CRPS after surgery in Germany and treatments used by patients with CRPS, using claims data from the BARMER, a German nationwide health care insurance. Methods: A total of N = 85,862 BARMER patients with inpatient surgery on the upper or lower limb in 2018 were included. Patients with CRPS were identified by documented International Statistical Classification of Diseases and Related Health Problems -10 diagnosis within 12 months after surgery. For the same period, medication and nonpharmaceutical therapies for inpatient and outpatient care were assessed. Results: The overall incidence of CRPS within 12 months after surgery was 0.34%. With 0.60%, the incidence of CRPS after surgeries of the upper limb was 3 times higher than after lower-limb surgeries (0.20%). Women were more frequently affected, and most patients were between 50 and 70 years old. About 80% to 90% of patients with CRPS received physiotherapy and nonopioid pain medication within 12 months after surgery. Approximately 40% to 50% were treated with opioids and/or antineuropathic medication. Cortisone, bisphosphonates, pain therapy, and occupational therapy were rarely claimed. Conclusion: We found a low incidence of CRPS after various types of surgeries. Although previous research has focused on distal radius fractures and ankle surgery, our data suggest that clinicians should be aware of CRPS after other types of surgeries as well. Real-world treatment of CRPS does not reflect recommendations in clinical practice guidelines.

Chronic postsurgical inguinal pain (CPIP) is the most common complication of groin hernia surgery. The characteristics of patients, their medical care, and choice of diagnostic tools remain to be defined to optimise preventive and therapeutic interventions. Claims data from 2018 and a 1-yr follow-up were analysed for incidence and medical care. A separate cohort (141 healthy controls and 17 CPIP patients) was examined by deep phenotyping. This included sensory testing, blood and skin biopsies, MRI of the dorsal root ganglion (DRG), and patient-reported outcomes. Of 11,221 patients with hernia surgery in 2018 identified, 8.5% had pain before that was relieved by surgery, but a similar percentage had novel pain in this region. Deep phenotyping of 141 healthy controls provided a map of the inguinal sensory system. The following analysis of patients with CPIP revealed that they suffered from moderate pain with neuropathic features, individual sensory abnormalities, and unilateral L1 DRG atrophy. In the blood, levels of C-C-motif chemokine ligand (CCL2) and brain-derived neurotrophic factor (BDNF) were upregulated, whereas apolipoprotein A1 (ApoA1) concentration was reduced. A cluster of DRG atrophy, BDNF, ApoA1, and anxiety correlated best with the diagnosis. CPIP patients with novel pain had significantly more DRG atrophy (-24% ipsilateral vs contralateral volume). CPIP is often newly acquired after surgery. A combination of DRG imaging, serum markers, and anxiety screening can support the diagnosis. In the future, this could guide clinicians towards more personalised therapies (e.g. targeting anxiety or lipid profiles) and possible altered surgical techniques. German Trial Registry DRKS00024588 and DRKS00016790.

Background: Research on the role of social support in the context of acute pain is lacking, although a possible correlation between social support and acute pain might imply consequences for clinical practice. We expected perceived social support to predict the intensity of acute postsurgical pain and the dose of opioids given. Methods: Within a multicentre prospective observational study, n = 217 adult patients undergoing major surgery were recruited at the University Hospital of Würzburg with an additional questionnaire for assessing perceived social support using the Multidimensional Scale of Perceived Social Support (MSPSS). We also measured pre‐operative pain, opioid intake and psychological factors, such as depressiveness or pain catastrophising. Main outcomes were pain intensities at rest and at movement, and morphine equivalent on Day 1 and Day 7 after surgery. Results: Perceived social support was higher in general than expected from previous studies and depended on marital status. Certain socio‐demographic characteristics, pre‐operative chronic pain and depressive symptoms also correlated with perceived social support. Using multiple linear regression, we could confirm known risk factors for high intensity acute postsurgical pain, for example, younger age and pre‐operative pain. Perceived social support, however, was not a significant predictor of neither postsurgical pain intensity nor postsurgical opioid requirements. Conclusions: Perceived social support measured by MSPSS does not add to the prediction of acute postsurgical pain in our study. Acute pain might be influenced more strongly by biological and psychological factors than social factors. More fine‐grained measures might be necessary to record, for example, daily social support. Significance: Although social interactions are known to influence pain perception, studies on the role of social support on post‐operative acute pain are lacking. In a broad spectrum of surgeries, we found that perceived social support was positively related to pre‐operative health measures, for example, lower average pain intensity over the past 3 months or lower morphine equivalent and opioid intake before surgery. Perceived social support, however, was not a significant predictor of neither postsurgical pain intensity nor postsurgical opioid requirements.

Background: Insomnia disorder in childhood and adolescence has severe implications on overall well-being and development. Age-specific treatments for insomnia disorder with cognitive behavioral interventions (CBT-I) are available and effective. Nightmare disorder also has severe consequences in children and adolescents. However, less is known about children with insomnia (I) and comorbid nightmare disorder (I + N). Methods: In this retrospective study, data from 499 children and adolescents with insomnia disorder were included. The prevalence of a comorbid nightmare disorder (I + N) was calculated within three subsamples (toddlers and preschoolers 0.5–4 years, elementary school children 5–10 years, and adolescents 11–18 years). Differences between children with insomnia (I) and those with additional nightmare disorder (I + N) regarding age, sex, family background, sleep quality (SOL, WASO, TST, and SE) based on sleep logs, behavior sleep problems (based on interviews), and behavioral problems (CBCL and YSR) were calculated within each age group. Results: The overall prevalence of additional nightmares or nightmare disorder in children or adolescents with insomnia was 15–24%. We found various clinically relevant differences between I and I + N for each age group; for example, there were more sleep onset association problems in I + N elementary school children, prolonged SOL of 56 min, and about 50 min less TST and SE of 76.8% in I + N adolescents. However, most statistical tests were not significant. Especially sleep parameters but also emotional burden were more pronounced in I + N groups than in the I groups. Toddlers and preschoolers with I + N were significantly older than those with only I, had another family situation (e.g., divorced parents) significantly more often, and I + N adolescents were statistically more often anxious and depressed. Discussion: Descriptively, I + N children and adolescents seemed to be more impaired than those with insomnia only. However, a comorbid nightmare disorder cannot be recognized by insomnia-specific sleep parameters. Therefore, diagnostic procedures for insomnia should always screen for nightmares but also other sleep disorders. If necessary, CBT-I should be supplemented with nightmare-specific interventions.

Background: Sleep problems are common in infancy, childhood, and adolescence, affecting up to 30% of individuals. Parents often seek help for such problems, for example by consulting their pediatrician. In addition to child and adolescent psychotherapists and specialists in sleep centers educated in classical cognitive behavioral therapy (CBT), treatments are also offered by sleep coaches on the internet. However, the quality and content of these offers remain unclear. Methods: In this study, the websites of 153 pediatric sleep coaches in Germany, Austria, and Switzerland were screened with regard to aspects such as educational background, training, sleep-related services, screening and diagnostics, and types of treatment for sleep disturbances offered as well as regarding media presence. All authors were involved in this process. Results: Of the 153 pediatric sleep coaches, 25.5% had a medical or psychological background, 7.3% a health-related background, 23.5% a pedagogical background, and 13.1% had other backgrounds; 35.9% offered no information about their background. Whereas 72.5% of the sleep coaches reported having participated in a sleep coach training, 27.5% did not mention any form of sleep-treatment education; 63.4% mentioned no sleep certification, but 32.7% reported some kind of certification. Coaches with a medical or health-related background were less likely to have participated in a sleep training. The addressed sleep problems were mostly related to insomnia. The target group was most often babies. As a screening or diagnostic procedure, only the sleep log was mentioned. Most sleep coaches offered single sessions. Costs for sessions ranged from 20 up to 199 €. A huge number of pediatric sleep coaches were active on social media. Conclusion: This study provides a critical overview of pediatric sleep coaches in German-speaking countries. We hope that these preliminary observations will inspire additional research and discussion on this important topic, e.g., on educational processes or networking structures, as has been mentioned in the stepped-care model for childhood insomnia.