Boys and girls did not differ on reported pain characteristics or memories for pain (all values of P > 0.05).
3.3. Associations between anxiety-related factors and memories for pain
All correlation analyses controlled for the initial pain rating that corresponded to each memory question (ie, when examining memory for pain at rest on the first day after surgery, the NRS-R on the first day after surgery was used; when examining memory for movement-evoked pain on the first day after surgery, the NRS-M on that was used; and when examining memory for pain during the hospital stay, an average of NRS-R or NRS-M on the first 3 days was used). The bivariate correlations between predictors are reported in Table 4.
Table 5 shows the partial correlation coefficients between the psychological measures (pain catastrophizing, anxiety sensitivity, and pain-related anxiety) at T0-T3 and pain recall at 12 months. T0 pain catastrophizing and anxiety sensitivity scores were positively correlated with greater negatively-biased recall of pain at rest during the first day after surgery. T1 pain catastrophizing, anxiety sensitivity, and pain anxiety scores were positively correlated with greater negatively-biased recall of movement-evoked pain. The pattern of significant correlations for T2 and T3 was the same: Higher levels of pain catastrophizing, anxiety sensitivity, and pain anxiety at 6 and 12 months were significantly correlated with greater negatively-biased recall of movement-evoked pain.
Based on the results of the correlation analyses, 4 hierarchical regression models were tested (baseline [model 1], in-hospital recovery [model 2], and 6- and 12-month follow-ups [models 3 and 4]) to examine the predictive value of risk factors on pain memory biases. Initial pain ratings that corresponded to each memory question were entered in the first step of each model followed by the key variables. Results of the regression analyses are summarized in Table 6. Only significant findings are presented.
Additionally, we conducted partial correlational analyses to determine whether age should be included as a covariate in the hierarchical regression models. After controlling for initial pain ratings, the association between age and biases in children's recall of pain intensity at rest during the first day after surgery was not significant, r = −0.001, P > 0.05. Therefore, age was not included as a covariate in model 1. After controlling for initial pain ratings, age was significantly associated with negatively-biased recall for movement-evoked pain intensity in the first days after surgery, r = 0.31, P < 0.01. Therefore, age was included as a covariate in models 2, 3, and 4.
3.4. Baseline predictors of memory biases (model 1)
After controlling for the initial ratings of pain intensity at rest, child anxiety sensitivity at baseline and pain catastrophizing, accounted for a significant amount of variance in children's memory for pain intensity, ΔR2 = 0.039, F(2, 143) = 3.22, P < 0.05. Collectively, the baseline predictor model accounted for 14.1% of the variance in recalled pain levels, F(3, 143) = 7.81, P < 0.001.
3.5. In hospital predictors of memory biases (model 2)
After controlling for initial ratings of movement-evoked pain intensity in the first 3 days after surgery and age, anxiety sensitivity, pain catastrophizing, and pain-related anxiety accounted for a significant amount of variance in children's pain recall of pain intensity during the first day after surgery. Together, the predictors accounted for 8.4% of the variance above and beyond the initial pain ratings and age, F(3, 92) = 3.17, P < 0.05. Collectively, the predictors accounted for 18.2% of the variance in recalled pain levels, F(5, 92) = 4.09, P < 0.05.
3.5.1. Six-month follow-up predictors of memory biases (model 3)
After controlling for initial ratings of pain intensity during movement, anxiety sensitivity, pain catastrophizing, and pain anxiety accounted for a significant amount of variance in children's recall of pain intensity, ΔR2 = 0.078, F(3, 95) = 2.76, P < 0.05. Collectively, the predictors accounted for 10.3% of the variance in recalled pain levels, F(4, 95) = 2.71, P < 0.05. However, after including age as a covariate, the set of predictors no longer accounted for a significant amount of variance. Specifically, in model 3 (6-month follow-up predictors of memory biases), the set of predictors accounted for 5.8% of variance in children's recall of pain intensity during the first days after surgery, above and beyond initial pain ratings and age, ΔR2 = 0.058, F(3, 93) = 2.19, P > 0.05. Collectively, the predictors accounted for 18.2% of the variance in recalled pain levels, F(5, 93) = 4.14, P < 0.05.
3.5.2. Twelve-month follow-up predictors of memory biases (model 4)
Finally, after controlling for initial ratings of pain intensity during movement, anxiety sensitivity, pain catastrophizing, and pain anxiety did not account for a significant amount of variance in children's recall of pain intensity, ΔR2 = 0.064, F(3, 100) = 2.33, P > 0.05. Collectively, the predictors accounted for 8.6% of the variance in recalled pain levels, F(4, 100) = 2.34, P > 0.05. However, after including age as a covariate, the set of predictors no longer accounted for a significant amount of variance. Specifically, in model 4 (12-month follow-up predictors of memory biases), the set of predictors accounted for 4.4% of variance in children's recall of pain intensity during the first days after surgery, above and beyond initial pain ratings and age, ΔR2 = 0.044, F(3, 96) = 1.66, P > 0.05. The overall model accounted for 15.9% of the variance in recalled pain levels, F(5, 96) = 3.62, P < 0.05.
3.6. Dominance analyses for models 1 and 2
To examine distinct contributions of individual predictors (anxiety sensitivity, pain catastrophizing, and pain anxiety) to biases in children's recall of pain, we conducted dominance analyses.5
3.6.1. Baseline predictors of memory biases (model 1)
In total, anxiety sensitivity and pain catastrophizing accounted for 3.9% of variance in children's memory for pain intensity, above and beyond initial pain ratings, F(2, 143) = 3.22, P < 0.05. Of the 3.9%, anxiety sensitivity accounted for 55.7% (2.2% of total variance) and pain catastrophizing accounted for 44.3% (1.7% of total variance).
3.6.2. In hospital predictors of memory biases (model 2)
In total, anxiety sensitivity, pain catastrophizing, and pain anxiety accounted for 8.5% in children's recall of pain intensity during the first days after surgery, above and beyond initial pain ratings and age, F(3, 92) = 3.17, P < 0.05. Of the 8.5%, pain catastrophizing accounted for 70.1% (5.9% of total variance), pain anxiety accounted for 16.1% (1.4% of total variance), and anxiety sensitivity accounted for 13.9% (1.2% of total variance).
3.7. Association of memories for pain with CPSP
A series of bivariate partial correlations revealed significant associations between greater negatively-biased recall of pain and postsurgical pain at 6 and 12 months. Specifically, at the 6-month follow-up, youth who at the 12-month follow-up were to report greater negatively-biased recall of in-hospital movement-evoked pain had higher levels of pain at rest at the surgical site over the past week (r = 0.27, P = 0.008). At 12 months after surgery, adolescents' report of higher pain levels at the surgical site over the past week were significantly related to greater negatively-biased recall of first day in-hospital movement-evoked pain and pain at-rest (r = 0.17, P = 0.032, r = 0.19, P = 0.020, respectively).
This study was the first to examine the relationship between anxiety-related risk factors for children's pain memory development 1 year after major surgery. It also examined anxiety-related risk factors for long-term pain memory biases at multiple time points before and after the inciting painful event. Findings revealed that baseline anxiety sensitivity, pain anxiety, and pain catastrophizing predicted negative biases in children's recall of pain intensity at rest. Moreover, these anxiety constructs assessed in-hospital at 48 to 72 hours after surgery significantly predicted biases in recall for movement-evoked pain 1 year later. Dominance analyses to determine the relative strength/superiority of predictors revealed that at baseline, anxiety sensitivity and pain catastrophizing were equally predictive of children's recall. However, at 48 to 72 hours after surgery, pain catastrophizing was the strongest predictor of pain memory biases. Children who developed greater negatively-biased recall of pain reported higher pain scores at 6 and 12 months post surgery. Thus, the results of this study also show that postsurgical pain intensity at 6 months is a risk factor for later pain memory distortion.
This study provides empirical support for the model of acute pain memory development that posits general (anxiety sensitivity) and pain-specific (pain catastrophizing and pain anxiety) anxiety are linked to greater exaggerations in recall of pain. Previous research on postsurgical pain memories has exclusively focused on baseline predictors of memory biases 2 to 4 months later.28 Contrary to this past research, pain catastrophizing (in addition to pain anxiety and anxiety sensitivity) was predictive of children's recall of the sensory but not the affective dimension of pain. To date, research on children's memories for pain in the context of surgery has not differentiated between movement-evoked pain and pain at rest nor assessed recall at 1 year. These findings support differentiated assessment of experienced and recalled pain at rest vs at movement, particularly in the acute recovery phase. Moreover, different relationships have been found between anxiety-related factors and memory for the sensory vs affective aspects of pain.26 This further supports the importance of assessing memory for pain in a comprehensive way as initially argued Ornstein et al.30 Moreover, it was catastrophic thinking about pain that occurred while in the first 48 to 72 hours after surgery that was the most powerful predictor of negative biases in children's memory, and specifically their recall of movement-evoked pain. It has been argued that a new baseline for pain intensity may develop in the first few days after the surgery due to a new experience of intense pain sensation (ie, postsurgical pain).16
Catastrophic thinking about pain before surgery may not adequately reflect catastrophic cognitions that youth develop after surgery.16 Memory in this study was assessed at 1 year after surgery, which is much later than previous research that used time frames of 2 to 4 months after surgery.27,28 It could be that catastrophic thinking immediately after (vs before) surgery has a particularly lasting impact on memory for pain because the new pain catastrophizing baseline represents a salient negative cognitive and emotional experience that contributes to memory distortion and bias. Indeed, pain catastrophizing assessed within 48 to 72 hours after surgery was significantly higher than pain catastrophizing at any other time point. Moreover, the pain catastrophizing scale does not specify a pain incident to focus on, and the surgery type was novel for the vast majority of children. Thus, it is likely that assessment of pain catastrophizing that occurred immediately after (vs before) surgery reflected children's catastrophic thoughts specifically about this surgery, just as the memory questions tapped pain associated with surgery, which could explain this finding.
Past research probed memories for postsurgical pain experienced in the first several weeks after surgery (after hospital discharge28), whereas the present study probed memory for pain experienced both at rest and during movement in the first few days while in hospital (ie, when pain is arguably most severe, particularly when moving). Indeed, peak effects have been shown to create biases in recalled pain.39 The pain memories assessed, while both specific to the postsurgical pain experience, are likely capturing different aspects of the broader postsurgical pain experience, thus explaining differences in their relationship to individual risk factors.
At baseline, anxiety sensitivity and pain catastrophizing were equally predictive of children's recall of pain intensity at 1-year follow-up. Anxiety sensitivity is a transdiagnostic risk factor that reflects the tendency to fear the symptoms of anxiety because of beliefs they have harmful cognitive, social, and physical consequences.44 Although the construct does not pertain specifically to the experience of pain itself, it is believed to be intricately tied to the pain experience29 and the development and maintenance of pain problems in children1 and adults.2 As a shared vulnerability risk factor for both anxiety disorders and pain problems, anxiety sensitivity is posited to heighten internal awareness to physical sensations to both threat and pain, which can fuel catastrophic thinking, attentional biases favouring threat, and avoidance.2 In youth with chronic headaches, higher anxiety sensitivity is linked to greater somatization and fear of pain, which drives avoidance.6 The cognitive interruption caused by the experience of pain and being highly anxiety sensitive may impede memory encoding, storage, and retrieval.23 Because of an excessive attentional focus on bodily sensations, anxiety sensitivity may lead to more postevent cognitive processing and rumination that may interfere with memory consolidation and introduce biases in recall. Only one study revealed that higher anxiety sensitivity led to children developing greater negatively-biased recall of pain 2 weeks after exposure to an experimental pain task.22 Core differences in experimental and clinical pain contexts (eg, uncontrollability and unpredictability) require extension of this work to clinical samples,19 which this study achieved.
This study adopted an intrapersonal focus on the influence of child anxiety-related factors on the development of biased pain memories. Recent research with younger children undergoing tonsillectomies revealed that it was parents' (and not children's) baseline anxiety that predicted biases in children's recall of pain-related fear 1 month after surgery.11 Differences across these studies could be due to several factors. First, this study examined older children and adolescents undergoing major, invasive surgeries, whereas the other study examined young (5- to 7-year-old) children undergoing tonsillectomies. These age and developmental differences are important given that children's pain memory development is under the influence of different cognitive and social influences across child and adolescent development. Specifically, the developmental model of children's pain memory development specifically isolates the period of early childhood as being a time when parental influences are greatest on children's pain memory development.25 This may account for the primary influence of parental (vs child) anxiety on young (5- to 7-year-old) children's pain memory development in the context of tonsillectomies. When shifting to the later developmental period of adolescence, parental influences become less predictive of longer term pain outcomes (beyond the acute recovery phase).27 Beyond developmental stage and age, we also note that there are important differences in pain trajectories between these 2 surgical contexts. Tonsillectomy is a surgery that involves acute pain in the first week after surgery that almost always resolves by the second week. This is not the case for more major surgeries such as spinal fusion, pectus repair, and a variety of orthopedic surgeries that are characterized by high levels of moderate-to-severe pain that often last for months and unfortunately, for approximately 22% of youth, leads to the development of persistent pain.33 Puberty is also a time when rates of pediatric chronic pain peak17; therefore, examining these types of surgeries in adolescence is an important context to understand the development of pain problems. These problems are not observed among young children undergoing tonsillectomies. Pain is a key predictor of memory for pain15,21,27,28; therefore, these differences in pain trajectories are important for understanding different findings across pain and developmental contexts.
There were limitations to this study. Pain memories were assessed at a single time point 1 year after surgery. Thus, it is unknown whether memories for pain became more or less biased for some children and how memories at 1 year compared with memories assessed at 2 to 4 months as has been performed in previous research. Moreover, consistent with previous research,21,27,28 this study assessed memories using single-item pain scales. Future research should expand memory assessment to include free recall (eg, open-ended questions that pull for a spontaneous account of the past) and probed recall (single-item pain items) to provide a richer account of children's memories.25 Furthermore, important anxiety-related constructs, such as fear of pain, that are closely associated with anxiety sensitivity and the pain experience6 were not assessed in the present study. Finally, it could be argued that the negatively-biased recall of pain observed in the present study is not really a bias at all and instead is an accurate representation of the initial, in-hospital pain experience. It is well-established that postsurgical pain intensity fluctuates within and across days. Since pain was assessed only once per day, it is possible that the participants' recalled pain was significantly higher than the specific measure of pain assessed, not because of a bias but because participants were accurately recalling the pain intensity from a different time of day. This is a difficult argument to refute empirically without a continuous record of in-hospital pain, which clearly is not possible to obtain. To address this argument, pain recall was compared with a variety of pain scores for each pain measure (intensity, movement-evoked, and unpleasantness), including pain on day 1 as well as average and peak pain scores across the first 3 days in-hospital. Recalled pain was significantly higher than all in-hospital pain scores obtained, including peak pain, arguing in favour of the interpretation that pain recall scores reflect a memory bias and not an accurate representation of the initial pain experience.
This study exclusively focused on anxiety-related constructs based on conceptual models of acute pain memory development23; however, there are other factors that were not assessed in the study that likely play an influential role. Indeed, postevent processing (ie, language-based interactions about the past pain painful event after the fact) have been shown to be critically important in shaping children's memories of needle pain24 and should be examined in future research in the surgical context. In addition, we were unable to obtain in-hospital pain ratings from youth who were admitted to the ICU because of hospital and REB protocols. There could be key differences in the experiences of youth who were vs who were not admitted to the ICU, which could influence children's pain memory development. One key factor could be medical trauma, experienced by both parents and youth (which could affect memory encoding and retrieval), as well as consciousness of youth (which could affect memory encoding). This is an interesting area for future research. In addition, there was considerable heterogeneity in the sample in terms of the types of surgeries performed, and this could be conceived of as a limitation. On the other hand, based on the past several decades of research on memory for pain (see reviews in Refs. 23, 26, 30, 45) as well as empirical research with pediatric18,23,38 and adult samples,14 the relationship between negative affect/anxiety and biased recall of pain is robust and found across ages, healthy and illness populations, and clinical and experimental pain contexts. Past research linking catastrophic thinking about pain to biased recall included different types of surgery (eg, pectus repair and spinal fusion).28 Thus, extending these findings to a much larger, heterogeneous sample of youth undergoing a variety of surgeries is important as it speaks to the robustness of this relationship. Finally, in-hospital pain ratings were collected between 48 and 72 hours after surgery. This time frame could be considered a limitation.
Memories for pain are by their nature, susceptible to distortion, and highly malleable.26 Previous trials of brief memory reframing interventions to provide children with postevent information (eg, emphasizing positive details, correcting negative exaggerations, and promoting self-efficacy) following needle procedures were found to lead to more accurate/positive pain memories.4,7,35 Modification of risk factors for distortions in pain memories is another avenue for intervention. The present findings suggest that interventions that reduce levels of anxiety, and particularly anxiety sensitivity and pain catastrophizing at baseline and pain catastrophizing during the in-hospital acute recovery phase, may buffer children against the development of negatively-biased pain memories 1 year later. From a treatment perspective, the general approach of reducing anxiety sensitivity, pain anxiety, and catastrophic thinking about pain could involve a similar cognitive-behavioral approach. Interventions to reduce anxiety sensitivity and anxiety related to pain sensations have been developed, albeit for use with adults, and involve cognitive behavioral therapy, psychoeducation, cognitive restructuring, and interoceptive exposure.47 Adaptations in these brief interventions could be a fruitful area for preoperative and postoperative interventions for youth. Similar cognitive-behavioral interventions aimed reducing catastrophic thinking about pain in the immediate acute recovery phase while in hospital could also be protective. With accumulating evidence for the maladaptive effects of anxiety on postsurgical pain trajectories36 and pain memories,28 this line of research could inform how to prevent chronic postsurgical pain.
In summary, this prospective study examined the role of anxiety-related factors, assessed at multiple time points over the course of a year, in children's memories of postsurgical pain 1 year after surgery. Findings revealed that children who had higher levels of anxiety at baseline and 48 to 72 hours after surgery developed greater negatively-biased recall of pain intensity 12 months after surgery. Specifically, higher anxiety sensitivity at baseline and greater tendencies to catastrophize about pain at baseline and in the immediate acute recovery phase in hospital were most strongly linked to greater negatively-biased recall of pain. Greater negatively-biased recall of pain was related to higher pain at 6 and 12 months after surgery. These findings provide empirical support for conceptual models of anxiety and pain memory biases and can inform intervention efforts to reduce anxiety in the pre- and post-op periods to foster more accurate and positive pain memories. Given the robust role of pain memories in subsequent pain experiences26 and the development of chronic pain,12 this could inform how to foster more optimal pain trajectories in childhood and beyond.
Conflict of interest statement
The authors have no conflict of interest to declare.
The authors thank Shima Razavi, Kerime Arisan, Arly Sutton, Kelly Chin, and Meghan Rossi for their assistance with this study. Melanie Noel is supported by the Vi Riddell Pain Research Initiative and the Alberta Children's Hospital Research Institute. Joel Katz is supported by a Canadian Institutes of Health Research (CIHR) Canada Research Chair in Health Psychology at York University.
M. Pavlova is supported by an Alberta Strategy for Patient Oriented Research Graduate Studentship. B. Rosenbloom is supported by a CIHR CGS Doctoral Award in Honor of Nelson Mandala. M. G. Pagé was supported by a CIHR Frederick Banting and Charles Best CGS Doctoral Award. The research reported herein was supported by operating grant FRN-102700 from the CIHR Institute of Neurosciences, Mental Health and Addiction.
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Keywords:© 2019 International Association for the Study of Pain
Pain; Surgery; Memory; Anxiety; Adolescents; Children