Phenomics and Genomics of Clinically Relevant Chronic Postsurgical Pain

Study Overview
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Brief Summary
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The investigators will approach elective cardiac and thoracic surgery patients in the preoperative consultation clinic. Consenting individuals will be administered, before surgery validated pain, psychological and sleep questionnaires. These questionnaires will be repeated at 3, 6 and 12 months postoperatively (PO) to follow up the progression of early PO pain and the transition to chronicity. Participants will define clinically relevant pain by calculating a chronic pain index (CPI). In addition, the investigators will follow the development of acute postsurgical and chronic pain from before surgery up to a year after, extract DNA from blood and contrast the genetic variations of participants with clinically significant chronic pain, to identify variations associated with the development of chronic post-surgical pain.

Detailed Description
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Most patients who undergo surgery heal within weeks to months and return to their baseline functional status or to an improved level of functioning. However, some patients have pain after surgery which continues. The purpose of this study is to see if there is a relationship between patient's genetic makeup (diseases that are passed on in families) and pain experience following cardiac and thoracic surgeries. This study will look for links between psychological factors, environmental factors and genetic factors in an attempt to uncover the risk for developing chronic post-surgical pain. This study hopes to determine differences between traditional pain surveys and a basic science approach called Phenomics to measure chronic pain response after cardiac and thoracic surgery. Phenomics or Phenomes is the study of physical characteristics, outside influences and biochemical changes (traits or chemical characteristics) and their response to either the environment or genetic changes. Validated pain questionnaires will be administered before surgery, and will repeated at 3, 6, and 12 months postoperatively to follow up the progression of early postoperative pain and the transition to chronicity. In general, the psychological and pain questionnaires are designed to measure the following: anxiety, thoughts, feelings and reactions toward pain and stressful experiences. In addition, the study will follow the development of acute postoperative and chronic pain from before surgery up to a year after. The investigators will extract DNA from blood and contrast the genetic variations of participants with clinically significant chronic pain, to identify variations associated with the development of chronic post-surgical pain. The blood sample will be drawn at the time of the surgery.

Official Title
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Phenomics and Genomics of Clinically Relevant Chronic Postsurgical Pain: A Multicenter Prospective Study

Conditions
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Chronic Pain, Surgery

Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age ≥ 18 years Non- Emergency Cardiac Surgery with Midline Sternotomy OR Thoracic Surgery via VATS or Lateral Thoracotomy Written informed consent to participate in the study Exclusion Criteria: Patient unable to understand the study protocol History of a psychotic psychiatric disorder Unable to speak English

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Post-Surgical Pain Intensity | Measured using the numeric rating scale (0=no pain; 10=worst pain imaginable) | 1 year from the day of surgery | 
| Pain: Measured using the McGill Pain Questionnaire- Short Form-2 (SF-MPQ-2) | The SF-MPQ-2 is a 22-item, expanded and revised version of the SF-MPQ designed to measure the qualities of neuropathic and non-neuropathic pain. Exploratory and confirmatory factor analyses revealed the presence of the following four factors or subscales: (1) continuous pain, (2) intermittent pain, (3) neuropathic pain, and (4) affective pain descriptor. | 1 year from the day of surgery | 
| Pain: Measured using the Self-completed Leeds Assessment of Neuropathic Symptoms and Signs (SLANSS) | The S-LANSS is a validated 7-item questionnaire designed to distinguish whether pain is predominately neuropathic or nociceptive in origin. | 1 year from the day of surgery | 
| Anxiety: Measured using the Anxiety Sensitivity Index-3 (ASI-3) | The ASI-3 is a revised version of the widely used, 16-item scale ASI that measures concerns that anxiety and anxiety-related symptoms will lead to harmful negative consequences. Each item is rated on a 5-point scale ranging from very little (0) to very much (4). | 1 year from the day of surgery | 
| Pain Catastrophizing: Measured using the Pain Catastrophizing Scale (PCS) | The PCS consists of 13 items describing thoughts and feelings that individuals may experience when they are in pain. Each item is rated on a 5-point scale ranging from not at all (0) to all the time (4). | 1 year from the day of surgery | 
| Pain Anxiety: Measured using the Pain Anxiety Symptoms Scale-20 (PASS-20) | The PASS-20 is a shortened 20-item version of the original Pain Anxiety Symptoms Scale designed to measure fear and anxiety responses specific to pain, including avoidance. The PASS-20 has four 5-item subscales, including (1) cognitive anxiety, (2) escape and avoidance, (3) fearful thinking, and (4) physiological anxiety. | 1 year from the day of surgery | 
| Pain Disability: Measured using the Pain Disability Index (PDI) | The PDI assesses the extent to which persistent pain interferes with an individual's ability to engage in seven different areas of everyday activity including: (1) family/home responsibilities, (2) recreation, (3) social activity, (4) occupation, (5) sexual behavior, (6) self-care, and (7) life-support activity. | 1 year from the day of surgery | 
| Posttraumatic Stress Disorder: Measured using the Posttraumatic Stress Disorder Checklist-Civilian Version (PCL-C) | The Posttraumatic Stress Disorder Checklist - Civilian Version (PCL-C) is a 17-item self-report measure based on the current DSM-IV symptoms for PTSD. Respondents are asked to indicate how much they have been bothered by each symptom 5-point scale ranging from not at all (1) to extremely (5). | 1 year from the day of surgery | 
| Anxiety and Depression: Measured using The Hospital Anxiety and Depression Scale (HADS) | The HADS is the most widely used scale for measuring symptoms of anxiety and depression among medical inpatients, outpatients and the general population and consists of 7 anxiety and 7 depression-related items. | 1 year from the day of surgery | 
| Somatization: Measured using the SCL-90-R-Somatization | The SCL-90-R is a widely-used self-report symptom inventory measuring psychological symptoms of psychiatric and medical patients. Participants rate each item on a five-point scale of distress, ranging from 0 (no distress) to 4 (extreme distress). | 1 year from the day of surgery | 
| Chronic Pain Acceptance: Measured using the Chronic Pain Acceptance Questionnaire (CPAQ) | The CPAQ is a 20-item questionnaire that measures how participants react and adapt to living with chronic pain. Participants respond to how true each item is by selecting a number from 0 (never true) to 6 (always true). | 1 year from the day of surgery | 
| Mindful Attention Awareness: Measured using the Mindful Attention Awareness Scale (MAAS) | The MAAS is a 15-item scale designed to measure a central feature of dispositional mindfulness characterized by open or receptive awareness of and attention to the present. Participants respond to how frequently/infrequently they experience each item by selecting one of six response options on a Likert rating scale ranging from 1 (Almost always) to 6 (Almost never). | 1 year from the day of surgery | 
| Pain Self Efficacy: Measured using the Pain Self-Efficacy Questionnaire (PSEQ) | The PSEQ is a 10-item Likert-type questionnaire, designed specifically for chronic pain, where patients are asked to rate their confidence to complete certain activities despite pain. | 1 year from the day of surgery | 
| Sensitivity to Pain Traumatization: Measured using the Sensitivity to Pain Traumatization Scale (SPTS) | The SPTS is a 12-item questionnaire that was designed to measure the anxiety-related cognitive, emotional and behavioural reactions to pain that resemble symptoms of a traumatic stress reaction. Each item is rated on a 5-item Likert scale (from 1 (not at all true) to 5 (entirely true)). | 1 year from the day of surgery | 
| Sleep Problems: Measured using the Sleep Problems Questionnaire | This is a general questionnaire that asks its questions providing responses in units of days. | 1 year from the day of surgery | 
| Sleep Quality: Measured using the Pittsburg Sleep Quality Index (PQSI) | The PSQI questionnaire is much more specific, identifying specific responses and reasons why patients may be having trouble sleeping such as: (1) cannot get to sleep within 30 minutes and (2) wake up in the middle of the night or early morning. | 1 year from the day of surgery | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Physical Activity for Thoracic Patients: Measured using Actiwatch--64 | The Actiwatch-64 is a small wrist watch-like device that contains an accelerometer that records limb movements and has a memory storage capacity for up to 11 days109. The Actiwatch-64 provides a non-invasive method of collecting activity data around the clock. Activity data are downloaded to a laptop and standard sleep parameters such as latency to sleep (SOL), wake time after sleep onset (WASO), and total sleep time (TST) are inferred by software based on the presence and absence of limb movements during specified time intervals. Total activity during periods scored as not sleep is also available. | Up to 11 days from surgery | 
| Sleep Quality for Thoracic Patients: Measured using the Sleep Quality Assessment | Each morning after surgery, up to and including the morning of discharge home from the hospital, a Sleep Diary will be completed. | Up to 11 days from surgery | 
| Mechanical Pain Pressure: Measured using the Mechanical Pressure Pain Threshold (PPT) | Pain thresholds in response to mechanical pressure applied to the skin will be obtained using a Pressure Algometer. | 1 year from the day of surgery | 
| Thermal Pain and Sensory: Measured using the Thermal Pain and Sensory Thresholds | Thermal stimuli will be delivered using the Medoc Thermal NeuroSensory Analyzer | 1 year from the day of surgery | 
| Pain Illusion: Measured using the Thermal Grill Illusion Test | Participants will be required to place their right hand on four plates, two of which will be pre-cooled to 10˚C and 20˚C and two preheated to 40˚C and 50˚C. Participants will alternate between these stimuli and a grill of mixed 20˚C and 40˚C interlaced bars with 5sec intervals between applications. | 1 year from the day of surgery | 
| Pain: Measured using the Vasoconstrictor Inspiratory Gasp | This simple test robustly activates the sympathetic system, which aggravates neuropathic pain in some chronic pain patients. Participants will be asked to rest supine on a couch and relax with eyes closed, and to take the deepest possible inspiration and then breathe normally. Three ratings of ongoing spontaneous pain will be taken at 1, 2, and 5 min after expiration. Two baseline blood pressure (systolic, diastolic and mean arterial pressure) and pulse rate measurements will be taken just before the Gasp Test and at 1 and 2 min thereafter, just after the pain ratings. Cardiovascular parameters will be carried out using an automated blood pressure cuff. | 1 year from the day of surgery | 
| Cold Pressor Pain: Measured using the Cold Pressor Pain Test | The participant will immerse their right hand (above the elbow) in ice cold water and keep it there until they cannot tolerate the pain. The pain tolerance threshold will be recorded with a stopwatch, as the time to withdrawal; cut-off at 3 min. They will then use the NRS (0-100) to rate the magnitude of pain and unpleasantness. | 1 year from the day of surgery |