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Original Research: COPD |

Pain and Its Clinical Associations in Individuals With COPDPain and Its Clinical Associations in COPD: A Systematic Review FREE TO VIEW

Annemarie L. Lee, PhD; Samantha L. Harrison, PhD; Roger S. Goldstein, MBChB, FCCP; Dina Brooks, PhD
Author and Funding Information

From the Department of Respiratory Medicine (Drs Lee, Harrison, Goldstein, and Brooks), West Park Healthcare Centre; and Department of Physical Therapy (Drs Lee, Harrison, Goldstein, and Brooks) and Department of Medicine (Dr Goldstein), University of Toronto, Toronto, ON, Canada.

CORRESPONDENCE TO: Dina Brooks, PhD, Department of Physical Therapy, University of Toronto, 160-500 University Ave, Toronto, ON, M5G 1V7, Canada; e-mail: dina.brooks@utoronto.ca


FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(5):1246-1258. doi:10.1378/chest.14-2690
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BACKGROUND:  Pain is emerging as a clinical complication in COPD, but the clinical impact of this comorbidity and the measurement properties of instruments used to assess pain require evaluation.

METHODS:  Electronic searches of five databases were performed up to September 2014 for the two phases of this review. To be included in phase 1, studies reported the clinical associations of pain and prevalence in individuals with COPD. To be included in phase 2, studies reported measurement properties of an instrument assessing pain in COPD. Two independent reviewers rated the quality of quantitative and qualitative evidence (phase 1) and the measurement properties using the four-point Consensus‐Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist (phase 2).

RESULTS:  Of the 358 studies identified in the literature, nine met the inclusion criteria for phase 1 and five for phase 2. The mean (SD) quality score (of 16) for the quantitative studies was 13.1 (1.7). The pooled prevalence of pain in moderate to very severe COPD was 66% (95% CI, 44%-85%). Higher pain intensity was associated with increased dyspnea, fatigue, poorer quality of life, and a greater quantity of specific comorbidities. Of the two identified instruments (Brief Pain Inventory and McGill Pain Questionnaire), the measurement properties analyzed were construct validity, internal consistency, and criterion-predictive validity, with variable findings based on “fair” or “poor” quality studies.

CONCLUSIONS:  In people with COPD, pain has negative clinical associations with symptoms and quality-of-life measures. Further research exploring the measurement properties of instruments assessing pain is required.

Figures in this Article

Common symptoms in individuals with COPD are dyspnea, fatigue, and anxiety, all of which are associated with impaired health-related quality of life (HRQOL) and reduced exercise tolerance.1,2 More recently, there is increased awareness that pain is a commonly reported symptom in COPD. Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or is described in terms of such damage.3 In COPD, pain appears to affect between 45% and 94% of individuals,1,49 including 21% to 77% with end-stage lung disease.1014

Pain has been reported in the spinal and chest wall regions,4,8,15 with higher pain levels linked to greater breathlessness,5,16 but its interaction with other symptoms of COPD are less clear. COPD is often accompanied by comorbidities,17,18 and individuals experiencing pain may have a higher proportion of musculoskeletal disorders.7,8,16,19 The current recommendations for assessing and evaluating the impact of pain are to incorporate the sensory and affective dimension of pain and its impact.20,21 With the emerging interest in understanding the extent and implications of pain in this population,22 there is a need to explore this issue further by determining the specific characteristics of pain experiences and its clinical associations in COPD.

The measurement and clinical associations of pain are complex. It is, therefore, important to determine whether the available assessment tools capture all of its dimensions. A better understanding of their measurement properties will assist clinicians in selecting the instruments best suited to assess pain in COPD.

Therefore, the primary aim of this systematic review was to determine the association between pain prevalence and specific pain characteristics with clinical features of COPD. The secondary aim was to explore the measurement properties of instruments assessing pain in COPD. This trial was registered with PROSPERO (CRD42014010618).

This review was completed in two phases based on the two aims and is reported according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.23 Phase 1 aimed to identify the association of pain characteristics, including prevalence in COPD with clinical features to give a contextual framework for any associations evident. Phase 2 identified instruments used to assess pain in COPD and their measurement properties.

Phase 1: Pain Characteristics and Clinical Associations

A systematic search was undertaken by one author (A. L. L.) of five databases, from inception to September 2014 (Fig 1), with reference lists of retrieved articles inspected to identify additional papers and authors contacted when necessary. The search strategy for MEDLINE is outlined in e-Appendix 1 and was adapted for other databases.

Figure Jump LinkFigure 1 –  Study flow from identification to inclusion of final studies for phase 1. CINAHL = Cumulative Index to Nursing and Allied Health Literature; EMBASE = Excerpta Medica Database.Grahic Jump Location
Inclusion Criteria:

Following duplicate removal, studies were screened by two independent reviewers (A. L. L. and S. L. H.). This included review of citations’ titles and abstracts from retrieved studies, followed by a full-text review of potentially eligible studies according to the inclusion criteria (Table 1). Any disagreement regarding eligibility was resolved by a consensus meeting, with consultation with a third reviewer (D. B.) when necessary.

Table Graphic Jump Location
TABLE 1 ]  Inclusion Criteria for Phase 1

Only studies published in English were included. HRQOL = health-related quality of life.

Data Extraction and Quality Assessment:

Data extraction was performed by one investigator (A. L. L.) (checked by a second investigator) using a standardized template. For quantitative studies, quality appraisal was conducted using the Critical Review Form–Quantitative Studies.24 This tool evaluates method rigor and bias, with a total score of 16. For qualitative studies, the Critical Appraisal Skills Program (CASP)25 was used, evaluating scientific rigor, credibility, and relevance.26 Appraisal was completed independently by two reviewers, with any disagreement resolved by consensus.

Phase 2: Instrument Measurement Properties

A similar search strategy of the same databases applied in phase 1 was undertaken by one author (A. L. L.). Search terms were customized for each database, with a validated sensitive search filter for finding studies on measurement properties of instruments applied.25 The search strategy for MEDLINE is described in e-Appendix 2.

Inclusion Criteria:

Following removal of duplicates, studies were screened by two independent reviewers (A. L. L. and S. L. H.). This included screening of titles and abstracts from all retrieved studies followed by full-text review of potentially eligible studies, based on the inclusion criteria (Table 2) with any disagreements resolved by consensus.

Table Graphic Jump Location
TABLE 2 ]  Inclusion Criteria for Phase 2

Only studies published in English were included.

Data Extraction and Quality Assessment:

Data were extracted using a standardized template. Two independent reviewers (A. L. L. and S. L. H.) evaluated the study quality using the Consensus-Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist.27 This is a validated tool composed of 10 sections, each scoring the quality of one measurement property. Within each section, items are individually scored based on a four-point scale (excellent, good, fair, or poor) with an overall quality score for each property obtained using the lowest score recorded among the items, as recommended.28

Analysis

Analysis of prevalence was based on the response to a question of “do you have pain?” in any instrument used. For studies which reported outcomes for the same series of patients,46,16,29 the prevalence was included only once in the meta-analysis. The pooled prevalence of pain was analyzed using MetaXL 1.3, a tool for meta-analysis in Microsoft Excel (EpiGear International Pty Ltd). The data were first transformed using the variance stabilizing double arcsine transformation.30 The quality effects model was then applied to determine the prevalence rate and 95% CI. This model was selected over the fixed or random effects models to explicitly address heterogeneity in pooled proportions caused by differences in study quality and distribution,31,32 allowing greater weighting to high-quality studies. MetaXL ensures that the pooled proportions add up to one. Heterogeneity assumption was assessed by the Q-test and I2 test. Clinical implications of pain were reported narratively.

Phase 1: Pain Characteristics and Clinical Associations

A total of 437 articles were identified; following references checks of included articles, an additional nine papers were identified. After removing 13 duplicates, 358 were reviewed for title and abstract, and 34 full-text articles were reviewed, with nine meeting the inclusion criteria (Fig 1). Study characteristics are outlined on Table 3, with two authors contacted for further information.6,7

Table Graphic Jump Location
TABLE 3 ]  Details of Study Characteristics

BPI = Brief Pain Inventory; CHAMPS = Community Health Activities Model Program for Seniors Questionnaire; CMS = Centers for Medicare and Medicaid Services; GSDS = General Sleep Disturbance Scale; HADS = Hospital Anxiety and Depression Scale; ICD-9 CM = International Classification of Diseases, Ninth Revision, Clinical Modification; LFS = Lee Fatigue Scale; MPQ = McGill Pain Questionnaire; NR = not reported; NRS = numerical rating scale; % pred = percent predicted; QOLS = Quality-of-Life Scale; RQOLQ = Respiratory Quality-of-Life Questionnaire; SF-36 = Short Form 36; SGRQ = St. George’s Respiratory Questionnaire; TSK = Tampa Scale for Kinesiophobia

Quality Assessment:

The mean (SD) quality score of quantitative studies22 was 13.1 (1.7) of 16 (Table 4). Common methodologic flaws were sampling biases, inadequate blinding, and inadequate sample size justification. The qualitative study15 evaluation is outlined in e-Table 1. Although study aims were clear, with appropriate methodology applied, participants were awaiting lung transplantation, suggesting recruitment bias. Interviews were semistructured, with analysis undertaken until saturation, although it is unclear how themes were derived.

Table Graphic Jump Location
TABLE 4 ]  Quality Assessment of Observational Studies

Key to scoring (Law et al24 all items ✓ for yes, × for no, except biases [× for yes, ✓ for no]). 1 = Was the study purpose stated clearly? 2 = Was relevant background literature reviewed? 3 = Was the design appropriate for the study question? 4 = Were there any biases present (minimum response rate of 80% for sample bias, blinding of investigators when physical measure were taken)? 5 = Was sample size justified? 6 = Was the sample described in detail? (had to include the number of participants by sex, age, and a description of where the cohort was sampled from). 7 = Was informed consent obtained? (if not described, assume no). 8 = Were the outcome measures valid? (if all not described, assume no). 9 = Were the outcome measures reliable? (if all not described, assume no). 10 = Results were reported in terms of statistical significance? 11 = Drop outs were reported? 12 = Clinical importance was reported? 13 = Were the statistical analysis methods appropriate? 14 = Conclusions were appropriate given the study methods? 15 = Are there implications for clinical practice given the results of the study (based on the experience of the reviewers)? 16 = Were limitations of the study acknowledged and described by the authors?

Study Characteristics:

Six studies were conducted in Norway,46,15,16,29 two studies in Canada,7,8 and one study in the United States.19 Three studies included both COPD and healthy control subjects,4,7,19 of which two studies matched populations for age and sex.8,19 All patients were in a stable clinical state, with moderate to very severe lung disease.2 One study incorporated qualitative analysis of pain experiences.15

The definition of pain varied considerably between studies. Five studies based prevalence on experience of pain within the past 24 h or past week according to the Brief Pain Inventory (BPI).58,15 One study established the presence of pain according to the question, “Are you generally bothered by pain”16 while two studies used a nonvalidated (yes/no) query.4,29

Prevalence was reported in nine studies (Table 5). Of these, six studies reported on a different series of patients with COPD.4,68,15,19 Prevalence (pain within the last 24 h or previous 7 days) was examined in six studies.48,29 Overall, the pooled prevalence was 66% (95% CI, 44%-85%) (Fig 2). The heterogeneity of I2 of 93% and Q = 73 suggests strong variability between studies.8 Compared with healthy control subjects, prevalence was greater in COPD.4,7,19

Table Graphic Jump Location
TABLE 5 ]  Outcomes of Prevalence Studies

Ca = cancer; Cx = cervical; DM = diabetes mellitus; LL = lower limb; Lx = lumbar; MI = myocardial infarction; NR = not reported; OA = osteoarthritis; OP = osteoporosis; QOL = quality of life; RA = rheumatoid arthritis; Tx = thoracic; UL = upper limb; USA = unstable angina. See Table 3 legend for expansion of other abbreviations.

a 

NRS = Numerical Rating Scale–Brief Pain Inventory.

b 

VAS = Visual Analog Scale–McGill Pain Questionnaire.

Figure Jump LinkFigure 2 –  Meta-analysis of point prevalence of pain in COPD.Grahic Jump Location

Common pain regions were lower back/lumbar (29%-48%),4,6,8,19 chest (16%-38%),4,6,8,15 upper back/thorax (16%-24%),4,6,8 neck/cervical (13%-46%),4,6,8,15,19 lower limb (14%-98%),4,6,8 and upper limb (41%-64%).4,6,8,15 Two studies reported more pain locations in COPD compared with control subjects,7,19 while the 2011 report by Bentsen et al4 found no difference between groups.

Five studies reported pain severity at its worst, ranging from 2.7 to 7.3 on the numerical rating scale of the BPI5,8,15,29 and from 1.0 to 1.3 cm on the McGill Pain Questionnaire (MPQ) Visual Analog Scale.7,8 Of the two studies comparing pain severity between groups, one found a higher severity in COPD,7 and one found no difference.4 The average duration that pain had been experienced by participants with COPD was 18 years in one study.4 Two studies found that pain interference in COPD was up to 5.4 times greater on the BPI interference scale compared with control subjects,7,8 although the 2011 report by Bentsen et al4 found no difference between groups.

Greater pain intensity was related to higher levels of breathlessness.5,16 One study described more fatigue in those with higher pain levels,5 although a 2013 report by Bentsen et al29 found no relationship. Higher pain intensity in COPD was associated with poorer HRQOL,5,8 poorer sleep quality,5,8,29 less physical activity, and an increased pain-related fear of movement.7,15 Pain negatively impacted on anxiety and depression,5 with reports that both pain and breathlessness contributed to severe anxiety.15

A higher proportion of individuals with COPD and pain had at least one comorbidity,4,16 with higher pain severity and interference associated with more comorbidites.7,8 Common comorbidities were musculoskeletal conditions,4,16,19 endocrine disorders,4,8 depression, and cancer.4,19 No difference in lung function was evident in those with COPD with or without pain.5,16 Approaches to pain management included pain medication,8,15,19 physical modalities, and acupuncture,8,16 with medication and acupuncture used more frequently in COPD than in the general population.16,19

Phase 2: Instrument Measurement Properties

A total of 248 studies were retrieved from the databases. Following duplicate removal, 218 studies were reviewed in full text and abstract form, with five meeting the inclusion criteria. With the exception of one study,33 all were included in phase 1.58 The measurement properties for the two identified instruments are summarized in e-Table 2 and included construct validity/hypothesis testing,58,33 internal consistency,6 and criterion-predictive validity.7 Overall, the studies scored “fair” or “poor” for the measurement properties evaluated. The poorest scoring areas were design requirements (lack of a prior hypotheses and sample size).

Measurement Properties:

High internal consistency for BPI pain intensity and interference was found (e-Table 2).6 For criterion-predictive validity of the BPI, a strong relationship between the MPQ pain severity score and the BPI pain intensity (r = 0.82) and BPI interference (r = 0.66) was evident.7 The construct validity explored the relationships between pain intensity or interference and other COPD outcome measures, with a weak to moderate relationship with disease severity5,7 and symptoms5 for the BPI and a moderate relationship with exercise capacity for both the BPI and MPQ.7,33 A weak-to-moderate relationship was evident between pain severity measured on the BPI and MPQ and comorbidities5,7,8,33 as well as HRQOL6,7,33 (e-Table 2).

Patients with moderate to severe COPD have a high prevalence of pain (66%) compared with healthy control subjects. Pain experiences have a positive association with dyspnea and a negative association with HRQOL. Possible contributing factors are comorbid conditions. There was insufficient information to establish the measurement properties of the instruments used in COPD, with the evidence rated as fair.

Heterogeneity in the prevalence of pain was evident. This may be attributed to the differing methods of population sampling; the use of convenience sampling and self-selection may have introduced some bias. The differing sample sizes between studies are also a likely factor. The variation appears to be unaffected by the time frame of pain reporting.4,5,7,8,15,19 In addition, it is unlikely to be influenced by slightly different pain definitions used in both validated or nonvalidated questionnaires to establish the presence of pain, with prevalence reported using nonvalidated questionnaires4,16,29 within the 95% CI of the pooled prevalence (44%-85%). While this suggests that asking patients if they experience pain may be sufficient to determine prevalence, clinically, this approach should be considered with caution when using nonvalidated questionnaires, in which measurement properties have not been established. A systematic review reported pain prevalence as a subdomain of HRQOL to be 67%20; this, together with our findings, suggests that pain is a common problem in COPD.

In comparison with the previous review,22 we determined the basis of pain prevalence from unidimensional and multidimensional pain scales, as per the current recommendations for assessing pain.20,21 van Dam van Isselt et al22 also used HRQOL tools, which inquired about the presence of pain. The primary purpose of these instruments is to measure health status or quality of life rather than to assess pain. In addition, the internal consistency of selected HRQOL tools could influence the strength of the link between pain prevalence and impact, which may increase the risk of overestimating any clinical associations. Finally, our objective was to establish the clinical association of pain within the context of pain prevalence in COPD, a different goal to the previous review.22

The role of disease severity in pain prevalence rates is unclear. One review found a strong positive correlation between lung function and pain prevalence (rho = 0.79), suggesting that pain is more common in those with moderate rather than severe COPD.20 However, our findings of similar prevalence rates between disease severity classifications,4,5,7,8,15 together with the lack of relationship between pain intensity and lung function,4,29 suggest that other factors may influence pain experience.

Comorbidities may be one of those factors, with a higher frequency of concurrent conditions in those with COPD experiencing pain compared with healthy control subjects4,19 or individuals with COPD without pain.16 The specific contribution of comorbidities appears variable. Current findings suggest that a greater pain intensity was associated with specific comorbidities, although this did not influence pain locations.8 However, another study found comorbidity quantity to be insignificant.6 With healthy control subjects aged-matched,4,7 it is unlikely that age-related comorbidities are relevant. Only one study reported the type of pain (neuropathic, inflammatory) experienced by patients.19 While this provides some insight into possible etiologies, further evaluation including the history of symptom experience is necessary to identify possible causes of pain in COPD.

The increase in breathlessness associated with higher pain intensity5,15,16 may be related to the altered respiratory mechanics observed in COPD.34 A similar relationship has been described between muscle overload, altered respiration, and pain in individuals without COPD diagnosed with low back pain.35 The relationship between pain and breathlessness is complex, with shared characteristics and common neural pathways which subserve discomfort in both symptoms.36 Further exploration of the interaction between these symptoms is required to identify the contribution of respiratory mechanics to pain.

Pain intensity was classed as mild to moderate, based on values established in other conditions including cancer and osteoarthritis.3739 While greater than those without COPD,7 it is comparable to individuals with cystic fibrosis and asthma.4044 The lack of consistent reporting of the least, average, and worst pain68,29 limits the ability to determine the dimensions of pain intensity in COPD. In addition, greater knowledge of the frequency and duration are needed to fully understand the pain experience.

The negative influence of pain experiences upon anxiety and its interference with daily activities, sleep, and HRQOL indicate that pain warrants clinical attention. The simultaneous occurrence of symptoms in patients with very severe COPD,15 particularly breathlessness and anxiety,45,46 may account for the pain-related fear of movement.7 This, together with reduced exercise capacity in those with COPD and pain,33 suggests it may be important to consider the effect of pain on pulmonary rehabilitation.

A variety of treatment options have been suggested to tackle pain in COPD,16,19 however, their effectiveness was not evaluated in this review due to the minimal reporting.16,19 Further research is required to evaluate the effectiveness of interventions to manage pain in COPD.

This is the first review exploring the measurement properties of instruments assessing pain in COPD. The assessment burden of the two questionnaires is low, making either a feasible choice. The BPI and the MPQ provide insight into the relationships between pain and key clinical factors in COPD. Although all relevant measurement properties of each instrument specific to pain have not been established, the construct validity of the BPI is the most comprehensive, suggesting this tool may be the optimal choice in clinical practice until further research is completed.

The decision to exclude papers which only reported pain prevalence and clinical associations may have influenced the overall prevalence in COPD subgroups, particularly those with end-stage disease.11,47 In addition, the classifications of pain intensity have largely been based on other chronic conditions; these should be further validated in COPD. Although the COSMIN scoring system is designed to evaluate studies on measurement properties, no study included in this review had this as its primary aim, which may influence the low COSMIN scores observed.

In conclusion, this review illustrates that pain is a common problem in people with moderate to very severe COPD. The associations between pain and HRQOL, fatigue, and breathlessness suggest that pain has important clinical repercussions. While comorbidities may influence the pain experience, the possible etiologies of pain require clarification. Greater exploration of patient experiences of pain through qualitative studies is warranted. There is limited information regarding the properties of current pain outcome measures. Further work to establish other measurement properties of the BPI and MPQ, including internal consistency, reliability, and responsiveness, is of clinical value.

Author contributions: A. L. L. is the guarantor for this study. A. L. L. contributed to the development of the research design and concept, data analysis, and manuscript preparation and review; S. L. H. contributed to the development of the research design, data analysis, and review of the manuscript; and R. S. G. and D. B. contributed to the development of the research design and concept, data analysis, and review of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Additional information: The e-Appendixes and e-Tables can be found in the Supplemental Materials section of the online article.

BPI

Brief Pain Inventory

COSMIN

Consensus-Based Standards for the Selection of Health Status Measurement Instruments

HRQOL

health-related quality of life

MPQ

McGill Pain Questionnaire

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Serlin RC, Mendoza TR, Nakamura Y, Edwards KR, Cleeland CS. When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain. 1995;61(2):277-284. [CrossRef] [PubMed]
 
Li KK, Harris K, Hadi S, Chow E. What should be the optimal cut points for mild, moderate, and severe pain? J Palliat Med. 2007;10(6):1338-1346. [CrossRef] [PubMed]
 
Kapstad H, Hanestad BR, Langeland N, Rustøen T, Stavem K. Cutpoints for mild, moderate and severe pain in patients with osteoarthritis of the hip or knee ready for joint replacement surgery. BMC Musculoskelet Disord. 2008;9:55. [CrossRef] [PubMed]
 
Stenekes SJ, Hughes A, Grégoire MC, Frager G, Robinson WM, McGrath PJ. Frequency and self-management of pain, dyspnea, and cough in cystic fibrosis. J Pain Symptom Manage. 2009;38(6):837-848. [CrossRef] [PubMed]
 
Sermet-Gaudelus I, De Villartay P, de Dreuzy P, et al. Pain in children and adults with cystic fibrosis: a comparative study. J Pain Symptom Manage. 2009;38(2):281-290. [CrossRef] [PubMed]
 
Flume PA, Ciolino J, Gray S, Lester MK. Patient-reported pain and impaired sleep quality in adult patients with cystic fibrosis. J Cyst Fibros. 2009;8(5):321-325. [CrossRef] [PubMed]
 
Kelemen L, Lee AL, Button BM, Presnell S, Wilson JW, Holland AE. Pain impacts on quality of life and interferes with treatment in adults with cystic fibrosis. Physiother Res Int. 2012;17(3):132-141. [CrossRef] [PubMed]
 
Lunardi AC, Marques da Silva CC, Rodrigues Mendes FA, Marques AP, Stelmach R, Fernandes Carvalho CR. Musculoskeletal dysfunction and pain in adults with asthma. J Asthma. 2011;48(1):105-110. [CrossRef] [PubMed]
 
Keil DC, Stenzel NM, Kühl K, et al. The impact of chronic obstructive pulmonary disease-related fears on disease-specific disability. Chron Respir Dis. 2014;11(1):31-40. [CrossRef] [PubMed]
 
Smoller J, Pollack M, Otto M, Rosenbaum J, Kradin R. Pain anxiety, dyspnea and respiratory disease. Theoretical and clinical considerations. Am J Respir Crit Care Med. 1996;154(1):6-17. [CrossRef] [PubMed]
 
Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006;31(1):58-69. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Study flow from identification to inclusion of final studies for phase 1. CINAHL = Cumulative Index to Nursing and Allied Health Literature; EMBASE = Excerpta Medica Database.Grahic Jump Location
Figure Jump LinkFigure 2 –  Meta-analysis of point prevalence of pain in COPD.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Inclusion Criteria for Phase 1

Only studies published in English were included. HRQOL = health-related quality of life.

Table Graphic Jump Location
TABLE 2 ]  Inclusion Criteria for Phase 2

Only studies published in English were included.

Table Graphic Jump Location
TABLE 3 ]  Details of Study Characteristics

BPI = Brief Pain Inventory; CHAMPS = Community Health Activities Model Program for Seniors Questionnaire; CMS = Centers for Medicare and Medicaid Services; GSDS = General Sleep Disturbance Scale; HADS = Hospital Anxiety and Depression Scale; ICD-9 CM = International Classification of Diseases, Ninth Revision, Clinical Modification; LFS = Lee Fatigue Scale; MPQ = McGill Pain Questionnaire; NR = not reported; NRS = numerical rating scale; % pred = percent predicted; QOLS = Quality-of-Life Scale; RQOLQ = Respiratory Quality-of-Life Questionnaire; SF-36 = Short Form 36; SGRQ = St. George’s Respiratory Questionnaire; TSK = Tampa Scale for Kinesiophobia

Table Graphic Jump Location
TABLE 4 ]  Quality Assessment of Observational Studies

Key to scoring (Law et al24 all items ✓ for yes, × for no, except biases [× for yes, ✓ for no]). 1 = Was the study purpose stated clearly? 2 = Was relevant background literature reviewed? 3 = Was the design appropriate for the study question? 4 = Were there any biases present (minimum response rate of 80% for sample bias, blinding of investigators when physical measure were taken)? 5 = Was sample size justified? 6 = Was the sample described in detail? (had to include the number of participants by sex, age, and a description of where the cohort was sampled from). 7 = Was informed consent obtained? (if not described, assume no). 8 = Were the outcome measures valid? (if all not described, assume no). 9 = Were the outcome measures reliable? (if all not described, assume no). 10 = Results were reported in terms of statistical significance? 11 = Drop outs were reported? 12 = Clinical importance was reported? 13 = Were the statistical analysis methods appropriate? 14 = Conclusions were appropriate given the study methods? 15 = Are there implications for clinical practice given the results of the study (based on the experience of the reviewers)? 16 = Were limitations of the study acknowledged and described by the authors?

Table Graphic Jump Location
TABLE 5 ]  Outcomes of Prevalence Studies

Ca = cancer; Cx = cervical; DM = diabetes mellitus; LL = lower limb; Lx = lumbar; MI = myocardial infarction; NR = not reported; OA = osteoarthritis; OP = osteoporosis; QOL = quality of life; RA = rheumatoid arthritis; Tx = thoracic; UL = upper limb; USA = unstable angina. See Table 3 legend for expansion of other abbreviations.

a 

NRS = Numerical Rating Scale–Brief Pain Inventory.

b 

VAS = Visual Analog Scale–McGill Pain Questionnaire.

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Li KK, Harris K, Hadi S, Chow E. What should be the optimal cut points for mild, moderate, and severe pain? J Palliat Med. 2007;10(6):1338-1346. [CrossRef] [PubMed]
 
Kapstad H, Hanestad BR, Langeland N, Rustøen T, Stavem K. Cutpoints for mild, moderate and severe pain in patients with osteoarthritis of the hip or knee ready for joint replacement surgery. BMC Musculoskelet Disord. 2008;9:55. [CrossRef] [PubMed]
 
Stenekes SJ, Hughes A, Grégoire MC, Frager G, Robinson WM, McGrath PJ. Frequency and self-management of pain, dyspnea, and cough in cystic fibrosis. J Pain Symptom Manage. 2009;38(6):837-848. [CrossRef] [PubMed]
 
Sermet-Gaudelus I, De Villartay P, de Dreuzy P, et al. Pain in children and adults with cystic fibrosis: a comparative study. J Pain Symptom Manage. 2009;38(2):281-290. [CrossRef] [PubMed]
 
Flume PA, Ciolino J, Gray S, Lester MK. Patient-reported pain and impaired sleep quality in adult patients with cystic fibrosis. J Cyst Fibros. 2009;8(5):321-325. [CrossRef] [PubMed]
 
Kelemen L, Lee AL, Button BM, Presnell S, Wilson JW, Holland AE. Pain impacts on quality of life and interferes with treatment in adults with cystic fibrosis. Physiother Res Int. 2012;17(3):132-141. [CrossRef] [PubMed]
 
Lunardi AC, Marques da Silva CC, Rodrigues Mendes FA, Marques AP, Stelmach R, Fernandes Carvalho CR. Musculoskeletal dysfunction and pain in adults with asthma. J Asthma. 2011;48(1):105-110. [CrossRef] [PubMed]
 
Keil DC, Stenzel NM, Kühl K, et al. The impact of chronic obstructive pulmonary disease-related fears on disease-specific disability. Chron Respir Dis. 2014;11(1):31-40. [CrossRef] [PubMed]
 
Smoller J, Pollack M, Otto M, Rosenbaum J, Kradin R. Pain anxiety, dyspnea and respiratory disease. Theoretical and clinical considerations. Am J Respir Crit Care Med. 1996;154(1):6-17. [CrossRef] [PubMed]
 
Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006;31(1):58-69. [CrossRef] [PubMed]
 
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