Meta-analysis

1. SYSTEMATIC REVIEW
Psychological correlates of acute postsurgical pain: A
systematic review and meta-analysis
M. Sobol-Kwapinska1
, P. Bazbel2
, W. Plotek3
, B. Stelcer3
1 Department of Personality Psychology, The Catholic University of Lublin, Lublin, Poland
2 Department of Psychology, The Jagiellonian University, Krakow, Poland
3 Department of Anesthesiology, The Poznan University of Medical Sciences, Poznan, Poland
Correspondence
Malgorzata Sobol-Kwapinska
E-mail: sobol@kul.pl
Funding sources
The preparation of this manuscript was sup-
ported by the grant ‘Time perspective, post-
operative pain perception and coping
strategies in pain’ 2013/09/B/HS6/02785 from
the National Science Centre (Poland).
Conflicts of interest
The authors have no conflicts of interest to
disclose.
Accepted for publication
13 March 2016
doi:10.1002/ejp.886
Abstract
Due to the frequency of surgeries, acute postsurgical pain (APSP) is a
common problem. However, the role of psychological factors in the
experience of this kind of pain has not been well established. In this
review, we focused on presurgical psychological factors associated with
the experience of APSP. A systematic search of articles was performed
using PsycARTICLES, PsycINFO, PubMed, MEDLINE, Scopus, Cochrane
and DARE. For each study, we assessed the risk of bias, the level of
evidence, the corresponding score points and the degree of association
with APSP. Separate meta-analyses were performed for the selected
variables. Fifty-three relevant publications were selected. Pain
catastrophizing, optimism, expectation of pain, neuroticism, anxiety
(state and trait), negative affect and depression were classified as likely
associated with APSP. Only one of the analysed psychological variables –
locus of control – was recognized as shown unlikely association with
APSP. Results of meta-analyses suggested that pain catastrophizing was
most strongly linked with APSP. Results of the studies reviewed suggest
that patients who do not exaggerate the negative aspects of the situation
and who have positive expectation of the future before undergoing
surgery report lower levels of APSP than patients who catastrophize pain
and expect negative events in the future. An increasing interest in
preoperative positive psychological variables has been observed over the
last few years in studies of surgical patients.
What does this review add?:
Pain catastrophizing, optimism, expectation of pain, neuroticism, anxi-
ety (state and trait), negative affect and depression were classified as
likely associated with acute postsurgical pain, and locus of control was
classified as unlikely associated with acute postsurgical pain.
Anxiety was the psychological variable most frequently measured
before surgery.
Pain catastrophizing was most strongly linked with acute postsurgical
pain.
1. Introduction
This systematic review and meta-analysis investigate
relationships between presurgical psychological fac-
tors and acute postsurgical pain (APSP). Research
results have indicated that what patients awaiting
surgery fear most is not so much the surgery itself
but rather postsurgical pain (Green and Tait, 2002).
Strong APSP poses a threat to the patient’s health,
and even increases postsurgical mortality (e.g. Apfel-
baum et al., 2003; Tse et al., 2005). Given the high
© 2016 European Pain Federation - EFICâ
Eur J Pain (2016) – 1

2. rate of surgery and that pain is still sometimes inef-
fectively addressed, research into the determinants of
APSP is of great importance.
Theoretical concepts of pain highlight the multidi-
mensional nature of this phenomenon. In the model
by Wade and Price (2000), experience of pain is
approached as a multistage process, strictly con-
nected to the person’s attitudes towards pain, per-
sonality traits and coping strategies. According to
Melzack and Wall’s (1965) gate control theory, indi-
vidual perception of pain is modulated by psycholog-
ical factors. Similarly, Beecher (1972) distinguished
between two inseparable dimensions of the response
to pain: the sensation – the intensity of the acting
pain stimulus, and the reaction – including individ-
ual perception of the experience and response to
sensation, dependent on psychological factors.
Results of many studies of patients undergoing
surgery suggest significant relationships between
psychological factors and APSP. Few reviews into
these associations have been published so far.
Vaughn et al. (2007) analysed the results of studies
pointing to the existence of a significant relationship
between presurgical anxiety and APSP as well as
those which revealed no such relationship. Nielsen
et al. (2007) performed a qualitative review into the
relationship between APSP and anxiety, depression,
neuroticism and catastrophizing. Ip et al. (2009)
identify independent predictors of APSP and anal-
gesic consumption. They concluded that anxiety was
the most significant psychological predictor of APSP.
Ip et al. (2009) divided psychological variables into
three groups: anxiety, psychological distress and cop-
ing strategies. This made the presentation of results
clearer and more lucid, but there were, naturally,
simplifications. The inclusion of many diverse psy-
chological variables, such as low well-being, mood
or neuroticism in the common category of ‘psycho-
logical distress’ can make it particularly difficult to
analyse the influence of each variable on APSP.
The knowledge of presurgical factors influencing
the intensity of APSP will enable early identification
of patients at risk of experiencing strong APSP. Such
identification will in turn enable more effective
interventions and better pain management. More-
over, determining the strength of the relationship
between each psychological variable and APSP is
important for setting the priority for intervention.
Therefore, the aim of this review was to identify and
quantify preoperative psychological variables associ-
ated with APSP. Unlike prior reviews, we dealt with
the relationships between each of the preoperative
psychological factors examined so far and APSP. To
facilitate comparisons, meta-analyses were per-
formed. Furthermore, our research includes several
additional articles which have been published since
the review by Ip et al. (2009).
2. Methods
2.1 Search method and study selection
We performed a systematic search of PsycARTICLES,
PsycINFO, PubMed, MEDLINE, Scopus, Cochrane
and DARE (Database of Abstract of Reviews of Effec-
tiveness) databases for literature published between
January 1960 and 30 November 2015. The research
question was as follows: ‘What is the relationship
between presurgical psychological variables and the
experience of APSP?’
We started by searching for existing systematic
reviews to avoid duplication. The following basic
structure of the search strategy was used: [((((postop-
erative pain) OR post-operative pain) OR postsurgical
pain) OR post-surgical pain] AND [((((((((((psycho-
logical) OR anxiety) OR fear) OR depression) OR
depressed) OR mood) OR catastrophizing) OR opti-
mism) OR pessimism) OR coping strategies) OR pain
expectation] AND [acute]. These terms were searched
primarily in title, abstract and keywords (The Scopus
search is described in the Supporting Information
Appendix S1). Two reviewers (MSK and PB) indepen-
dently analysed the abstracts of all the publications.
The differences arising in evaluations were resolved
by the third reviewer (BS). Manual reference search
identified additional studies. To minimize the pres-
ence of publication bias, conference reports and dis-
sertations were also searched. In some cases, the
authors of unavailable articles were contacted via
mail. We documented the search in a protocol (avail-
able from the corresponding author upon request)
according to the recommendations set out by Liberati
et al. (2009).
The article was included in the review if it was in
English, if the participants in the studies were
patients (17 y.o. and older) undergoing surgeries in
hospitals, if psychological variables before surgery
were tested, and if the level of the experienced APSP
was measured using scales.
2.2 Risk of bias
Risk of bias of included studies was assessed according
to the Quality in Prognostic Studies (QUIPS) tool
(Hayden et al., 2013) by two reviewers independently
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Psychological correlates of acute postsurgical pain M. Sobol-Kwapinska et al.

3. (MS and PB). Assessment was based on following cri-
teria: (1) Study participation; (2) Study attrition; (3)
Prognostic factor measurement; (4) Outcome mea-
surement; (5) Study confounding and (6) Statistical
analysis and reporting (based on Hayden et al., 2013).
Each criterion was scored as high (H), moderate (M)
and low (L) risk of bias (see Table 5). The full QUIPS is
available at www.annals.org.
Each of the categories were evaluated separately
in every study. We excluded studies with high risk
of bias (H) with any of the quality assessment cate-
gories. The total score was computed by counting
the number of criteria scored as low score of bias
(L). Studies with a score of 3 or higher were defined
as low risk of bias; a score lower than 3 was
described as moderate risk of bias.
2.3 Data extraction and analysis
The following data were extracted from studies: the
country where the study was conducted, sample
size, type of surgery, participants’ ages, manner and
time of measuring APSP and measures of correlates
of APSP. Data were extracted independently by two
review authors (MS and WP), and any disagreement
were consulted with a third review author (BS) if
necessary. These characteristics of each article are
presented in Supporting Information Appendix S2.
Two levels of analyses were performed. We evalu-
ated the correlates of APSP identified in each study.1
The criteria of evaluation were adapted from Hin-
richs-Rocker et al. (2009) and modified for our
review. We chose this evaluation due to its clarity
and transparency as well as the possibility of further
comparisons of the results obtained for APSP with
the results for chronic postsurgical pain (CPSP). First,
we determined the level of evidence of each study
(A1, A2, B1, B2) using the number of subjects and
the level of risk of bias (see Table 1). To make com-
parisons easier, the level of evidence was scored
from 1 to 4 (see Supporting Information
Appendix S3). The higher the number of points, the
higher the level of evidence. For each psychological
variable in the presurgical period, the degree of asso-
ciation with APSP was determined using the points
from all the studies available (see Supporting Infor-
mation Appendix S4). One point was granted if a
particular correlate was investigated in at least three
studies and if the sum of points scored by all the
studies pointing to a relationship between a given
predictor and APSP was at least twice as high as the
sum of points scored by all the studies showing no
relationship between those variables. Grade of
association 2 means that it was not possible to draw
any conclusions. This grade was assigned when there
were up to two studies concerning a given correlate
or when the sum of points was unconvincing. Grade
of association 3 means unlikely association. It was
assigned when a given variable was investigated in
at least three studies and the sum of points scored
by the studies showing no relationship between this
variable and APSP was at least twice as high as the
sum of points scored by studies indicating the exis-
tence of a significant relationship between that vari-
able and APSP (see Hinrichs-Rocker et al., 2009).
2.4 Meta-analysis
At the second level of analysis, we conducted a
meta-analysis for these psychological variables that
were analysed in at least four studies and in which it
was possible to perform. All analyses were performed
using the program Comprehensive Meta-Analysis
(Version 2) [Computer software] (2014). There were
following kinds of the source effects available for
meta-analysis: Pearson r, standardized coefficients
from multiple regression (betas), odds ratios with
confidence intervals and R squared. Two final meta-
effects were calculated: Pearson r, and odds ratios
(Kim, 2011).
In the case when the given effect was calculated
more than once (e.g. because of multiple repeated
measure at different time points), the median size of
the effect was chosen. When there were just two effects
available, the lower one was chosen. Random effects
were calculated. Whenever available, univariate statis-
tics were chosen for the meta-analysis, as the values of
multivariate statistics (e.g. beta) are heavily dependent
on other predictors in the model, which in turn vary
heavily from study to study. Meta-regression analyses
were also performed to identify potential moderators.
The potentially confounding relationship of sample
size, the publication year, risk of bias on the relation-
ship of interest were evaluated. Furthermore, hetero-
geneity between the studies was assessed using the Q-
test (as the indicator of the probability of heterogene-
ity), and the I² index (as the indicator of the magnitude
of the heterogeneity) (see Deeks et al., 2008). More-
over, we evaluated publication bias using the Egger’s
test of intercept (a correlation between study precision
and the standardized effect) (see Moher et al., 2009).
3. Results
Fig. 1 illustrates a summary of the study selection
process. A total of 5582 potentially relevant citations
© 2016 European Pain Federation - EFICâ
Eur J Pain (2016) – 3
M. Sobol-Kwapinska et al. Psychological correlates of acute postsurgical pain

4. Table1Summaryoftheriskofbiasofthestudies
123456789101112131415161718192021222324
Reference11784725574828297944-119393752824554553031573145
StudyIDAubrun
etal.,
2008
Bachiocco
etal.,
1990
Bisgaard
etal.,
2001
Boeke
etal.,
1991
Bruce
etal.,
2012
Caumo
etal.,
2002
Cohen
etal.,
2005
DeCosmo
etal.,
2008
Desai
and
Cheung,
2012
Ene
etal.,
2008
Farooq
etal.,
2014
Fraser
etal.,
1989
Gerbershagen
etal.,2009
Gramke
etal.,
2009
Granot
and
Goldstein
Ferber,
2005
Grosen
etal.,
2014
Hirakawa
etal.,
2014
Hsu
etal.,
2005
Kain
etal.,
2000
Kalkman
etal.,
2003
Katz
etal.,
2005
Katz
etal.,
2008
Kaunisto
etal.,
2013
Khan
etal.,
2012
Study
participationa
LMMMMMMMLMHMMMMMMMMLMMLM
StudyattritionMMMMLMMMMMHLMMMMMMMMLMLM
Prognostic
factor
measurement
MMMMLLLLLLMLLLLLLLLLLLLL
Outcome
measurement
LLLLLLLLMLMLLLLLLLLLLLLL
Study
confounding
LMMMLMMMMMHMMMMLMMMMMMMM
Statistical
analysis
andreporting
MMMMMMMMLMMHMLMLMMMMMMLL
Overallratingof
riskofbias
LMMMLMMMLMHHMLMLMMMLLMLL
Levelof
evidence(see
Supporting
Information
AppendixS3)
422242213200141311144243
25262728293031323334353637383940414243444546
Reference322526383365506022362891110495956255373456223
StudyIDKil
etal.,
2012
Kinjo
etal.,
2012
Lautenbacher
etal.,
2011
Lunn
etal.,
2013
Mamie
etal.,
2004
Montgomery
etal.,
2010
Munafoand
Stevenson,
2003
€Ozalp
etal.,
2003
Pan
etal.,
2006
Papaioannou
etal.,
2009
Pavlin
etal.,
2005
Pinto
etal.,
2012
Pinto
etal.,
2013
Pinto
etal.,
2014
Pinto
etal.,
2015
Pud
and
Amit,
2005
Radinovic
etal.,
2014
Raichle
etal.,
2015
Rakel
etal.,
2012
Ronaldson
etal.,
2014
Roth
etal.,
2007
Rudin
etal.,
2008
StudyparticipationLLMLLMMMMMMLLMMMMLLLMM
StudyattritionLMMLMLMMMMMLLMMMMMMLMM
Prognosticfactor
measurement
LLLLMLLLLLLLLLLLLHLLLL
Outcome
measurement
LLLLLLLLLLLLLLLLLLLLLL
StudyconfoundingLMMLMMMMMMMMLMMMMMMMMM
Statisticalanalysis
andreporting
LLMLMLMMMMLLLLLMLMLLMM
Overallratingof
riskofbias
LLMLMLMMMMLLLLLMLHLLMM
Levelofevidence
(seeSupporting
Information
AppendixS3)
4414241111344441404411
4 Eur J Pain (2016) – © 2016 European Pain Federation - EFICâ
Psychological correlates of acute postsurgical pain M. Sobol-Kwapinska et al.

5. were identified through a search. After removing
duplicates, 3235 were screened by title and abstract.
A total of 57 studies were identified as eligible, from
which four studies were excluded due to high risk of
bias (see Table 1). Agreement between reviewers
(MS and PB) estimation of the risk of bias on the
base of QUIPS criteria, expressed in Cohen’s kappa
was 0.83. After this process, 53 studies were selected
for the final review. In 26 of the studies risk of bias
was moderate, and in 27 risk of bias was low. Stud-
ies scored poorly mainly in the study attrition and
study confounding. Altogether, the articles presented
the results of examinations from 10 749 patients.
Next, studies were rated in terms of their level of
evidence and were given appropriate score points
(see Table 1). Twenty-one papers were categorized
into the A1 level of evidence (score points = 4); six
articles were classified into the A2 level of evidence
(score points = 3); nine articles represented the B1
level of evidence (score points = 2) and 17 articles
represented the B2 level of evidence (score
points = 1). Next, the grade of association between
APSP and each of the psychological correlates was
determined. Table 2 presents the psychological vari-
ables that have a likely association with APSP (grade
of association: 1); Table 3 shows the psychological
variables with unclear results (grade of association:
2) and Table 4 presents those psychological variables
which, according to the adopted criteria, were classi-
fied as unlikely to be associated with APSP (grade of
association: 3).
Meta-analysis was carried out for state anxiety,
trait anxiety, pain catastrophizing, depression, expec-
tation of postsurgical pain and optimism (based on,
respectively, 12, 17, 20, 17, 4 and four studies),
because they were adequately reported among the
studies in a consistent way. The results of meta-ana-
lyses suggest significant, but not too strong, relation-
ships between APSP and all psychological variables
subjected to these analyses. The strongest relation-
ship occurred between catastrophizing and APSP
(see Table 5).
We evaluated sample size, the publication year
and risk of bias as moderators of the relation
between each psychological variable included in
meta-analyses (see Table 6). Results of meta-regres-
sion were mostly (in four out of six cases) signifi-
cant for sample size, which suggests that the smaller
the sample sizes, the stronger the correlations
between state anxiety, trait anxiety, depression,
optimism and APSP. In the cases of trait anxiety and
optimism, the more recent the studies, the lower
correlations of these variables with APSP. For pain
4748495051525354555657
Reference5380403763834650403650
StudyIDScott
etal.,
1983
Seebach
etal.,
2012
Sommer
etal.,
2009
Sommer
etal.,
2010
Strulov
etal.,
2007
Sullivan
etal.,
2009
Taenzer
etal.,
1986
Thomazeau
etal.,2015
Tolver
etal.,
2011
Vranceanu
etal.,2010
Weissman-Fogel
etal.,
2009
StudyparticipationMLLMMLMLLLL
StudyattritionMMLMLLMMLLL
PrognosticfactormeasurementLLMLMLLLMLM
OutcomemeasurementLLLLLLLLLLL
StudyconfoundingMMMMMLMMMMM
StatisticalanalysisandreportingMHMMMLMLMML
OverallratingofriskofbiasMHLMMLMLLLL
Levelofevidence
(seeSupporting
InformationAppendixS3)
10421314443
H,highriskofbias;M,moderateriskofbias;L,lowriskofbias;Overallratingsofriskofbiasandlevelofevidenceareprintedinboldtype.
a
BasedonHaydenetal.(2013).
Table1(Continued)
© 2016 European Pain Federation - EFICâ
Eur J Pain (2016) – 5
M. Sobol-Kwapinska et al. Psychological correlates of acute postsurgical pain

6. catastrophizing, the relation was inverse – the more
recent the studies, the higher correlations with
APSP. Risk of bias was a significant moderator for
two links: trait anxiety-APSP and pain catastrophiz-
ing-APSP. The higher risk of bias, the higher corre-
lations of trait anxiety and pain catastrophizing with
APSP.
In the case of studies into relationship between pre-
operative state anxiety and APSP, studies were hetero-
geneous (Q-test = 84.64; p 0.001; I² index = 87%).
The Egger’s test (intercept = 2.53; from 1.50 to 3.56;
p 0.001) was significant, suggesting a possible publi-
cation bias. Studies of anxiety trait and APSP relation-
ship were also heterogeneous (Q-test = 360.73;
p 0.001; I² index = 95.56%). The Egger’s test (inter-
cept = 3.10; from 0.81 to 5.38; p 0.001) indicated a
publication bias. In the case of pain catastrophizing
and APSP, studies were heterogeneous (Q-
test = 316.90; p 0.001; I² index = 94.00%). A possi-
ble publication bias was suggested by the Egger’s test
(intercept = 4.02; from 3.03 to 5.02; p 0.001).
Indexes (Q-test = 55.36; p 0.001; I² index =
71.10%) also suggested heterogeneity of studies con-
cerning the relationship between depression and
APSP. The Egger’s test (intercept = 0.54; from À2.61
to 3.70; p = 0.718) did not suggest a substantial publi-
cation bias. Studies regarding expectation of pain and
APSP were not heterogeneous (Q-test = 2.76; p =
0.43; I² index = 0.1%). The Egger’s test (intercept =
3.52; from À0.21 to 7.26, p = 0.055) did not indicate
a publication bias. The studies of links between opti-
mism and APSP were heterogeneous (Q-test = 8.90;
p = 0.031; I² index = 66.29%). The Egger’s test was
significant (intercept = 8.56; from À0.01 to 17.15,
p = 0.050) suggesting a possible publication bias.
These results suggest that general results of meta-
analyses should be interpreted with caution as the
relationship between preoperative psychological vari-
ables and APSP can be overestimated.
4. Discussion
The aim of this study was to provide a review of
the literature to analyse the relations between
presurgical psychological factors and APSP. Twenty-
seven out of the 53 studies included were unique;
they were not included in the earlier reviews of
Nielsen et al. (2007), Vaughn et al. (2007) and Ip
Potential relevant records identified
through database searching
(n = 5544)
Screening
Identification
Additional records identified
through other sources
(n = 38)
Records after duplicates removed
(n = 3235)
Records screened
(n = 3235)
Records excluded
(n = 2873)
- Not adults
- Not measuring
psychological variables
- Not related to APSP
Full-text articles assessed
for eligibility
(n = 362)
Full-text articles excluded,
with reasons
(n = 309)
- Not adults
- Not English
- Psychological variables
were not measured before
surgery
- APSP was not assessed
by scales
- The study design was not
prospective
- High risk of bias
Studies included in
qualitative synthesis
(n = 53)
Studies included in
quantitative synthesis
(meta-analysis)
(n = 44)
Eligibility
Included
Figure 1 Flow of information about different phases of a review. Based on the PRISMA 2009 Flow Diagram (Moher et al., 2009).
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Psychological correlates of acute postsurgical pain M. Sobol-Kwapinska et al.

7. Table 2 Grade of association 1: association likely
Predictor/correlate Association with APSP
Level of
evidence
Score
points
No association
with APSP
Level of
evidence
Score
points
Pain catastrophizing 62
Gramke et al. (2009) (PCS) A1 4
Granot and Goldstein
Ferber (2005) (PCS)
B2 1
Grosen et al. (2014) (SPCS) A2 3
Hirakawa et al. (2014) (PCS) B2 1
Khan et al. (2012) (PCS) A2 3
Lunn et al. (2013) (PCS) A1 4
Papaioannou
et al. (2009) (PCS)
B2 1
Pavlin et al. (2005) (PCS) A2 3
Pinto et al. (2012) (PCS) A1 4
Pinto et al. (2013) (PCS) A1 4
Pinto et al. (2014) (CSQ-R) A1 4
Pinto et al. (2015) (CSQ-R) A1 4
Rakel et al. (2012) (PCS) A1 4
Roth et al. (2007) (PCS) B2 1
Sommer
et al. (2009) (PCS)
A1 4
Sommer et al. (2010) (PCS) B1 2
Strulov
et al. (2007) (PCS)
B2 1
Sullivan et al. (2009) (PCS) A2 3
Tolver et al. (2011) (PCS) A1 4
Vranceanu
et al. (2010) (PCS)
A1 4
Weissman-Fogel
et al. (2009) (PCS)
A2 3
Optimism 20
Bruce et al. (2012) LOT A1 4
Pinto et al. (2013) (LOT-R) A1 4
Pinto et al. (2014) (LOT-R) A1 4
Pinto et al. (2015) (LOT-R) A1 4
Ronaldson
et al. (2014) (LOT-R)
A1 4
Expectation of pain 18
Bisgaard et al. (2001) B1 2
Desai and
Cheung (2012)
A2 3
Gramke et al. (2009) A1 4
Mamie et al. (2004) B1 2
Montgomery
et al. (2010)
A1 4
Pan et al. (2006) B2 1
Sommer et al. (2010) B1 2
Neuroticism 7
Bachiocco
et al. (1990) (EPI)
B1 2
Bisgaard et al. (2001)
(scale by Bisgaard et al.)
B1 2
Rudin et al. (2008)
(scale by Rudin et al.)
B2 1
Taenzer et al. (1986) (EPI) B1 2
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8. Table 2 (Continued)
Predictor/correlate Association with APSP
Level of
evidence
Score
points
No association
with APSP
Level of
evidence
Score
points
Anxiety 98 24
Anxiety state 48 9
Aubrun et al. (2008) (NRS) A1 4 Grosen et al. (2014) (STAI) A2 3
Bachiocco et al. (1990) (STAI) B1 2 Pan et al. (2006) (STAI) B2 1
Boeke et al. (1991) (STAI) B1 2 Rudin et al. (2008) (STAI) B2 1
Caumo et al. (2002) (STAI) B1 2 Taenzer et al. (1986) (STAI) B2 1
Gramke et al. (2009) (BGFS) A1 4 Weissman-Fogel et al. (2009)(STAI) A2 3
Granot and Goldstein
Ferber (2005) (STAI)
B2 1
Hsu et al. (2005) (STAI) B2 1
Kain et al. (2000) (STAI) B2 1
Kalkman et al. (2003) (STAI, APAIS) A1 4
Katz et al. (2005) (STAI) A1 4
Kaunisto et al. (2013) (STAI) A1 4
Kil et al. (2012) (STAI) A1 4
Mamie et al. (2004)
(questions by Mamie et al.)
B1 2
€Ozalp et al. (2003) (STAI) B2 1
Pinto et al. (2014) (SFQ) A1 4
Pud and Amit (2005) (STAI) B2 1
Scott et al. (1983) (STAI) B2 1
Sommer et al.
(2009)(questions by Koivula et al.)
A1 4
Sommer et al.
(2010)(questions by Koivula et al.)
B1 2
Anxiety trait 50 15
Caumo et al. (2002) (STAI) B1 2 Kain et al. (2000) (STAI) B2 1
De Cosmo et al. (2008) (SAS) B2 1 Khan et al. (2012) (HAD-A) A2 3
Gerbershagen
et al. (2009) (HAD-A)
B2 1 Pan et al. (2006) (STAI) B2 1
Granot and Goldstein
Ferber (2005) (STAI)
B2 1 Pinto et al. (2014) (HAD-A) A1 4
Kalkman et al. (2003) (STAI) A1 4 Rudin et al. (2008) (STAI) B2 1
Katz et al. (2005) (HDARS) A1 4 Sommer et al. (2010) (BIS) B1 2
Kil et al. (2012) (STAI) A1 4 Weissman-Fogel
et al. (2009) (STAI)
A2 3
Lunn et al. (2013) (HAD-A) A1 4
Munafo and
Stevenson (2003) (STAI)
B2 1
Papaioannou
et al. (2009) (HAD-A)
B2 1
Pinto et al. (2012) (HAD-A) A1 4
Pinto et al. (2013) (HAD-A) A1 4
Pinto et al. (2015) (HAD-A) A1 4
Pud and Amit (2005) (STAI) B2 1
Rakel et al. (2012) (STAI) A1 4
Scott et al. (1983) (STAI) B2 1
Taenzer et al. (1986) (STAI) B2 1
Thomazeau et al. (2015) (HAD-A) A1 4
Tolver et al. (2011) (HAD-A) A1 4
Negative affect 7 1
Cohen et al. (2005) (NA) B1 2 Gerbershagen
et al. (2009) (HWBQ-7)
B2 1
Katz et al. (2005) (FACT) A1 4
Roth et al. (2007) (MMSE) B2 1
8 Eur J Pain (2016) – © 2016 European Pain Federation - EFICâ
Psychological correlates of acute postsurgical pain M. Sobol-Kwapinska et al.

9. et al. (2009). The following presurgical psychologi-
cal variables were classified as likely associated with
APSP: pain catastrophizing, optimism, expectation
of pain, neuroticism, anxiety (state and trait), nega-
tive affect and depression. Only one of the psycho-
logical variables investigated in the articles analysed
turned out to be unrelated to APSP: locus of con-
trol. The remaining 32 psychological variables were
investigated in fewer than three articles, and it was
therefore difficult to determine the degree to which
these variables were related to APSP. However, this
does not mean that these variables were not signifi-
cant. Further studies should include those variables,
especially those that were shown in individual
studies to be significant correlates of APSP.
All psychological variables subjected to meta-ana-
lysis – pain catastrophizing, expectation of pain, anx-
iety (state and trait), depression and optimism –
were significantly related with APSP. These results
suggest significant relationship between several pre-
operative psychological factors and APSP. However,
additional analyses indicate that these relations
might be overestimated.
The strongest psychological preoperative correlate
of APSP was pain catastrophizing. In all studies in
which catastrophizing was measured, results were
obtained that pointed to a significant relationship
between this variable and APSP. Anxiety, in turn,
proved to be the most frequent psychological vari-
able measured before surgery. In a majority of stud-
ies a significant relationship was found between
anxiety (trait and state) and APSP, but some studies
suggest no links between these variables. It should
be emphasized that a curvelinear relationship
between anxiety and APSP has also been found (see
Granot and Goldstein Ferber, 2005). The study by
Pinto et al. (2012) suggested that it is not presurgical
anxiety per se that influences the intensity of APSP
but anxiety mediated by pain catastrophizing. It is
also worth noting that Kain et al. (2001) found no
relation between administering anxiety-reducing
medicines before surgery and the level of APSP.
In all the studies, a significant positive relationship
was found between neuroticism and APSP and
between expectation of pain and APSP. Neuroticism
is one of the basic personality traits, indicating a ten-
dency to respond with strong negative emotions
even in response to relatively weak stimuli (Eysenck,
1967). Therefore, people with high levels of neuroti-
cism tend to react with fear, depressed mood and
Table 2 (Continued)
Predictor/correlate Association with APSP
Level of
evidence
Score
points
No association
with APSP
Level of
evidence
Score
points
Depression 46 23
Bachiocco et al. (1990) (MMPI) B1 2 Gerbershagen et al.(2009)(HAD-D) B2 1
Caumo et al. (2002) (MDRS) B1 2 Grosen et al. (2014) (BDI) A2 3
De Cosmo et al. (2008) (SRQ-D) B2 1 Kaunisto et al. (2013) (BDI) A1 4
Ene et al. (2008) (HAD-D) B1 2 Khan et al. (2012) (HAD-D) A2 3
Katz et al. (2005) (BDI) A1 4 Pinto et al. (2014) (HAD-D) A1 4
Kinjo et al. (2012) (GDS) A1 4 Rudin et al. (2008) (HAD-D) B2 1
€Ozalp et al. (2003) (BDI) B2 1 Sullivan et al. (2009) (PHQ) A2 3
Papaioannou et al. (2009) (HAD-D) B2 1 Thomazeau et al. (2015) (HAD-D) A1 4
Pinto et al. (2012) (HAD-D) A1 4
Pinto et al. (2013) (HAD-D) A1 4
Pinto et al. (2015) (HAD-D) A1 4
Radinovic et al. (2014) (GDS) A1 4
Rakel et al. (2012) (GDS) A1 4
Taenzer et al. (1986) (BDI) B2 1
Tolver et al. (2011) (HAD-D) A1 4
Vranceanu et al. (2010) (PHQ) A1 4
STAI, Spielberger State-Trait Anxiety Inventory; SPCS, Situational Pain Catastrophizing Scale; HAD-A, Hospital Anxiety Scale; HAD-D, Hospital
Depression Scale; LOT, Life orientation Test; LOT-R, Life orientation Test – revised; NRS, numerical rating scale; BGFS, Bypass Grafting Fear Scale;
APAIS, Amsterdam Preoperative Anxiety and Information Scale; SFQ, Surgical Fear Questionnaire; MMPI, Minnesota Multiphasic Personality Inven-
tory; MDRS, Montgomery-Asberg Depression Rating Scale; SRQ-D, Self-Rating Questionnaire for Depression; BDI, Beck Depression Inventory; GDS,
Geriatric Depression Scale; PHQ, Patient Health Questionnaire; PCS, Pain Catastrophizing Scale; EPI, Eysenck Personality Inventory; SAS, Self-Rating
Anxiety Scale; BIS, Behavioural Inhibition Scale; HDARS, Hamilton Depression and Anxiety Rating Scales; CSQ-R, Coping Strategies Questionnaire
Revised; NA, Negative Affect Scale; FACT, Functional Assessment of Cancer Treatment; HBWQ-7, Habitual Well-Being Questionnaire; The total
points for each variable is written in bold; Level of evidence and score points - see Supporting Information Appendix S3.
© 2016 European Pain Federation - EFICâ
Eur J Pain (2016) – 9
M. Sobol-Kwapinska et al. Psychological correlates of acute postsurgical pain

10. Table 3 Grade of association 2: no conclusion possible
Predictor/correlate Association with APSP
Level of
evidence
Score
points No association with APSP
Level of
evidence
Score
points
Extroversion 3
Bachiocco et al. (1990) (EPI) B1 2
Taenzer et al. (1986) (EPI) B2 1
Avoidant coping 4
Cohen et al. (2005)
(Brief COPE and IES)
B1 2
Katz et al. (2008) (IES) B1 2
Intrusion 4
Cohen et al. (2005) (IES) B1 2
Katz et al. (2008) (IES) B1 2
Distress 6
Cohen et al. (2005) (IES) B1 2
Montgomery
et al. (2010) (SV-POMS)
A1 4
Self-efficacy 6
Sommer et al. (2010) (GSES)a
B1 2
Vranceanu et al. (2010) (PSE)a
A1 4
Pain-related fear
of movement
7
Sullivan et al. (2009) (TSK) A2 3
Vranceanu et al. (2010) (PASS) A1 4
Psychological
well-being/quality of life
3
Cohen et al. (2005) (MHI) B1 2
Gerbershagen
et al. (2009) (HWBQ-7)
B2 1
Positive affect Bruce et al. (2012) (PANAS)b
A1 4 Gerbershagen
et al. (2009) (HWBQ-7)
B2 1
Hypochondriasis Bachiocco et al. (1990) (MMPI) B1 2
Hysteria Bachiocco et al. (1990) (MMPI) B1 2
Psychopathic deviate Bachiocco et al. (1990) (MMPI) B1 2
Psychosthenia Bachiocco et al. (1990) (MMPI) B1 2
Active coping Cohen et al. (2005)
(Brief COPE)
B1 2
Use of social support Cohen et al. (2005)
(Brief COPE)
B1 2
Reframing Cohen et al. (2005) (Brief COPE) B1 2
Planning Cohen et al. (2005) (Brief COPE) B1 2
Acceptance Cohen et al. (2005)
(Brief COPE)
B1 2
Venting Cohen et al. (2005)
(Brief COPE)
B1 2
Humour Cohen et al. (2005)
(Brief COPE)
B1 2
Religious-based coping Cohen et al. (2005) (Brief COPE) B1 2
Denial Cohen et al. (2005) (Brief COPE) B1 2
Substance use Cohen et al. (2005)
(Brief COPE)
B1 2
Behavioural disengagement Cohen et al. (2005) (Brief COPE) B1 2
Monitor coping style Kain et al. (2000) (MBSS) B2 1
Blunting coping style Kain et al. (2000) (MBSS) B2 1
Evaluation of situations
as stressful
Kain et al. (2000) (MBSS) B2 1
Need for information
regarding the surgery
Kalkman et al. (2003) (APAIS)c
A1 4
Sensitivity to pain Kil et al. (2012) (PSQ) A1 4
Illness coherence Pinto et al. (2013) (IPQ-R) A1 4
Negative emotional
representation
of surgical disease
Pinto et al. (2013) (IPQ-R) A1 4
Defensive style Taenzer
et al. (1986) (MCS)
B2 1
Brief COPE, Brief Cope Questionnaire; IES, Impact of Event Scale; SV-POMS, Profile of Mood States; GSES, General Self-Efficacy Scale; EPI, Eysenck
Personality Inventory; HWBQ-7, Habitual Well-Being Questionnaire; PANAS, Positive and Negative Affect Schedule; MMPI, Minnesota Multiphasic
Personality Inventory; IPQ-R, Revised Illness Perception Questionnaire; PSE, Pain Self-Efficacy Questionnaire; TSK, Tampa Scale for Kinesiophobia;
PASS, Pain Anxiety Symptom Scale; MHI, Mental Health Inventory; MBSS, Monitor-Blunting Style Scale; APAIS, Amsterdam Preoperative Anxiety
and Information Scale; PSQ, Pain Sensitivity Questionnaire; MCS, Marlowe–Crowne Scale. The total points for each variable is written in bold; Level
of evidence and Score points - see Supporting Information Appendix S3.
a
The higher sense of self-efficacy the less pain.
b
The higher positive affect the less pain.
c
The higher need for information the less pain.
10 Eur J Pain (2016) – © 2016 European Pain Federation - EFICâ
Psychological correlates of acute postsurgical pain M. Sobol-Kwapinska et al.

11. exaggerate the threat in stressful situations. Also
interesting is the relationship between expectation of
pain and APSP. These results can be interpreted in
the context of the theory of self-fulfilling prophecies
(e.g. Madon et al., 2011) – the patient feels a level
of pain similar to that which he or she expected. If
before surgery the patient expects strong APSP, it is
very likely that he or she will indeed report a high
level of pain after surgery. This interpretation is also
supported by the relationship between presurgical
optimism and the level of APSP – the more the
patient expects positive events in the future, the
lower level of pain he or she experiences. Studies
also suggested a significant positive relationship
between depression before surgery and APSP but it
is interesting that in over 30 % of the studies where
depression was analysed, no relationship was found
between this variable and APSP. Similarly, a signifi-
cant relationship between negative presurgical affect
and the level of APSP was not found in all studies in
which this variable was analysed. These ambiguous
relationships between depression and negative affect
before surgery and the level of APSP can be inter-
preted as showing that some negative emotions
before surgery are related to the discomfort the
patient experiences at that time – to presurgical pain,
inconvenience, anxiety, etc. After surgery, some of
the stimuli causing negative emotions disappear.
What is more, the relief experienced after surgery,
compared to the negative emotional state before sur-
gery, can even be a source of positive emotions.
To sum up, the results of our review suggest that it
is important for better coping with APSP not to exag-
gerate the negative aspects of the situation and to
have positive expectation about the future. What is
also interesting is the lack of significant relationship
between locus of control and the experience of APSP.
Perhaps the relationship between this variable and
APSP is moderated by personality traits, particularly
by neuroticism and extraversion. Extraverts have
higher well-being when they experience a sense of
control over reality, whereas neurotics have higher
well-being when they believe that life is governed by
forces largely beyond human control (Sobol-Kwa-
pinska, 2016). Perhaps, then, extraverts cope with
pain better when they have a sense of high control
over the situation, whereas neurotics deal with pain
better when they have a sense of external control,
which relieves them from the tension connected with
relying on themselves. This is an interesting direction
of inquiry to pursue in further psychological research
on the determinants of APSP.
It is also worth noting that an increasing interest in
positive variables has been observed over the last few
years. Since the publication of the review by Ip et al.
(2009), new variables such as optimism, positive
affect or self-efficacy have been included in studies.
As regards the limitations of our review, it covered
only articles in English; language bias must therefore
be taken into account in the interpretation of the
results. Moreover, positive correlations between neg-
ative psychological variables measured before sur-
gery and APSP can be partly explained by the fact
that patients with a tendency to complain or lament
– that is to admit to having a high level of anxiety,
depressed mood, et cetera – will also more readily
admit a high intensity of pain, and the other way
around: patients with a tendency to conceal or
ignore their own negative feelings will score lower
both in presurgical psychological measurements and
on scales measuring the intensity of APSP. It is
worth remembering also the desire to present one-
self in an appropriate way, e.g. when pain examina-
tion is carried out by a woman, men usually report
a lower level of pain than they do when it is carried
out by a man (Gijshers and Nicholson, 2005). In
addition, results received in meta-analyses have to
be interpreted cautiously, because of the studies’
heterogeneity and potential publication bias. To
avoid these kinds of biases in future, further studies
should be carried out in large groups of patients,
using reliable research methods, and researchers
should take into account intercorrelations between
preoperative psychological variables.
Table 4 Grade of association 3: association unlikely
Predictor/correlate
Association
with APSP
Level of
evidence Score points No association with APSP
Level of
evidence Score points
Locus of control/Health
locus of control
7
Ene et al. (2008) (MHLC) B1 2
Pinto et al. (2013) (IPQ-R) A1 4
Taenzer et al. (1986) (I-E) (HLOC) B2 1
MHLC, multidimensional health locus of control; IPQ-R, revised illness perception questionnaire; I-E, Rotter locus of control scale; HLOC, health
locus of control scale. Level of evidence and score points – see Supporting Information Appendix S3.
© 2016 European Pain Federation - EFICâ
Eur J Pain (2016) – 11
M. Sobol-Kwapinska et al. Psychological correlates of acute postsurgical pain

12. Conclusions
Significant preoperative psychological correlates of
APSP were the following: pain catastrophizing,
expectation of pain, anxiety (state and trait),
depression, optimism, negative affect and neuroti-
cism/psychological vulnerability. Results of meta-
analyses suggested that pain catastrophizing was
most strongly associated with APSP. It must be noted
that the expression ‘the most common/frequent cor-
relates’ should not be confused with the ‘most
important correlates’.
Author contributions
Co-authors are responsible for specific parts of the work:
MS and PB compiled the conception of the study and pre-
pared the design of the study. MS, PB and BS conducted
the search of databases. MS, PB and WP performed the
data interpretation. MS formulated and developed the
manuscript. PB, WP and BS performed critical revision of
the manuscript. MS, PB, WP and BS gave approval for the
publishing of this manuscript.
Acknowledgements
We thank Waclaw Adamczyk, Paweł Kicman and Natalia
Lisinska for their assistance with the quality assessment of
the reviewed studies.
Note
1
In the case of multivariate analyses, presurgical
variable was qualified as having no relationship with
APSP based only on insignificant correlation with APSP.
If variable was not a significant predictor in regression
analysis but it correlated with APSP significantly, it was
qualified as having a relationship with APSP.
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Supporting Information
Additional Supporting Information may be found online in
the supporting information tab for this article:
Appendix S1. Search strategy: Scopus.
Appendix S2. Characteristics of studies.
Appendix S3. Level of evidence.
Appendix S4 Grade of association.
14 Eur J Pain (2016) – © 2016 European Pain Federation - EFICâ
Psychological correlates of acute postsurgical pain M. Sobol-Kwapinska et al.
The author has requested enhancement of the downloaded file. All in-text references underlined in blue are linked to publications on ResearchGate.The author has requested enhancement of the downloaded file. All in-text references underlined in blue are linked to publications on ResearchGate.