Abstract
Background
Persistent postsurgical pain (PPSP) following thoracic surgery affects 40%–60% of patients undergoing lung resection due to malignancies. Postoperative pain‐related symptoms are common, leading to limitations in activities of daily living (ADL) and deterioration in physical function, which significantly impacts quality of life. Pain‐related limitations are of interest, as postsurgical pain may present as a target for intervention to improve postoperative rehabilitation. This study aimed to evaluate the association between PPSP and ADL limitations during the first 12 postoperative months after surgery for lung cancer.
Methods
A total of 124 patients undergoing surgery for lung cancer were followed for 12 months. Every 2 months, participants reported ADL limitations attributed to PPSP. Cumulative pain impairment scores were calculated from reported limitations in 14 daily activities, and recovery trajectory patterns were analysed.
Results
Daily activities most affected by PPSP were carrying bags, arm elevation, climbing stairs, cleaning floors and coughing, with >50% reporting limitations across all assessment times. Reported pain intensities were generally mild (NRS≤3), but still associated with significant impairment. Some recovery was observed in patients reporting pain at rest, but PPSP was consistently associated with higher cumulative pain impairment scores at all assessments during the 12‐month follow‐up period.
Conclusions
Findings indicate that persistent postsurgical pain, even of mild intensity, is associated with significant limitations in daily activities up to 12 months post‐surgery. Some improvement in pain‐related impairment was observed, although limitations remained significantly higher in patients reporting persistent postsurgical pain, as compared to pain‐free patients.
Significance
Surgery remains a cornerstone in the treatment of early‐stage lung cancer. Despite advances in minimally invasive techniques and rehabilitation, persisting postsurgical pain and pain‐related limitations in daily activities may endure. This study investigated specifically the pain‐related limitations in activities of daily living and described recovery trajectories during the first 12 postoperative months. Patients with persistent postsurgical pain experienced multiple limitations compared to pain‐free patients. Although partial recovery was observed, impairments remained significant for up to 12 months after surgery.
1. INTRODUCTION
Persistent postsurgical pain (PPSP) is prevalent following thoracic surgery with reported incidences of up to 60% in, for example, lung cancer surgery (Wildgaard et al., 2011). Despite widespread and successful adaptation of minimal invasive techniques by video‐assisted thoracoscopic surgery (VATS) over the past two decades, PPSP continues to affect lung cancer survivors. Studies, however report some improvement in pain and quality of life outcomes after VATS compared to open thoracotomy (Bendixen et al., 2016). A frequent and considerable consequence of PPSP in lung cancer patients is decreased physical functioning and limitations in activities of daily living (ADL) (Gottschalk & Ochroch, 2008; Hersini et al., 2015; Kinney et al., 2012; Linwan et al., 2023; Peng et al., 2014; Perttunen et al., 1999; Pompili et al., 2011; Wildgaard et al., 2011). These consequences may be attributed to multiple concomitant factors beyond the surgical procedure, including patients specific factors such as age, disease stage, comorbidities, overall health condition, and perioperative complications (Koczywas et al., 2013; Takei et al., 2023). Some studies report a significant impact of acute postsurgical pain on both short‐ and long‐term functional outcomes (Bayman et al., 2017; Huang et al., 2022). While some studies indicate a return to preoperative levels after 6–12 months, particularly after VATS (Bendixen et al., 2016; Handy et al., 2010), assessments focusing on PPSP impact on daily activities generally reveal a significant decline in functional levels (Bayman et al., 2017; Gottschalk & Ochroch, 2008; Peng et al., 2014; Wildgaard et al., 2011).
In this exploratory longitudinal study, postoperative pain and pain‐related limitations of ADL were evaluated in a prospective, repeated 12‐month survey, utilizing a procedure specific questionnaire by Ringsted et al. which specifically assesses pain‐related limitations in several daily activities after surgery for lung cancer (Ringsted et al., 2013).
The study aimed to (1) characterize and quantify ADL limitations after lung cancer surgery, (2) investigate the effect of PPSP on overall ADL impairment and (3) assess postoperative recovery trajectories in ADL limitations up to 12 months after surgery. The hypotheses were that patients with PPSP would experience greater ADL limitations and protracted recovery compared to patients without PPSP.
2. METHODS
2.1. Study design and settings
The sample population of this exploratory study was a convenient sample drawn from a larger single‐centre observational cohort study evaluating preoperative risk factors for chronic post‐thoracotomy pain (Danielsen et al., 2023). Participants were recruited among patients undergoing surgery for suspected or confirmed lung cancer at the Department of Cardiothoracic surgery, Aalborg University Hospital, where approximately 180 surgeries for lung cancer were performed annually during the study period.
2.2. Study population and recruitment
Patients undergoing lung resection due to confirmed or presumptive primary non‐small cell lung cancer were consecutively recruited over a 4‐year period from May 2014 to April 2018. Patients were approached for inclusion whenever research staff was available. Inclusion criteria were age ≥18 years and ability to read and understand Danish. Exclusion criteria were cancellation of surgery, reoperation or presence of synchronous cancer diagnoses other than primary lung cancer.
2.3. Data collection
Questionnaires were distributed at baseline, 1–3 days before scheduled surgery, and subsequently issued repeatedly during follow‐up, either by conventional mail or by email, depending on participants' preferences. Six postoperative assessments were performed every two months from 2 to 12 months after surgery. Questionnaires were reissued to non‐responders followed by phone or email contact after 2 weeks.
2.3.1. Baseline characteristics
Demographic data, type of surgical procedure and approach (either thoracotomy or VATS), regional anaesthesia and tumour histology were extracted from the electronic medical records.
2.3.2. Repeated survey of limitations in activities of daily life
Pain‐related limitations of daily activities were evaluated 2 months after surgery and then every two months for up to 12 months using a procedure specific questionnaire developed by Ringsted et al. (2013). The questionnaire has been translated into other languages and shown good external validity for evaluation of pain‐related impairment in patients undergoing surgery for lung cancer (Bayman et al., 2017; Dreyfus et al., 2019). The questionnaire consists of 17 ADL items; running, carrying bags/groceries, elevating arm above shoulder height, cleaning, walking 1 km, climbing stairs, kneeling/crouching, standing for 30 min, getting out of bed, swimming, cycling, driving a car, lying on operated side, coughing, sitting in a chair for 30 min, watching TV and sleeping. Three high‐intensity ADL items (running, cycling and swimming) were omitted due to redundancy and ‘driving a car’ was included as earlier suggested (Dreyfus et al., 2019; Ringsted et al., 2013). Participants were asked if they felt that pain from their surgery caused limitations, with six possible answers and corresponding impairment points; ‘Never perform’ / ‘Pain does not impair me at all’ (0 points), ‘Pain impairs me a little’ (1 point), ‘Pain impairs me somewhat’ (2 points), ‘Pain impairs me a lot’ (3 points) and ‘Never perform due to pain’ (4 points). A cumulative pain impairment score was calculated as the sum from the answers on pain‐related ADL limitations in 14 items.
2.3.3. Pain intensity survey
Pain questionnaires were issued at baseline and during follow‐up along with ADL questionnaires. Participants reported the intensity of movement‐evoked pain (MEP) and pain at rest (PAR) on a numeric rating scale (NRS) form 0 (no pain) to 10 (worst pain imaginable).
PPSP was defined as any pain (NRS≥1) in relation to the operation area present beyond 2 months post‐surgery.
2.4. Statistical analyses
Continuous variables are presented as means with standard deviations (SD) or medians with interquartile range (IQR) after evaluation of normality by QQ‐plots. Comparison between means and medians were performed using Student's t‐test and Mann–Whitley U‐test as appropriate. Categorical variables were compared using Pearson's Chi‐square test or Fisher's exact test. The overall proportions of reported pain across assessments were presented with a clustered bootstrap confidence interval to account for repeated measurements. For each assessment time, linear regression was used to assess the association between pain intensity and cumulative pain impairment score.
Linear mixed modelling was used in the analysis of repeated ADL assessments to account for variability between and within subjects. As fixed effect, time of measurement and pain status were included with interaction term. Further fixed effects in the adjusted analysis included age, surgical approach (VATS/thoracotomy), preoperative pain (yes/no) and tumour histology (benign/malignant).
Participants with incomplete data were excluded from individual analyses. Statistical analyses were conducted in STATA Version 16.1 software package, StataCorp. College Station, Texas.
2.5. Ethics
The study was approved by The North Denmark Region Committee on Health Research Ethics (N‐20140062) and conducted in accordance with the Declaration of Helsinki. All patients received oral and written information about the study and signed an informed consent form prior to enrolment.
3. RESULTS
3.1. Study cohort and response rate
A flow chart of study population with dropouts and exclusions is presented in Figure 1. Demographics and clinical characteristics at baseline are shown in Table 1.
FIGURE 1.
Flow chart of study population with exclusions, dropouts and withdrawals.
TABLE 1.
Baseline demographics and clinical characteristics.
| N = 124 | Missing n (%) | |
|---|---|---|
| Demographics | ||
| Age (years) mean (SD) | 67.8 (9.7) | |
| Sex (female) n (%) | 68 (54.8) | |
| Body mass index (kg/m2) mean (SD) | 26.0 (4.9) | |
| Preoperative pain | ||
| Any preoperative pain n (%) | 39 (31.5) | |
| Movement evoked pain | ||
| Yes (NRS ≥1) n (%) | 36 (23.1) | 2 (1.6) |
| Pain intensity (NRS) median (IQR) | 3 (2; 5.5) | |
| Pain at rest | ||
| Yes (NRS ≥1) n (%) | 27 (21.8) | |
| Pain intensity (NRS) median (IQR) | 1.5 (0; 3) | |
| Surgery | ||
| Surgical approach n (%) | ||
| Open thoracotomy | 49 (39.5) | |
| VATS | 75 (60.5) | |
| Surgical procedure n (%) | ||
| VATS lobectomy | 35 (28.2) | |
| Open lobectomy | 32 (25.8) | |
| VATS wedge resection | 35 (28.2) | |
| Open wedge resection | 6 (4.9) | |
| Pneumonectomy | 7 (5.7) | |
| Other open resection | 4 (3.2) | |
| Other VATS resection | 5 (4.0) | |
| Length of hospital stay (days) median (IQR) | 5 (2; 8) | 2 (1.6) |
| Maximum acute pain POD 0 (NRS) median (IQR) | 4 (0; 6) | 12 (9.7) |
| Histology | ||
| Primary lung cancer n (%) | 90 (72.6) | 1 (0.8) |
| Benign histology n (%) | 33 (26.6) | |
Abbreviations: NRS, numeric rating scale; POD, postoperative day; VATS, video‐assisted thoracoscopic surgery.
Response rates declined from the first assessment 2 months after surgery, where complete data were available from 89 of 124 participants (71.8%), until the end of follow‐up after 12 months, where complete data were available form 78 of 124 participants (62.1%). In general, participants completed more pain surveys than ADL surveys during follow‐up. The median (IQR) numbers of returned surveys was 5 (3; 6) and 6 (5; 6), of six issued surveys for ADL and pain status, respectively. Completion rates of both the ADL and pain surveys at each assessment varied between 62.1% at 12 months and 72.6% at 4 months. Response rates at each assessment time and available data in relation to pain status are presented in Table 2.
TABLE 2.
Overall response rates (N = 124) at each assessment time during follow‐up.
| Overall response rates | ||||||
|---|---|---|---|---|---|---|
| 2 months | 4 months | 6 months | 8 months | 10 months | 12 months | |
| Completed ADL surveys, n (%) | 94 (75.8) | 93 (75.0) | 89 (71.8) | 86 (69.4) | 87 (70.2) | 87 (70.2) |
| Completed pain surveys, n (%) | 110 (88.7) | 110 (88.7) | 105 (84.7) | 103 (50.8) | 101 (81.5) | 90 (72.6) |
| Completed both surveys, n (%) | 89 (71.8) | 90 (72.6) | 85 (68.6) | 86 (68.6) | 87 (69.4) | 78 (62.1) |
| Complete responders in relation to PPSP status | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2 months | 4 months | 6 months | 8 months | 10 months | 12 months | |||||||
| Pain (n = 66) | No pain (n = 44) | Pain (n = 51) | No pain (n = 59) | Pain (n = 48) | No pain (n = 57) | Pain (n = 40) | No pain (n = 63) | Pain (n = 36) | No pain (n = 65) | Pain (n = 35) | No pain (n = 55) | |
| Completed both surveys n (%) | 56 (84.9) | 33 (75.0) | 41 (80.4) | 49 (83.1) | 38 (79.2) | 47 (82.5) | 34 (85.0) | 52 (82.5) | 31 (86.1) | 56 (86.2) | 30 (85.7) | 48 (87.3) |
Abbreviations: ADL, activities of daily life.
3.2. Prevalence and properties of PPSP
The prevalence of MEP of any intensity was 60% (95%CI: (50.2%; 69.2%)) at 2 months and declined to 38.9% (95%CI: (28.8%; 49.7%)) after 12 months. The prevalence of PAR was 36.4% (95%CI: (27.4%; 46.1%)) at 2 months and declined to 23.1% (95%CI: (14.9%; 33.1%)) after 12 months.
Between 2% and 6% of the participants reported new occurrence of pain between the bi‐monthly assessments. The numbers of participants with shifting pain status at each assessment are available in supplemental material (Table S1).
Across all assessments, reported PPSP was generally of mild intensity (NRS≤3): 75.1% (95%CI: (65.7%; 84.5%)) of participants reported mild MEP and 82.9% (95%CI: (73.6%; 92.3%)) reported mild PAR. The median (IQR) NRS for MEP were 2 (1; 4) at 2 months, 2 (1; 3) at 4 months, 1 (1; 3) at 6 months, 2 (1; 3) at 8 months, 2 (1; 3) at 10 months and 1 (1; 4) at 12 months after surgery. For PAR, the median NRS (IQR) were 2 (1; 3) at 2 months, 1 (1; 2) at 4 months, 1 (1; 2) at 6 months, 2 (1; 4) at 8 months, 1.5 (1; 2) at 10 months and 2 (1; 3) at 12 months after surgery.
When distinguishing between MEP and PAR, three participants reported only PAR at three different occasions during follow‐up. In average, 61.6% (95%CI: (51.7%; 71.5%)) of participants with PPSP reported both MEP and PAR, and 43.8% (95%CI: (33.4%; 54.3%)) reported only MEP.
No association between PPSP and surgical approach (open vs VATS) was observed at any of the assessments (Fisher's exact test: p = 0.31 at 2 months, p = 0.43 at 4 months, p = 0.43 at 6 months, p = 0.41 at 8 months, p = 0.53 at 10 months and p = 0.83 at 12 months).
3.3. ADL limitations
Participants most often reported pain‐related ADL limitations when carrying bags (70.0%–85.7%), arm elevation (51.4%–64.7%), climbing stairs (66.7%–90%), cleaning floors (56.8%–76.7%) and coughing (56.8%–75.0%). The least restricted activities included watching TV (8.1%–17.6%) and driving (16.2%–39.3%). Up to 4.2% (95%CI: (0.1%; 14.3%)) reported some surgery‐related ADL limitations at final follow‐up after 12 months when carrying bags, cleaning floors and climbing stairs. The proportions of participants reporting pain‐related ADL limitations in individual items are presented in Figure 2.
FIGURE 2.
Proportion of participants reporting any impairment in 14 ADL‐items at bimonthly assessments in relation to PPSP‐status. PPSP is defined as any pain NRS≥1 in relation to the operation area. Available data (number of observations, n) at each assessment: 2 months; n = 89, 4 months; n = 90, 6 months; n = 85, 8 months; n = 86, 10 months; n = 87, 12 months; n = 78. ADL, activities of daily life; PPSP, persistent postsurgical pain; NRS, numeric rating scale.
The extend of ADL limitations in relation to PPSP‐status after 2 and 12 months are presented in Figure 3 (results from all assessments during follow‐up are available in supplemental material, Figure S1).
FIGURE 3.
Proportions and extend of ADL limitations in relation to PPSP‐status at 2 and 12 months after surgery. PPSP is defined as any movement‐evoked pain (NRS≥1) with or without concomitant pain at rest. ADL, activities of daily living; PPSP, persistent postsurgical pain; NRS, numeric rating scale.
3.4. Cumulative pain impairment score and pain intensity
Cumulative impairment scores increased with the intensity of MEP (Figure 4) and PAR (Figure 5), showing a linear trend at all assessments. Results from linear regression modelling at each assessment time are presented in Table 3.
FIGURE 4.
Scatterplots of cumulative pain impairment scores and reported MEP intensity. Linear prediction trend lines (solid) with 95% confidence intervals (dashed) indicated in plots. NRS, numeric rating scale; MEP, movement‐evoked pain.
FIGURE 5.
Scatterplots of cumulative pain impairment scores and reported PAR intensity. Linear prediction trend lines (solid) with 95% confidence intervals (dashed) indicated in plots. NRS, numeric rating scale; MEP, movement‐evoked pain.
TABLE 3.
Simple linear regression analysis of the effect of pain intensity on cumulative pain impairment score at each assessment time during follow‐up.
| Pain intensity (NRS) | Movement evoked pain | Pain at rest | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| n | Coefficient | 95% CI | p‐value | R 2 | n | Coefficient | 95% CI | p‐value | R 2 | |
| 2 months | 89 | 2.87 | 2.37; 3.36 | <0.01 | 0.60 | 89 | 4.39 | 3.39; 5.40 | <0.01 | 0.46 |
| 4 months | 90 | 2.61 | 2.04; 3.18 | <0.01 | 0.48 | 90 | 4.97 | 3.80; 6.13 | <0.01 | 0.45 |
| 6 months | 85 | 2.44 | 2.0; 2.81 | <0.01 | 0.69 | 85 | 3.25 | 2.63; 3.87 | <0.01 | 0.56 |
| 8 months | 86 | 2.82 | 2.36; 3.28 | <0.01 | 0.63 | 86 | 3.71 | 2.92; 4.49 | <0.01 | 0.51 |
| 10 months | 87 | 2.73 | 2.22; 3.23 | <0.01 | 0.57 | 87 | 4.48 | 3.36; 5.59 | <0.01 | 0.42 |
| 12 months | 78 | 1.93 | 1.45; 2.41 | <0.01 | 0.45 | 79 | 2.05 | 1.24; 2.86 | <0.01 | 0.24 |
Note: The R 2‐value indicates the proportion of variance in cumulative pain impairment score explained by pain intensity. Coefficients represent slope of the regression line, that is, the increase in cumulative pain impairment score for each NRS‐point increase in pain intensity. ‘n’ denotes number of participants with available data.
3.5. Cumulative pain impairment scores and recovery
Mean cumulative pain impairment scores according to PPSP status are presented in Figure 6. Significantly higher cumulative pain impairment scores were observed in participants reporting PPSP (p < 0.01). Crude and adjusted estimates of mean differences in cumulative pain impairment scores from multilevel mixed‐effects modelling are presented in Table 4. No significant effects were observed for the adjustment variables. Impairment scores increased by 1.7 (95%CI: (−0.1; 3.4), p = 0.06) among patients with preoperative pain, 0.0 (95%CI: (−0.1; 0.1), p = 0.40) per year for age, 1.1 (95%CI: (−0.5; 2.7), p = 0.19) for open thoracotomy, while scores decreased −0.2 (95%CI: (−2.0; 1.7), p = 0.85) for benign tumour histology.
FIGURE 6.
Trajectories of cumulative pain impairment scores in relation to Persistent postsurgical pain (PPSP) status with 95% confidence intervals (whiskers). PPSP is defined as any movement‐evoked pain (NRS≥1) with or without concomitant pain at rest.
TABLE 4.
Results from multilevel mixed‐effects linear regression.
| Time after surgery | No PPSP | PPSP movement‐evoked pain | PPSP movement‐evoked pain and pain at rest | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| n | Mean (SD) | n | Mean difference (95% CI) | p‐value a | n | Mean difference (95% CI) | p‐value a | |||
| Cumulative pain impairment score | Unadjusted | 2 months | 33 | 2.1 (4.7) | 21 | 6.1 (3.7; 8.5) | <0.01 | 35 | 9.3 (7.2; 11.5) | <0.01 |
| 4 months | 49 | 2.8 (4.9) | 16 | 3.7 (1.2; 6.2) | <0.01 | 24 | 6.1 (3.8; 8.3) | <0.01 | ||
| 6 months | 47 | 1.4 (5.0) | 17 | 3.6 (1.5; 6.0) | <0.01 | 20 | 7.8 (5.4; 10.2) | <0.01 | ||
| 8 months | 52 | 1.8 (4.9) | 15 | 4.9 (2.4; 7.4) | <0.01 | 19 | 9.2 (6.8; 11.6) | <0.01 | ||
| 10 months | 56 | 1.5 (5.0) | 12 | 5.8 (3.0; 8.5) | <0.01 | 18 | 7.7 (5.3;10.12) | <0.01 | ||
| 12 months | 48 | 1.5 (4.9) | 12 | 4.8 (2.0; 7.6) | <0.01 | 18 | 5.3 (2.9; 7.8) | <0.01 | ||
| Adjusted | 2 months | 33 | 2.2 (4.8) | 21 | 6.0 (3.6; 8.4) | <0.01 | 35 | 9.4 (7.2; 11.6) | <0.01 | |
| 4 months | 49 | 2.8 (4.9) | 16 | 3.7 (1.2; 6.2) | <0.01 | 24 | 6.3 (4.0; 8.6) | <0.01 | ||
| 6 months | 47 | 1.5 (4.9) | 17 | 3.6 (1.2; 6.0) | <0.01 | 20 | 7.7 (5.3; 10.1) | <0.01 | ||
| 8 months | 52 | 1.7 (5.0) | 15 | 5.0 (2.5; 7.5) | <0.01 | 19 | 9.2 (6.8; 11.7) | <0.01 | ||
| 10 months | 56 | 1.6 (5.0) | 12 | 5.6 (2.9; 8.3) | <0.01 | 18 | 7.6 (5.2; 10.0) | <0.01 | ||
| 12 months | 48 | 1.6 (4.9) | 12 | 4.8 (2.1; 7.5) | <0.01 | 18 | 5.2 (2.7; 7.6) | <0.01 | ||
Note: Mean differences in cumulative pain impairment scores (with 95% confidence intervals) in relation to PPSP status. Available data denoted by ‘n’. Estimates from the adjusted model are adjusted for preoperative pain (yes/no), age, surgical approach (VATS/open thoracotomy) and tumour histology (benign/malignant). Cumulative pain impairment scores were calculated from 14 items: Carrying bags/groceries, elevating arm above shoulder height, cleaning, walking 1 km, climbing stairs, kneeling/crouching, standing for 30 min, getting out of bed, driving a car, lying on operated side, coughing, sitting in a chair for 30 min, watching TV and sleeping. Each item contributed with 0 points (not impaired) up to 4 points (most impaired).
Abbreviations: NRS, numeric rating scale; PPSP, persistent postsurgical pain; VATS, video‐assisted thoracoscopic surgery.
Cumulative pain impairment score from pain‐free patients (No PPSP) is used as reference for calculation of p‐values. PPSP defined as NRS≥1.
Some recovery in ADL impairment was observed from 2 to 12 months, as cumulative pain impairment scores improved in participants reporting both MEP and PAR, with an adjusted mean decrease of −4.0 (95%CI: (−7.0; −1.0), p < 0.01). Participants reporting only MEP did not experience any significant recovery from 2 to 12 months, with an adjusted decrease in mean impairment score of −1.3 (95%CI: (−4.; 2.3), p = 0.49).
When comparing cumulative pain impairment scores between participants reporting both MEP and PAR to those reporting only MEP (Figure 4), scores were significantly higher at 2 months (p < 0.01), 6 months (p < 0.01) and 8 months (p < 0.01), but not at 4 months (p = 0.13), 10 months (p = 0.38) and 12 months (p = 0.83).
4. DISCUSSION
This longitudinal study assesses the trajectory of pain‐related limitations in daily activities and functional recovery in relation to persistent postsurgical pain following surgery for lung cancer, based on repeated bi‐monthly surveys over a 12‐month period. The findings indicate that even mild intenisty pain is associated with significant limitations in daily activities up to 12 months after surgery. Some recovery in pain‐related impairment was observed among patients reporting persistent postsurgical pain; however, more than half of the patients continued to report some pain‐related limitations in eight of 14 activities of daily living.
4.1. Functional impairment and persistent postsurgical pain following lung cancer surgery
Previous studies in operated lung cancer patients have examined functional impairment, revealing a substantial pain‐related impacts on ADL and quality of life (Bayman et al., 2017; Bendixen et al., 2016; Hersini et al., 2015; Kinney et al., 2012; Linwan et al., 2023; Peng et al., 2014; Wildgaard et al., 2011). By an exploratory approach, this study aimed to evaluate pain‐related ADL limitations using a procedure specific questionnaire. Our study includes a prospective, repeated ADL assessment, and findings indicate that patients with PPSP consistently experience more limitations in daily activities compared to pain‐free patients, up to 12 months after surgery.
The prevalence of PPSP declined from 2 to 12 months post‐surgery, decreasing from 60% to 39% for MEP and 36% to 23% for PAR. The intensity of PPSP was generally mild with a reported NRS≤3 in 75% of patients for MEP and 83% for PAR across all assessments. The extent of impairment, evaluated by cumulative impairment score, with correlated to pain intensity. Nevertheless, even mild pain was associated with limitations in several daily activities. In addition, patients reporting both MEP and PAR experienced greater impairment during recovery than those with MEP alone. These findings support the relevance of a more detailed characterization of postoperative pain. Larger studies are needed to determine and characterize the true impact of PPSP on functional outcomes. Ultimately, a more detailed understanding of postoperative pain‐related ADL impairment may provide valuable insights for further development of rehabilitation programs in specific subpopulations, and facilitate precise preoperative patient education regarding recovery and functional outcomes (Mani et al., 2023; Oswald et al., 2018; Renna et al., 2020).
4.2. Cumulative pain impairment score
The cumulative pain impairment scores after 12 months were 6.3 (SD: 4.8) for patients with MEP only and 6.8 (SD: 4.7) in patients reporting both PAR and MEP. Comparable scores of 6.95 (SD: 9.5) and 8.16 (SD: 10.5) have been reported in two previous studies (Bayman et al., 2017; Ringsted et al., 2013). These scores were based on data collected retrospectively between 6 months and 3 years after surgery, based on 13 ADL items. When calculating the cumulative pain impairment score at 12 months, using the same 13 items in our study cohort, the mean scores were 3.7 (SD: 5.5) and 8.67 (SD: 6.1) in patients with PPSP. In a study by Dreyfus et al. (2019) assessing cumulative impairment scores in a French cohort, a direct comparison can be made for the score on nine items categorized as ‘routine daily activities’. The prevalence of PPSP was 40% in the French cohort and 46% in ours, with median (IQR) cumulative impairment scores of 10 (5; 15) and 5 (2; 8), respectively. When scrutinizing the degree of impairment on item level, the frequencies of any impairment are comparable; however, the French cohort reported higher impairment within each item, while pain intensities between studies were comparable.
The repeated cumulative pain impairment scores in our study appear to be lower than previous reports. However, our results account for time interaction, potential shifts in pain status, and adjustments for potential confounders, making direct comparisons challenging. Nevertheless, patients suffering from PPSP consistently report higher cumulative pain impairment scores across studies underscoring the clinical significance of PPSP in relation to functional outcomes (Bayman et al., 2017; Dreyfus et al., 2019; Ringsted et al., 2013).
4.3. Persistent postsurgical pain and functional recovery
To our knowledge, this is the first study to report repeated detailed assessments of limitations in various activities of daily living following surgery for lung cancer. Pain and pain interference may fluctuate over time, and pain‐related impairment may decline with remission or as patients adapt or learn to cope with their limitations despite PPSP. The chosen method and design accommodate for shifting pain status, which is a phenomenon earlier observed (Hetmann et al., 2017; Perttunen et al., 1999). Additionally, our method considers potential interactions between PPSP status and assesment time.
We chose to differentiate between MEP and PAR, as not all patients reporting MEP also reported PAR. It has recently been suggested that a distinction between MEP and PAR is clinically important and enhances comparability between studies when assessing pain outcomes (Gilron et al., 2023). When distinguishing between MEP and PAR, we observed that patients with both MEP and PAR initially reported higher cumulative pain impairment scores which later declined to levels similar to those of patients reporting only MEP. This may indicate that the recovery seen in patients with both MEP and PAR is primarily driven by recovery in PAR. However, this conclusion cannot be conformed based on findings from this small exploratory study. Only very few patients exclusively reported PAR without MEP, so results should be interpreted cautiously when considering the effect of PAR alone on ADL recovery.
Our study specifically focused on pain‐related ADL recovery paths utilizing a procedure specific questionnaire. It is one of few prospective studies to report repeated assessments of ADL limitations and PPSP after lung cancer surgery (Balduyck et al., 2009; Bendixen et al., 2016; Gottschalk & Ochroch, 2008; Perttunen et al., 1999). While the observed differences in cumulative impairment scores between patients with and without PPSP may appear modest, the overall association between PPSP and ADL limitations remains substantial, considering the number of affected activities and the extent of limitations.
Given the association and seemingly considerable effect of PPSP on ADL limitations, preventing and alleviating postsurgical pain after lung cancer surgery could be an important target for enhancing rehabilitation and improving functional outcomes after lung cancer surgery.
4.4. Limitations
Information regarding preoperative pain was gathered, but detailed data concerning its location were not collected. Including such information would have strenghthened the study, as research suggests associations between PPSP and certain chronic pain conditions such as headaches and back pain, while others do not (Bayman et al., 2017; Wildgaard et al., 2016).
Early dropouts within the first 3 months constituted approximately 24% of included patients and 44% was attributed to non‐pain‐related reasons. Among the 201 patients initially recruited, 9.5% did not complete the pain survey at baseline, and 15.9% either remained unresponsive or withdrew consent. This could introduce selection bias if the reasons for non‐participation were related to pain‐related incapability to answer the questionnaires. Furthermore, no information was collected on postoperative psychological factors, analgesics and physiotherapy, which could potentially influence reported pain scores and ADL limitations.
No widely adapted standard method for the evaluation of ADL limitations in surgical patients yet exists,making direct comparisons between studies difficult. A detailed assessment method developed specifically for thoracic patients could offer more precise information on procedure‐related ADL limitations. The ADL survey chosen for this study was designed solely to inquire about postoperative pain‐related limitations. Consequently, our method does not allow for a comparison between pre‐ and postoperative ADL limitations in general, which is of interest, as some studies suggest a return to preoperative functional levels (Linwan et al., 2023).
Generalizability of the presented results may depend on differences in study populations, such as disease stages, cultural variations and local differences in clinical practices. These limitations are inherent to single‐centre studies. In addition, only about one‐third of patients undergoing lung cancer surgery at our institution were approached for inclusion, and no information was available from those who declined participation, which increases the risk of selection bias.
The observed prevalence of PPSP and ADL limitations aligns with previous studies in lung cancer patients that employ the same assessment method for ADL limitations (Bayman et al., 2017; Dreyfus et al., 2019; Ringsted et al., 2013).However, we consistently observed lower cumulative impairment scores. It is important to note, that our results are not directly comparable to previous studies which were cross‐sectional, in contrast to our prospective design with repeated assessments.
5. CONCLUSIONS
This longitudinal study indicates that persistent postsurgical pain, even of mild intensity, is associated with significant limitations in daily activities. Some improvement in pain‐related impairment was observed during the 12‐month postoperative period; however, limitations remained significantly higher in patients reporting persistent postsurgical pain compared to pain‐free patients.
AUTHOR CONTRIBUTIONS
AVD contributed to acquisition, validation, analysis and interpretation of the data together with drafting, revision and submission of the published version of this article. BD and JH contributed with expertise in electronic data acquisition and provided the platform and design of the database. Furthermore, JH contributed to data collection. CS included patients and performed preoperative assessments and contributed to data collection and interpretation. KD contributed to data analysis and interpretation together with critical inputs in the writing of the article. JJA, LAN and KKP contributed to conception and design of the study, data analysis and interpretation together with critical inputs in the writing of the article. All authors contributed to critical revision and final approval of the published article.
FUNDING INFORMATION
Department of Cardiothoracic Surgery, Aalborg University Hospital. Speciallæge Heinrich Kopps Research Grant. Center for Neuroplasticity and Pain (CNAP), supported by the Danish National Research Foundation (Grant number: DNRF121).
CONFLICT OF INTEREST STATEMENT
The authors have no present or potential conflicts of interest to declare in relation to this study.
Supporting information
Figure S1: Proportions and extend of ADL limitations in relation to PPSP‐status at each bimonthly assessment from 2 to 12 months after surgery. PPSP defined as any movement‐evoked pain NRS≥1 with or without concomitant pain at rest. ADL, activities of daily life; PPSP, persistent postsurgical pain; NRS, numeric rating scale.
Table S1: Shifts in pain status between assessments during follow‐up. Pain is defined as NRS≥1, no pain is defined as NRS = 0. ‘n’ denotes number of participants with available data.
ACKNOWLEDGEMENTS
The authors thank project nurses Anita Tracey and Dorte Nøhr for their assistance in study inclusion and data collection, and Kamelia Javanshir Hersini for help in writing the study protocol.
Danielsen, A. V. , Andreasen, J. J. , Dinesen, B. , Hansen, J. , Petersen, K. K. , Duch, K. S. , Simonsen, C. , & Arendt‐Nielsen, L. (2025). Pain‐related impairment in daily activities after lung cancer surgery: A 1‐year prospective cohort study. European Journal of Pain, 29, e4749. 10.1002/ejp.4749
REFERENCES
- Balduyck, B. , Hendriks, J. , Lauwers, P. , Sardari Nia, P. , & Van Schil, P. (2009). Quality of life evolution after lung cancer surgery in septuagenarians: A prospective study. European Journal of Cardio‐Thoracic Surgery: Official Journal of the European Association for Cardio‐Thoracic Surgery, 35(6), 1070–1075. 10.1016/j.ejcts.2009.01.050 [DOI] [PubMed] [Google Scholar]
- Bayman, E. O. , Lennertz, R. , & Brennan, T. J. (2017). Pain‐related limitations in daily activities following thoracic surgery in a United States population. Pain Physician, 20(3), E367–E378. 10.36076/ppj.2017.e378 [DOI] [PubMed] [Google Scholar]
- Bendixen, M. , Jorgensen, O. D. , Kronborg, C. , Andersen, C. , & Licht, P. B. (2016). Postoperative pain and quality of life after lobectomy via video‐assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: A randomised controlled trial. The Lancet. Oncology, 17(6), 836–844. 10.1016/S1470-2045(16)00173-X [DOI] [PubMed] [Google Scholar]
- Danielsen, A. V. , Andreasen, J. J. , Dinesen, B. , Hansen, J. , Kjær‐Staal Petersen, K. , Simonsen, C. , & Arendt‐Nielsen, L. (2023). Chronic post‐thoracotomy pain after lung cancer surgery: A prospective study of preoperative risk factors. Scandinavian Journal of Pain, 23(3), 501–510. 10.1515/sjpain-2023-0016 [DOI] [PubMed] [Google Scholar]
- Dreyfus, J.‐F. , Kassoul, A. , Michel‐Cherqui, M. , Fischler, M. , & Le Guen, M. (2019). A French version of Ringsted's questionnaire on pain‐related impairment of daily activities after lung surgery: A cohort study. Anaesthesia, Critical Care & Pain Medicine, 38(6), 615–621. 10.1016/j.accpm.2019.02.014 [DOI] [PubMed] [Google Scholar]
- Gilron, I. , Lao, N. , Carley, M. , Camiré, D. , Kehlet, H. , Brennan, T. J. , & Erb, J. (2023). Movement‐evoked pain versus pain at rest in postsurgical clinical trials, and, in meta‐analyses: An updated systematic review. Anesthesiology, 140(3), 442–449. 10.1097/ALN.0000000000004850 [DOI] [PubMed] [Google Scholar]
- Gottschalk, A. , & Ochroch, E. A. (2008). Clinical and demographic characteristics of patients with chronic pain after major thoracotomy. The Clinical Journal of Pain, 24(8), 708–716. 10.1097/AJP.0b013e318174badd [DOI] [PubMed] [Google Scholar]
- Handy, J. R. J. , Asaph, J. W. , Douville, E. C. , Ott, G. Y. , Grunkemeier, G. L. , & Wu, Y. (2010). Does video‐assisted thoracoscopic lobectomy for lung cancer provide improved functional outcomes compared with open lobectomy? European Journal of Cardio‐Thoracic Surgery: Official Journal of the European Association for Cardio‐Thoracic Surgery, 37(2), 451–455. 10.1016/j.ejcts.2009.07.037 [DOI] [PubMed] [Google Scholar]
- Hersini, K. J. , Andreasen, J. J. , Birthe Dinesen, P. G. , & Arendt‐Nielsen, L. (2015). Prevalence, characteristics and impact of the post‐thoracotomy pain syndrome on quality of life: A cross‐sectional study. Journal of Pain & Relief, 4(5), 201‐207. 10.4172/2167-0846.1000201 [DOI] [Google Scholar]
- Hetmann, F. , Kongsgaard, U. E. , Sandvik, L. , & Schou‐Bredal, I. (2017). Post‐thoracotomy pain syndrome and sensory disturbances following thoracotomy at 6‐ and 12‐month follow‐ups. Journal of Pain Research, 10, 663–668. 10.2147/JPR.S126639 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Huang, L. , Kehlet, H. , & Petersen, R. H. (2022). Functional recovery after discharge in enhanced recovery video‐assisted thoracoscopic lobectomy: A pilot prospective cohort study. Anaesthesia, 77(5), 555–561. 10.1111/anae.15682 [DOI] [PubMed] [Google Scholar]
- Kinney, M. A. O. , Hooten, W. M. , Cassivi, S. D. , Allen, M. S. , Passe, M. A. , Hanson, A. C. , Schroeder, D. R. , & Mantilla, C. B. (2012). Chronic postthoracotomy pain and health‐related quality of life. The Annals of Thoracic Surgery, 93(4), 1242–1247. 10.1016/j.athoracsur.2012.01.031 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Koczywas, M. , Williams, A. C. , Cristea, M. , Reckamp, K. , Grannis, F. W. J. , Tiep, B. L. , Uman, G. , & Ferrell, B. (2013). Longitudinal changes in function, symptom burden, and quality of life in patients with early‐stage lung cancer. Annals of Surgical Oncology, 20(6), 1788–1797. 10.1245/s10434-012-2741-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Linwan, Z. , Kondo, K. , Bando, T. , Kawakita, N. , Toba, H. , Imai, Y. , & Takizawa, H. (2023). Assessment of dyspnea, ADL, and QOL in the perioperative period in lung cancer patients treated with minimally invasive surgery. The Journal of Medical Investigation: JMI, 70(3.4), 388–402. 10.2152/jmi.70.388 [DOI] [PubMed] [Google Scholar]
- Mani, K. , Luttman, J. , Nowell, J. , Carrol, A. , & Jahangiri, M. (2023). Patients' expectation of postoperative course and satisfaction following cardiac surgery. Annals of the Royal College of Surgeons of England, 105(1), 20–27. 10.1308/rcsann.2022.0137 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Oswald, N. , Hardman, J. , Kerr, A. , Bishay, E. , Steyn, R. , Rajesh, P. , Kalkat, M. , & Naidu, B. (2018). Patients want more information after surgery: A prospective audit of satisfaction with perioperative information in lung cancer surgery. Journal of Cardiothoracic Surgery, 13(1), 18. 10.1186/s13019-018-0707-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Peng, Z. , Li, H. , Zhang, C. , Qian, X. , Feng, Z. , & Zhu, S. (2014). A retrospective study of chronic post‐surgical pain following thoracic surgery: Prevalence, risk factors, incidence of neuropathic component, and impact on qualify of life. PLoS One, 9(2), e90014. 10.1371/journal.pone.0090014 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Perttunen, K. , Tasmuth, T. , & Kalso, E. (1999). Chronic pain after thoracic surgery: A follow‐up study. Acta Anaesthesiologica Scandinavica, 43(5), 563–567. [DOI] [PubMed] [Google Scholar]
- Pompili, C. , Brunelli, A. , Xiumé, F. , Refai, M. , Salati, M. , & Sabbatini, A. (2011). Predictors of postoperative decline in quality of life after major lung resections. European Journal of Cardio‐Thoracic Surgery : Official Journal of the European Association for Cardio‐Thoracic Surgery, 39(5), 732–737. 10.1016/j.ejcts.2010.08.046 [DOI] [PubMed] [Google Scholar]
- Renna, M. S. , Metcalfe, A. , Ellard, D. , & Davies, D. (2020). A patient satisfaction survey investigating pre‐ and post‐operative information provision in lower limb surgery. BMC Musculoskeletal Disorders, 21(1), 754. 10.1186/s12891-020-03761-w [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ringsted, T. K. , Wildgaard, K. , Kreiner, S. , & Kehlet, H. (2013). Pain‐related impairment of daily activities after thoracic surgery: A questionnaire validation. The Clinical Journal of Pain, 29(9), 791–799. 10.1097/AJP.0b013e318278d4e2 [DOI] [PubMed] [Google Scholar]
- Takei, H. , Kunitoh, H. , Wakabayashi, M. , Kataoka, T. , Sekino, Y. , Mizutani, T. , Tsuboi, M. , Ikeda, N. , Asamura, H. , Okada, M. , Takahama, M. , Ohde, Y. , Okami, J. , Shiono, S. , Aokage, K. , & Watanabe, S.‐I. (2023). Prospective, multi‐institutional observational study of deterioration in activities of daily living in elderly patients after lung cancer surgery. JTO Clinical and Research Reports, 4(8), 100550. 10.1016/j.jtocrr.2023.100550 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Wildgaard, K. , Ravn, J. , Nikolajsen, L. , Jakobsen, E. , Jensen, T. S. , & Kehlet, H. (2011). Consequences of persistent pain after lung cancer surgery: A nationwide questionnaire study. Acta Anaesthesiologica Scandinavica, 55(1), 60–68. 10.1111/j.1399-6576.2010.02357.x [DOI] [PubMed] [Google Scholar]
- Wildgaard, K. , Ringsted, T. K. , Hansen, H. J. , Petersen, R. H. , & Kehlet, H. (2016). Persistent postsurgical pain after video‐assisted thoracic surgery ‐ an observational study. Acta Anaesthesiologica Scandinavica, 60(5), 650–658. 10.1111/aas.12681 [DOI] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Figure S1: Proportions and extend of ADL limitations in relation to PPSP‐status at each bimonthly assessment from 2 to 12 months after surgery. PPSP defined as any movement‐evoked pain NRS≥1 with or without concomitant pain at rest. ADL, activities of daily life; PPSP, persistent postsurgical pain; NRS, numeric rating scale.
Table S1: Shifts in pain status between assessments during follow‐up. Pain is defined as NRS≥1, no pain is defined as NRS = 0. ‘n’ denotes number of participants with available data.