Goals, mood and performance duration on cognitive tasks during experimentally induced mechanical pressure pain

BACKGROUND

The present study tested the hypothesis that the affective and motivational context influences performance duration in the presence of pain. More specifically, the Mood-as-Input model (MAI) proposes that the interaction between goals and moods affects performance duration. When people adopt achievement goals, negative, as opposed to positive moods, signal that not enough progress has been made leading to task continuance. Negative as opposed to positive moods lead to task disengagement when adopting hedonic goals.

METHODS

Participants completed three open-ended cognitive tasks while being exposed to mechanical pressure pain to a finger. Before each task, mood (positive versus negative) and goal pursuit (hedonic versus achievement) were manipulated, with mood as between-subjects and goal pursuit as within-subjects factor. Performance duration was the dependent variable and goal order and performance duration during a no-goal task were the covariates.

RESULTS

In line with common theories on goals and mood, but in contrast to the MAI model, only main effects were found of mood and goal pursuit. Participants showed greater performance duration in an achievement than in a hedonic goal context. Moreover, they showed greater performance duration in relative positive than negative moods.

LIMITATIONS

Pain may have decreased participants' mood below a certain threshold, which in turn may have obscured the MAI interaction effect.

CONCLUSIONS

This study demonstrates that affective and motivational factors influence performance duration in a pain context.

Observational learning and pain-related fear: exploring contingency learning in an experimental study using colored warm water immersions

This study investigated observational learning of pain-related fear and subsequent extinction after first-hand exposure to the feared stimulus. Moreover, the specific contingencies that are learned when observing others in pain were explored. A differential fear-conditioning paradigm was used, showing video models displaying either a painful (CS+ color; aversively conditioned stimulus) or a neutral (CS- color; neutrally conditioned stimulus) facial expression in the presence of a colored warm water task (WWT; observation phase). In 1 condition (open WWT cover), the model's hand was immersed in the colored liquid, while in the other condition (closed WWT cover), no contact was displayed between the model and the liquid. During exposure, participants subsequently immersed their own hand into each WWT with equal temperatures. Results revealed successful acquisition of pain-related fear. Participants with higher levels of pain catastrophizing, intolerance of uncertainty, trait fear of pain, or dispositional empathy were more prone to develop pain-related fear. Pain-related fear extinguished quickly after direct exposure to both WWTs. Contingencies between the color of the WWT and either the painful facial expressions or the assumed properties of the colored liquid were learned in both conditions. Clinical implications and limitations of the current study are discussed, providing avenues for future research in observational learning of pain-related fear.

PERSPECTIVE

Pain-related fear promotes the development as well as the continuation of chronic pain. A better understanding of the acquisition and extinction of this fear may help to improve pain treatment programs. Furthermore, we intended to identify individuals who are more prone to develop pain-related fear.

Feasibility of a nurse-led in-home cognitive behavioral program to manage concerns about falls in frail older people: a process evaluation

Concerns about falls and related avoidance of activities are common problems among older people living in the community. In this study we examined the feasibility and acceptability of AMB-Home (the Dutch in-home version of A Matter of Balance), a nurse-led in-home cognitive behavioral program developed for frail community-living older people with concerns about falls and related activity avoidance. The multicomponent program consisted of seven individual sessions, including three home visits and four telephone contacts. Data were collected from eight nurses and 194 participants. Generally, the program was considered acceptable and feasible by both the nurses and the participants. When AMB-Home turns out to be effective, the implementation of a fine-tuned version of this in-home program in regular health care, would be a natural next step.

Pain catastrophizing moderates the effects of pain-contingent task interruptions

BACKGROUND

A prominent behavioural consequence of pain is the temporary suspension of current activities with intent to resume them later. Little is known about the effects of such pain-contingent task interruptions. This experiment examines the influence of pain-contingent interruptions on the amount of time spent performing a cognitive achievement task: We expected that people would spend more time on task when task performance was interrupted in response to pain (vs. no interruption), and that negative mood and pain catastrophizing would enhance this negative impact.

METHODS

Healthy volunteers read behaviour descriptions until they felt they could form a good impression. Before task performance, participants underwent a negative or positive mood induction. During the task, all participants expected painful stimulation. Half of the participants in each mood induction group received an acute (electrocutaneous) pain stimulus, resulting in a 2-min break from the task. The other participants received no sensory stimulation during task performance and their performance was not interrupted.

RESULTS

Results revealed no effect of mood on task performance (i.e., total number of descriptions read). There was, however, a significant interaction between task interruption and pain catastrophizing, indicating that participants with low levels of catastrophizing tended to read more descriptions when performance was interrupted than when not, whereas participants reporting relatively high levels of catastrophizing showed the reverse behavioural pattern.

CONCLUSIONS

The impact of pain-contingent task interruptions was reversed in participants reporting relatively high levels of pain catastrophizing. Results are discussed with regard to interruption management in the context of chronic pain.

The acquisition and generalization of cued and contextual pain-related fear: an experimental study using a voluntary movement paradigm

Recent evidence indicates that pain-related fear can be acquired through associative learning. In the clinic, however, spreading of fear and avoidance is observed beyond movements/activities that were associated with pain during the original pain episode. One mechanism accounting for this spreading of fear is stimulus generalization. In a voluntary movement-conditioning paradigm, healthy participants received predictable pain (ie, one movement predicts pain, another does not) in one context, and unpredictable pain in another context. The former procedure is known to induce cued pain-related fear to the painful movement, whereas the latter procedure generates contextual pain-related fear. In both experimental pain contexts, we subsequently tested fear generalization to novel movements (having either proprioceptive features in common with the original painful movement or nonpainful movement). Results indicated that in the predictable pain context, pain-related fear spreads selectively to novel movements proprioceptively related to the original painful movement, and not to those resembling the original nonpainful movement. In the unpredictable context, nondifferential fear generalization was observed, suggesting persistent contextual pain-related fear and poor safety learning. These data illustrate that spreading of pain-related fear is fostered by previously acquired movement-pain contingencies. Based on recent advances in anxiety research, we proposed an innovative approach conceptualizing predictable pain as a laboratory model for fear of movement in regional musculoskeletal pain, and unpredictable pain generating contextual pain-related fear as a prototype of widespread musculoskeletal pain. Consequently, fear generalization might play an important role in spreading of pain-related fear and avoidance behavior in regional and widespread musculoskeletal pain.

More optimism, less pain! The influence of generalized and pain-specific expectations on experienced cold-pressor pain

Accumulating evidence suggests that dispositional optimism might be a protective factor against experiencing pain. The current paper presents two studies investigating the association between dispositional optimism and experimental pain. Moreover, the influence of pain-specific expectations on this association is investigated. In Study 1, mediation of pain-specific expectations in the relation between dispositional optimism and pain was hypothesized. Expected and experienced pain ratings were obtained from 66 healthy participants undergoing a cold pressor tolerance task. In Study 2, the moderating effect of dispositional optimism on the association between induced pain expectations and pain reports was studied in 60 healthy participants undergoing a 1-min cold pressor task. Both studies controlled for individual differences in fear of pain. Significant associations between dispositional optimism and pain ratings were found in both studies, although the exact time point of these associations differed. Subscale analyses revealed that only the pessimism subscale contributed significantly to these findings. We found no evidence for hypothesized mediation and moderation effects. Alternative explanations for the optimism-pain association are discussed.

Optimism lowers pain: evidence of the causal status and underlying mechanisms

Previous studies have demonstrated a relation between dispositional optimism and lower pain sensitivity, but the causal status of this link remains unclear. This study sought to test the causal status by experimentally inducing a temporary optimistic state by means of writing about and visualizing a future best possible self. In addition, we explored pain expectations and (situational) pain catastrophizing as possible underlying mechanisms of the link between optimism and pain. Seventy-nine university students participated in a cold pressor task (CPT). Before the CPT, half of them received the optimism manipulation and the other half a control manipulation. Induced optimism was related to lower pain intensity ratings during the CPT compared to the control group, thereby experimentally confirming causality. This effect was not explained by pain-related expectations about the task. Situational pain catastrophizing, however, did seem to mediate the relation between optimism and pain. This study is novel in that it confirms the causal status of optimism towards pain. Additionally, the results reveal that positive interventions might provide a useful alternative in reducing pain catastrophizing as an extremely relevant target in pain treatment.

Specialised treatment based on cognitive behaviour therapy versus usual care for tinnitus: a randomised controlled trial

BACKGROUND

Up to 21% of adults will develop tinnitus, which is one of the most distressing and debilitating audiological problems. The absence of medical cures and standardised practice can lead to costly and prolonged treatment. We aimed to assess effectiveness of a stepped-care approach, based on cognitive behaviour therapy, compared with usual care in patients with varying tinnitus severity.

METHODS

In this randomised controlled trial, undertaken at the Adelante Department of Audiology and Communication (Hoensbroek, Netherlands), we enrolled previously untreated Dutch speakers (aged >18 years) who had a primary complaint of tinnitus but no health issues precluding participation. An independent research assistant randomly allocated patients by use of a computer-generated allocation sequence in a 1:1 ratio, stratified by tinnitus severity and hearing ability, in block sizes of four to receive specialised care of cognitive behaviour therapy with sound-focused tinnitus retraining therapy or usual care. Patients and assessors were masked to treatment assignment. Primary outcomes were health-related quality of life (assessed by the health utilities index score), tinnitus severity (tinnitus questionnaire score), and tinnitus impairment (tinnitus handicap inventory score), which were assessed before treatment and at 3 months, 8 months, and 12 months after randomisation. We used multilevel mixed regression analyses to assess outcomes in the intention-to-treat population. This study is registered with ClinicalTrials.gov, number NCT00733044.

FINDINGS

Between September, 2007 and January, 2011, we enrolled and treated 492 (66%) of 741 screened patients. Compared with 247 patients assigned to usual care, 245 patients assigned to specialised care improved in health-related quality of life during a period of 12 months (between-group difference 0·059, 95% CI 0·025 to 0·094; effect size of Cohen's d=0·24; p=0·0009), and had decreased tinnitus severity (-8·062, -10·829 to -5·295; d=0·43; p<0·0001) and tinnitus impairment (-7·506, -10·661 to -4·352; d=0·45; p<0·0001). Treatment seemed effective irrespective of initial tinnitus severity, and we noted no adverse events in this trial.

INTERPRETATION

Specialised treatment of tinnitus based on cognitive behaviour therapy could be suitable for widespread implementation for patients with tinnitus of varying severity.

FUNDING

Netherlands Organisation for Health Research and Development (ZonMW).

Pain-related fear at the start of a new low back pain episode

Previous research supports the fear-avoidance model in explaining chronic low back pain (LBP) disability. The aims of the present study were to determine: (1) whether fear-avoidance model variables are associated already during acute stages of LBP and (2) whether (increases in) pain-related fear are associated with other patient characteristics routinely assessed by the General Practitioner (GP). General practice patients consulting because of a new episode of LBP completed questionnaires on pain-related fear, avoidance, pain and disability. A sample of 247 acute LBP patients (median duration of current episode was 5 days) was collected. Significant associations were found between pain intensity, pain-related fear, avoidance behaviour and disability, but correlations were generally modest. A strong association was found between pain and disability. Pain-related fear was slightly higher in patients reporting low job satisfaction and in those taking bedrest. These results suggest that the fear-avoidance model as it was developed and tested in chronic LBP, might not entirely apply to acute LBP patients. Future research should focus on the transition from acute to chronic LBP and the shifts that take place between fear-avoidance model associations.

Pain and pain-related fear are associated with functional and social disability in an occupational setting: Evidence of mediation by pain-related fear

This study examined the role of work-related, psychosocial and psychological factors in predicting functional and social disability in working employees. In a cross-sectional design, 890 working employees (reporting at least 1 day of back pain during the past year) completed self-report measures of back pain, disability, pain-related fear, negative and positive affectivity, job satisfaction, job stress and physical work load. Regression analyses revealed that pain intensity was a strong predictor of functional (beta = .69, p < .001) and social disability (beta = .67, p < .001). Fear of (re)injury due to movement (beta = .25, p < .001; beta = .28, p < .001) had additional predictive value in both models. Further, (singular) mediation tests indicated that fear for (re)injury partially mediated the relation between pain intensity and disability, and between negative affectivity and disability. Finally, path analyses revealed both fear and pain intensity as mediators between negative affectivity and disability. Overall, our findings point at the relevance of the cognitive-behavioral model of avoidance in occupational settings.

The Tampa Scale for Kinesiophobia: further examination of psychometric properties in patients with chronic low back pain and fibromyalgia

The present study attempted to replicate the robustness of a two-factor model of the Tampa Scale for Kinesiophobia (TSK) in chronic low back pain (CLBP) patients and fibromyalgia patients, by means of confirmatory factor analysis. Construct and predictive validity of the TSK subscales were also examined. Results clearly indicated that a two-factor model fitted best in both pain samples. These two factors were labelled somatic focus, which reflects the belief in underlying and serious medical problems, and activity avoidance, which reflects the belief that activity may result in (re)injury or increased pain. Construct validity of the TSK and its subscales was supported by moderate correlation coefficients with self-report measures of pain-related fear, pain catastrophising, and disability, predominantly in patients with CLBP. Predictive validity was supported by moderate correlation coefficients with performance on physical performance tests (i.e., lifting tasks, bicycle task) mainly in CLBP patients. Implications of the results are discussed and directions for future research are provided.

Decline in physical activity, disability and pain-related fear in sub-acute low back pain

AIM OF INVESTIGATION

To evaluate whether a perceived decline in the level of physical activity after the onset of pain (PAD) is more appropriate in the explanation of disability as compared to the actual level of physical activity (PAL) in patients with sub-acute back pain.

METHODS

Patients with 4-7 weeks of non-specific low back pain (LBP) participated in this study. Their habitual physical activity level before the back pain started (H-PAL), their actual level of physical activity (PAL) and their perceived decline in the level of physical activity after the onset of pain (PAD) were assessed. The association between these physical activity related variables and perceived disability (QBPDS), fear of movement/(re)injury (TSK), pain catastrophizing (PCS) and pain intensity (VAS) was examined. The role of PAD as a mediator in the association between fear of movement/(re)injury and disability was examined by three linear regression analyses.

RESULTS

123 patients (66 male and 57 female) with a mean age of 44.1 years (SD=10.3) participated in this study. PAD was significantly correlated with disability, fear of movement/(re)injury, pain catastrophizing and pain intensity. PAD and PAL appeared more important in the explanation of disability in the subgroup of patients who were physically active before their back pain started. Generally, PAD indeed mediated the association between fear of movement/(re)injury and disability.

CONCLUSIONS

The perceived decline in physical activity, rather than the current physical activity itself is important in the evaluation of the impact of activity related changes on disability in low back pain.

Quality of life in chronic pain is more associated with beliefs about pain, than with pain intensity

OBJECTIVES

The objectives of this study were to investigate pain cognitions and quality of life of chronic pain patients referred to a multi-disciplinary university pain management clinic and to search for predictors of quality of life.

METHODS

A heterogeneous group of 1208 chronic pain patients referred to the Maastricht university hospital pain clinic participated in this cross-sectional study. At the initial assessment, all patients completed a set of questionnaires on demographic variables, cause, location, pain intensity (McGill pain questionnaire, MPQ), pain coping and beliefs (pain coping and cognition list, PCCL), pain catastrophising (pain catastrophising scale, PCS) and eight dimensions of quality of life (Rand-36).

RESULTS

The results showed that the present sample of heterogeneous pain patients reported low quality of life on each domain and significantly lower scores than has been found in previous studies with other Dutch chronic pain populations. Patients with low back pain and multiple pain localisations experienced most functional limitations. Women reported more pain, more catastrophising thoughts about pain, more disability and lower vitality and general health. When tested in a multiple regression analysis, pain catastrophising turned out to be the single most important predictor of quality of life. Especially social functioning, vitality, mental health and general health are significantly associated with pain catastrophising.

CONCLUSIONS

Patients from a multi-disciplinary university pain clinic experience strikingly low quality of life, whereby low back pain patients and patients with multiple pain localisations have the lowest quality of life. Pain catastrophising showed the strongest association with quality of life, and stronger than pain intensity.

Pain-related fear in low back pain: A prospective study in the general population

A cognitive behavioural account of chronic low back pain (CLBP) proposes that the relationship between pain catastrophizing and functional disability is mediated by fear of movement/(re)injury. Several clinical studies already demonstrated the contribution of pain catastrophizing and fear of movement/(re)injury in the development and maintenance of CLBP. This study included people with low back pain (LBP) in the general population, and aimed to investigate whether fear of movement/(re)injury mediated the relationship between pain catastrophizing and functional disability, by examining several prerequisites for mediation. Data from the Dutch population-based Musculoskeletal Complaints and Consequences Cohort (DMC(3)) study were used, including 152 people suffering from LBP who completed both a follow-up questionnaire and a baseline questionnaire 6 months previously. This study was unable to demonstrate that the relationship between pain catastrophizing and functional disability was mediated by fear of movement/(re)injury, since the prerequisite that pain catastrophizing and functional disability were related, was not fulfilled. However, pain catastrophizing was significantly related to fear of movement/(re)injury 6 months later, above and beyond other contributing variables such as fear of movement/(re)injury already present at baseline. On its turn, fear of movement/(re)injury was related to functional disability, in addition to pain intensity. Although this study leaves some indistinctness concerning the actual relationships between pain catastrophizing, fear of movement/(re)injury, and functional disability, it does provide some evidence for the contributing role of these factors in LBP in the general population.

Development of and recovery from short- and long-term low back pain in occupational settings: A prospective cohort study

Using the data of the EuroBack Unit prospective cohort study, this paper investigated the role of work-related physical factors and psychological variables in predicting the development of and recovery from short-term and long-term LBP. At baseline, 1294 predominantly male industrial workers from 10 companies in Belgium and the Netherlands filled in questionnaires. At follow-up, data from 812 employees were available. Odds ratios (ORs) were calculated using simple and multiple logistic regression analyses. For those workers reporting 0 days LBP in the year prior to baseline, negative affectivity (OR 1.06, 95% CI 1.01-1.11) was a risk factor for the development of short-term LBP (=1-30 days total of LBP in the year prior to follow-up). For those who reported 1-30 days total of LBP in the year prior to baseline, only high fear of (re)injury due to movement (OR 1.07, 95% CI 1.02-1.12) increased the risk for failure to recovery from short-term LBP. For the development of long-term LBP (=more than 30 days total of LBP in the year prior to follow-up), a significant increased risk was observed among workers with high pain severity (OR 1.19, 95% CI 1.01-1.40) and with pain referred to the ankles or feet (OR 2.92, 95% CI 1.09-7.83). The risk was reduced by social support of co-workers (OR 0.73, 95% CI 0.59-0.92) and by manual handling of materials (OR 0.63, 95% CI 0.46-0.85). For those who reported more than 30 days total of LBP in the year prior to baseline, high pain severity (OR 1.18, 95% CI 1.04-1.34) increased the risk for failure to recovery from long-term LBP. Results are compared to the baseline study (Gheldof et al., 2005) and discussed in relation with prospective studies.

Pain-related fear, perceived harmfulness of activities, and functional limitations in complex regional pain syndrome type I

Numerous studies have shown that pain-related fear is one of the strongest predictors of pain disability in patients with chronic musculoskeletal pain, and there is evidence that the reduction of pain-related fear through an exposure treatment can be associated with restoration of functional abilities in patients with complex regional pain syndrome type I (CRPS-I). These findings suggest that pain-related fear may be associated with functional limitations in neuropathic pain as well. The aim of the current study was to test whether the debilitating role of pain-related fear generalizes to patients with CRPS-I. The results of 2 studies are presented. Study I includes a sample of patients with early CRPS-I referred to an outpatient pain clinic. In Study II, patients with chronic CRPS who are members of a patients' association were invited to participate. The results show that in early CRPS-I, pain severity but not fear of movement/(re)injury as measured with the Tampa Scale for Kinesiophobia was related to functional limitations. In patients with chronic CRPS-I, however, perceived harmfulness of activities as measured with the pictorial assessment method significantly predicted functional limitations beyond and above the contribution of pain severity. Not fear of movement/(re)injury in general, but the perceived harmfulness of activities appears a key factor that might be addressed more systematically in the clinical assessment of patients with CRPS-I. These results support the idea that pain-related fear might be a promising concept in the understanding of pain disability in patients with neuropathic pain.

PERSPECTIVE

This is the first study showing that perceived harmfulness of activities contribute to the functional limitations in CRPS-I. The current findings may help clinicians customizing cognitive-behavioral treatments for patients with chronic neuropathic pain.

Dyspnea-related anxiety: The Dutch version of the Breathlessness Beliefs Questionnaire

Dyspnea-related anxiety may lead to reduced quality of life and functional disability through fearful avoidance of dyspnea-evoking activity. We describe the validation of a generic - diagnosis-independent - instrument assessing dyspnea-related anxiety. A total of 187 patients with respiratory diseases completed the Breathlessness Beliefs Questionnaire (BBQ), a 17-item questionnaire adapted from the Tampa Scale for Kinesiophobia (TSK), a measure of how harmful pain patients think painful movement is and to what extent they think activity should be avoided. Measures of negative and positive affectivity (PANAS), anxiety and depression (HADS), functional status (PFSDQ), and health-related quality of life (CRDQ) were also completed. Principal component analysis and item-total correlations suggested a reliable (reduced) 11-item BBQ (Cronbach's alpha = .85) with two factors converging with the TSK factors: a 'somatic focus' factor assessing the harmfulness of dyspnea and the underlying pathology and an 'activity avoidance' factor assessing beliefs that activity should be avoided. Correlational analyses support the construct validity of the BBQ: higher scores on the BBQ are associated with reduced health-related quality of life and functional status. Associations between 'somatic focus' and negative affectivity and anxiety and between 'activity avoidance' and positive affectivity and depression further supported the validity of the BBQ and its subscales. The BBQ is a valid, short, and useful instrument to assess respiratory patients' beliefs about the harmfulness of their disease and physical activities. Further research is needed to document to what extent BBQ scores are related to daily life activities and symptoms.

Fatigue and physical disability in patients with multiple sclerosis: a structural equation modeling approach

Although fatigue is one of the most common and disabling symptoms in patients with multiple sclerosis (MS), its pathogenesis is still poorly understood and it is difficult to treat. The aim of the current study was to test the assumptions of a cognitive-behavioral model that explains fatigue and physical disability in MS patients, by comparing this approach with a more traditional biomedical approach. Structural equation modeling was applied to a sample of 262 MS patients. Neither the cognitive-behavioral, nor the biomedical model showed an adequate fit of our data. The modification indices supported an integration of both models, which showed a better fit than those of the separate models. This final model, is notable for at least three features: (1) fatigue is associated with depression and physical disability, (2) physical disability is associated with disease severity and fatigue-related fear and avoidance behavior, and (3) catastrophic interpretations about fatigue, fueled by depression, mediated the relationship between fatigue and fatigue-related fear and avoidance behavior. Our results suggest that an integrated approach, including the modification of catastrophic thoughts about fatigue, would be beneficial in the treatment of fatigue in MS patients.

Dimensional and componential structure of a hierarchical organization of pain-related anxiety constructs

Research has identified several anxiety and fear constructs that contribute directly or indirectly to the chronic course of pain. One way to gain insight into the frequently observed interrelations between these constructs may be by conceptualizing them within a hierarchical structure. In this structure, general and specific constructs are proposed at different levels of a hierarchical tree. The present study sought to find evidence for this idea by exploring the dimensional and componential structure of a hierarchical representation of pain-related anxiety constructs. Small cards describing the individual items of 9 pain-related anxiety measures were presented to undergraduate students (N = 294), who were asked to sort them into piles of what they perceived as items of similar meaning. Cluster analysis (additive tree analyses) revealed cluster groups that could be interpreted along the lines of the proposed hierarchical structure. Multidimensional scaling analysis showed that the similarity data are characterized by a dimension that runs from general affective to pain-specific concerns. This study thus offers empirical support for the postulation of a general and specific hierarchical ordering of these constructs. Furthermore, its results endorse the independent use of various pain-related anxiety measures in research and practice aiming to assess negative emotional constructs that contribute to pain.