Clinical assessment of behavioral coping responses: preliminary results from a brief inventory

Patients and clinicians sometimes take coping with chronic pain primarily as a process of gaining more control over pain. An alternate approach might include helping the pain sufferer to discriminate parts of their situation that can be effectively controlled from those that cannot. When faced with situations that do not yield to attempts at direct control patients may gain better results from leaving those situations as they are and investing their efforts elsewhere. This study was designed to examine this type of expanded view of coping with pain, a view that includes both attempts at control and acceptance. 200 adults seeking treatment for chronic pain were the subjects of this investigation. They completed a number of self-report inventories including a measure called the Brief Pain Coping Inventory, an inventory assessing accepting responses to pain as well as pain management responses standardly targeted by cognitive-behavioral treatment methods. Preliminary results showed that the BPCI yields scores with adequate temporal consistency and validity. Further results showed that a number of the responses assessed by the BPCI were reliable predictors of patient functioning. In general less frequent struggling to control pain, fewer palliative and avoidant coping responses, and more explicit persistence with activity despite acknowledged pain were associated with less depression and anxiety and greater life functioning. These results demonstrate that, in some instances, attempts at avoidance and control of chronic pain may be less helpful compared with a willingness to experience pain and focus on functioning.

Gender moderates the association between depression and disability in chronic pain patients

Pain-related anxiety and depression are important correlates of disability amongst chronic pain patients. Furthermore, women may differ in their experience of pain, anxiety and depression when compared to men. The aim of the current study was to determine the relative contribution of anxiety and depression on disability in male and female chronic pain patients. The sample consisted of 260 patients (101 males, 159 females) referred to the Pain Management Unit at the Royal National Hospital for Rheumatic Diseases in Bath, UK. As part of an initial assessment, all patients completed measures of depression, pain-related anxiety and disability. As predicted, both anxiety and depression were found to be significant positive predictors of pain, number of medications used and disability. Although gender did not significantly predict disability, it did moderate the relationship between depression and disability, in that when depression was high, women report greater disability than men. Gender was also found to moderate the relationship between depression and number of medications used, in that a positive association was found for men, but not women. However, gender did not significantly moderate the relationship between anxiety and disability. Together these results not only suggest that gender is an important moderator of the relationship between emotional responses and disability, but that such associations may be related more to depression than anxiety.

Contextual cognitive-behavioral therapy for severely disabled chronic pain sufferers: Effectiveness and clinically significant change

Interdisciplinary pain management programs have an established record of significantly improving the functioning of persons disabled with chronic pain. There is a group of pain sufferers, however, who have difficulty accessing these programs and for whom the effectiveness of these treatments in unknown, these are patients whose mobility and self-care deficits leave them unable to meet the practical demands of many treatment environments. The purpose of this study was to examine the results of a treatment program designed to meet the needs of these highly disabled individuals (n=53) in comparison to results obtained from a standard less-disabled group attending treatment at the same facility (n=234). Results from the highly disabled patients showed statistically significant change after treatment in eight of nine outcome variables, including improvements in pain-related distress, disability, depression, pain-related anxiety, daytime rest, and performance during an activity tolerance test. Effect size calculations showed a number of large treatment effects, for psychosocial disability, depression, and acceptance of pain. Analysis of reliable change and clinical significance demonstrated that results were not merely statistically significant but clinically meaningful. Results appeared stable at three months following treatment. This research plays an important part in establishing an evidence base to inform service development, ensuring that chronic pain services do not exclude people on the basis of the severity of their disability.

Why women prefer epidural analgesia during childbirth: The role of beliefs about epidural analgesia and pain catastrophizing

This study investigated the reasons that might lead women to choose or not choose epidural analgesia as a strategy for the management of pain in childbirth. In our sample 55% of 114 women chose EA. Logistic regression resulted in a statistical model with four unique and independent predictors: Parity status and the fear of the side effects of EA each reduced the odds of choosing EA by half, whereas the desire to have a pain-free childbirth and positive experiences with EA of family and friends each doubled the odds of choosing EA. Pain catastrophizing was not related to EA use. The lack of an interrelationship between pain catastrophizing and EA use is probably due to an ambivalent attitude towards EA in pain catastrophizers. Pain catastrophizing was positively associated with the fear of being overwhelmed by labour pain and tendencies to avoid the pain, but also positively with the fear of pain during the insertion of the EA needle. Pain catastrophizing was also strongly related to recommendations to use EA from others, in particular from the midwife and from the gynecologist. Results are discussed in terms of the social impact of pain catastrophizing.

Fit for purpose? Using the fit note with patients with chronic pain: a qualitative study

BACKGROUND

Staying in work may benefit patients with chronic pain, but can be difficult for GPs to negotiate with patients and their employers. The new fit note is designed to help this process, but little is known of how it is operating.

AIM

To explore GPs' views on the fit note, with particular reference to sickness certification for patients with chronic pain.

DESIGN AND SETTING

Qualitative study using semi-structured interviews in eight primary care trusts in south-west England.

METHOD

In-depth interviews with 13 GPs.

RESULTS

GPs reported that the rationale behind the fit note is sound and that it may help patients with chronic pain to return to work earlier. However, GPs also reported barriers to successful fit note use, including the need to preserve doctor-patient relationships, inconsistent engagement from employers, GPs' lack of specialist occupational health knowledge, issues with fit note training, and whether a new form can achieve cultural shift.

CONCLUSION

While doctors agree that good work improves health outcomes, they do not think that fit notes will greatly alter sickness-certification rates without more concerted initiatives to manage the tripartite negotiation between doctor, patient, and employer.

Training for general practitioners in opioid prescribing for chronic pain based on practice guidelines: a randomized pilot and feasibility trial

This study is a pilot and feasibility study that compares 2 training experiences to improve appropriate opioid prescribing for chronic pain. Both training conditions included education in relation to opioid guidelines. Following education, 1 condition included training aimed at improving psychological flexibility and the other included training in practical knowledge and skills related to pain management. Eighty-one general practitioners (GPs) took part in the study, each having been randomly assigned to 1 of the training conditions. It proved easy to recruit GPs to the training. Overall, GPs demonstrated increased knowledge of opioid prescribing for chronic pain and decreases in concerns related to prescribing following training. However, there were no changes observed in reported prescribing practices or in secondary measures of well-being. There were also no significant differences between the training conditions, other than a greater increase in intention to use prescribing guidelines in the psychological flexibility condition. Feasibility and acceptability of the training methods were generally rated high. The psychological flexibility condition was rated higher than the comparison condition in terms of interest and satisfaction. Finally, processes of psychological flexibility before and after training significantly correlated with measures of GP well-being, providing partial support for the relevance of these processes as a focus in GP training.

PERSPECTIVE

A training intervention for GPs including education on opioid guidelines for chronic pain and psychological flexibility training increased knowledge of prescribing and reduced concerns but did not change prescribing behavior or well-being. The training was highly acceptable to GPs but may have been too short to produce other effects.

Interview: A normal psychology of pain

Christopher Eccleston is the Director of the Centre for Pain Research at The University of Bath, which is a wholly grant-funded research center focussed on innovation in behavioral science and pain. He is also Coordinating Editor of the Pain, Palliative and Supportive Care Cochrane Review Group.

Smartphone applications for pain management

Smartphone applications (or apps) are becoming increasingly popular. The lack of regulation or guidance for health-related apps means that the validity and reliability of their content is unknown. We have conducted a review of available apps relating to the generic condition of pain. The official application stores for five major smartphone platforms were searched: iPhone, Android, Blackberry, Nokia/Symbian and Windows Mobile. Apps were included if they reported a focus on pain education, management or relief, and were not solely aimed at health-care professionals (HCPs). A total of 111 apps met the inclusion criteria. The majority of apps reviewed claimed some information provision or electronic manual component. Diary tracking of pain variables was also a common feature. There was a low level of stated HCP involvement in app development and content. Despite an increasing number of apps being released, the frequency of HCP involvement is not increasing. Pain apps appear to be able to promise pain relief without any concern for the effectiveness of the product, or for possible adverse effects of product use. In a population often desperate for a solution to distressing and debilitating pain conditions, there is considerable risk of individuals being misled.

Adolescent chronic pain and disability: A review of the current evidence in assessment and treatment

Adolescents who suffer from chronic pain also report complex syndrome-associated disability and distress that can detrimentally affect the quality of their lives and the lives of their family members. Over the past 10 years, there have been significant developments in both methods of assessment and in treatment programs. There have also been good developments in clinical assessment tools, although many need further study. However, the evidence base of available treatments remains small, and there is an urgent need for new trials in both pharmacological and nonpharmacological treatments. The greatest challenges are organizational, and the concern is how to bring patients in contact with available treatments. Many patients who could benefit from evidence-supported treatments are not currently able to access treatment. Theoretical developments aimed at explaining chronic pain within the context of the family, as well as family attempts at coping with complex disability, are underway.

An investigation of constructions of justice and injustice in chronic pain: A Q-methodology approach

This study used Q-methodology to explore justice-related accounts of chronic pain. Eighty participants completed the Q-sorting procedure (33 chronic pain sufferers and 47 non-pain sufferers). Analysis revealed five main factors. Three factors blame: society for poor medical and interpersonal treatment; the chronic pain sufferer for indulging in self-pity and unempathic healthcare workers for ignoring patients. A fourth factor acknowledges the unfairness of pain and encourages self-reliance. The fifth factor rejects injustice in the chronic pain discourse. Overall, there is a shared view that chronic pain brings unfair treatment, disrespect and a de-legitimization of pain. Future research ideas are suggested.

Concerns about medication and medication adherence in patients with chronic pain recruited from general practice

This study examines the concerns and beliefs about medication reported by patients with nonmalignant chronic pain encountered within general practice. Two hundred thirty-nine patients with chronic pain took part in this research. Patients completed the Pain Medication Attitudes Questionnaire, a measure of patient concerns and beliefs relating to addiction, withdrawal, side effects, mistrust in doctors, perceived need of medication, scrutiny from others, and tolerance. The data revealed that patient concerns and beliefs predicted general medication nonadherence. In addition, concerns were related to the direction of nonadherence: overuse of medication was related to increased perceived need for medication and greater concern over side effects; underuse was related to decreased concerns over withdrawal and increased mistrust in the prescribing doctor. Analyses also indicated that patient attitudes and concerns about medication were more predictive of nonadherence than both level of pain and the reported frequency of experienced side effects. This research contributes to the increasing evidence that patient attitudes and beliefs about pain medication are associated with adherence behavior. Training general practitioners to identify and address these concerns may reduce concerns, improve adherence, and facilitate the doctor-patient relationship.

It’s not fair: An Interpretative Phenomenological Analysis of discourses of justice and fairness in chronic pain

Quantitative research suggests that perceiving injustice can impact negatively upon physical and psychological health in chronic pain. However, little is known about the experience and perceptions of injustice in this context. This study examines the phenomenology of justice and injustice in chronic pain. Fifteen chronic pain sufferers recruited from General Practices in upper, middle and lower socioeconomic areas participated in one of three focus group discussions. Semi-structured interviews were conducted to interrogate justice-related conceptions. All discussions were observed, audio-recorded, transcribed verbatim and subjected to Interpretative Phenomenological Analysis. The dominant theme of the upper socioeconomic group was ‘seeking equality’. For the middle socioeconomic group the dominant theme was ‘battle for quality of life’ and for the lower socioeconomic group the dominant theme was ‘the unfair advantage of others’. It is concluded that this group of chronic pain sufferers prioritize justice-related issues in terms of what is dominant to their social concerns and personal needs.

Disentangling the complex relations among caregiver and adolescent responses to adolescent chronic pain

The social context surrounding chronic pain is important, particularly in the case of pain in adolescents, where caregivers can be a key influence on adolescent social and physical activities. In general, greater adolescent difficulties are related to greater caregiver difficulties, and vice versa, although the strength of these relations has not been consistent across studies. Further, existing analyses have not evaluated more complex multivariate models involving both direct and indirect relations among adolescents and caregivers. There is consequently a lack of clarity in this area. The present analyses represent an initial attempt at explicating more precisely how adolescent and caregiver behaviors in response to pain influence adolescent functioning. Initially, a hypothetical model was constructed that included caregiver pain management behaviors, as well as adolescent and caregiver psychosocial responses to pain. The adequacy of this model was first evaluated with Pearson correlations and then with structural equation modelling using data from 120 adolescent-caregiver dyads. After some modification of the model to allow for adequate fit with the data, findings indicated that caregiver variables were only indirectly related to adolescent functioning via adolescent psychosocial responses to pain. This indirect relation may explain previous inconsistency across studies. Perhaps more importantly, the model tested may allow for an improved understanding of the complex relations among adolescents and caregivers factors. Finally, the need to adequately understand caregiver experiences in response to adolescent pain is highlighted and calls for appropriate intervention in young people struggling with chronic pain are reinforced within these analyses.

Smart self management: assistive technology to support people with chronic disease

We have developed a personalised self management system to support self management of chronic conditions with support from health-care professionals. Accelerometers are used to measure gross levels of activity, for example walking around the house, and used to infer higher level activity states, such as standing, sitting and lying. A smart phone containing an accelerometer and a global positioning system (GPS) module can be used to monitor outdoor activity, providing both activity and location based information. Heart rate, blood pressure and weight are recorded and input to the system by the user. A decision support system (DSS) detects abnormal activity and distinguishes life style patterns. The DSS is used to assess the self management process, and automates feedback to the user, consistent with the achievement of their life goals. We have found that telecare and assistive technology is feasible to support self management for chronic conditions within the home and local community environments.