Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain

Predictors of treatment outcome in cognitive behavioural therapy for chronic pain: a systematic review

PURPOSE

The aim of this systematic review was to synthesise the research identifying possible influences on CBT outcomes in chronic pain. Variations in the effectiveness of psychological therapies, such as CBT, in chronic pain have led to research investigating predictors of improved treatment outcomes.

MATERIALS AND METHODS

We identified randomised controlled and cohort studies of CBT for chronic pain, published between 1974 to 2nd August 2023, which identified predictors of CBT outcomes.

RESULTS

Nineteen studies were included in the review. Baseline sociodemographic, physical and emotional factors that influence the outcomes of CBT for chronic pain were identified. The most commonly reported predictors of CBT outcome, with medium to large effect sizes, were anxiety, depression and negative cognitions about pain and coping. Sociodemographic predictors of outcomes demonstrated small effects and lacked replicability.

CONCLUSIONS

There was variability across study designs, CBT delivery and outcomes measures. Further research is needed in chronic pain to identify the predictive factors which influence treatment outcomes, and consistency across study designs and outcome variables is needed to reduce heterogeneity.

The association between physical intervention use and treatment outcomes in patients participating in an online and psychologically informed pain management program

BACKGROUND

The availability of multidisciplinary care for the management of chronic pain is uncommon outside specialist clinics. The present study aims to determine the physical intervention use of patients participating in an online psychological pain management program and whether exposure to physical interventions in these patients alters treatment outcomes compared with patients who do not access physical interventions.

METHODS

Data were obtained from 2 previously published randomized controlled trials of an online psychological pain management program. Physical intervention exposure (categories: none, 1-3 sessions, 4+ sessions) was assessed at baseline, after treatment, and at 3-month follow-up. Primary outcomes included depression, anxiety, pain intensity, and pain-related disability. Generalized estimating equation models were used to compare treatment outcomes among those with different physical intervention frequencies and periods of exposure. We assessed whether changes in primary outcomes differed (moderated) by the period and category of physical intervention exposure.

RESULTS

Of the patients (n = 1074) who completed the baseline questionnaire across both randomized controlled trials, 470 (44%) reported physical intervention use at baseline, 383 (38%) reported physical intervention use after treatment, and 363 (42%) reported physical intervention use at 3-month follow-up. On average, there were moderate-large reductions from baseline to after treatment with respect to all outcomes (Cohen's d = 0.36-0.82). For all outcomes, the interaction of time by physical intervention exposure was statistically nonsignificant.

CONCLUSION

A substantial proportion of patients who participated in a psychologically informed pain management program were establishing, continuing, or stopping additional physical interventions. The frequency of and period of exposure to physical interventions did not appear to moderate treatment outcomes.

CLINICAL TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ACTRN12613000252718 and ACTRN12615001003561). The website for registration information is https://www.anzctr.org.au.

Use of Intervention Mapping to Adapt a Psychologically Informed Physical Therapy Telerehabilitation Intervention for Latino Persons with Chronic Spine Pain

The need for culturally tailored pain care is well recognized yet few studies report how existing interventions can be adapted to the needs of culturally and linguistically diverse (CALD) populations. This report describes a formative mixed methods approach using Intervention Mapping-Adapt (IM-Adapt) and the expanded Framework for Reporting Adaptations and Modifications to Evidence based interventions (FRAME) to adapt and report modifications of an existing physical therapy intervention for Latino persons with chronic spine pain in Federally Qualified Health clinics in the southwestern United States (US). Mixed methods included literature reviews, patient surveys, an Adaptation Advisory Panel, and sequential case series with semi-structured interviews. Six steps of IM-Adapt guided the adaptation process and adaptations were prospectively documented with FRAME. A needs assessment revealed an absence of culturally tailored physical therapy interventions for Latino persons with chronic spine pain in the US. An intervention logic model and review of the sociocultural context guided selection of essential interventions, determinants of behavior change, and outcomes. An existing Cognitive Behavioral based Physical Therapy (CBPT) telerehabilitation intervention was selected for adaptation based on accessibility and strong congruency with the logic model. An Adaptation Advisory Panel planned and evaluated iterative adaptations of the CBPT intervention content, activities, delivery, materials, and design. The adapted Goal Oriented Activity for Latino persons with Spine pain (GOALS/Metas) intervention aimed to reduce pain intensity and disability through patient-centered goal setting in physical and cognitive treatment domains. Sequential case series supported feasibility and acceptability of the adapted intervention in the target population. PERSPECTIVE: We describe the systematic adaptation and reporting of an evidence-based physical therapy intervention for culturally and linguistically diverse populations. Greater rigor and transparency in adapting evidence-based interventions using tools such as IM-Adapt and FRAME in future studies will accelerate efforts to reduce ethnic and racial disparities in pain rehabilitation.

Psychologically Informed Physical Therapy Management of Chronic Musculoskeletal Pain in Culturally Diverse Populations: An Intervention Logic Model

Culturally and linguistically diverse (CALD) individuals are underrepresented in pain research, including studies of psychologically informed physical therapy (PIPT) for musculoskeletal pain. This perspective describes a conceptual framework for PIPT management of chronic musculoskeletal pain that identifies essential elements which can be culturally tailored to meet the needs of different CALD populations. Essential interventions, determinants of behavior change, and clinical outcomes were identified from studies of existing PIPT interventions for chronic pain. PIPT approaches shared the following essential interventions: (1) cognitive skill training, (2) general aerobic activity, (3) impairment-based therapeutic exercises, and (4) graded functional movement training. An intervention logic model was developed to conceptualize how these interventions might promote active coping behaviors and greater engagement in physical activity, therapeutic exercise, and functional mobility. The model included physical and cognitive-emotional processes that may contribute to behavioral changes which ultimately reduce pain-related disability. To illustrate cultural tailoring of model constructs, we describe how intervention delivery and assessments were customized for Latino persons with chronic spine pain at a health center located near the United States (US)-Mexico border. A literature review of sociocultural influences on the pain experience of Latino persons was conducted, and essential elements of the model were operationalized to ensure that therapeutic goals, language, content, and processes were compatible with Latino cultural beliefs, values, and behaviors. Future research using the proposed model to adapt and test PIPT interventions for other CALD populations may help identify shared and divergent mechanisms of treatment response for culturally tailored pain management programs. PERSPECTIVE: A novel conceptual framework may help inform cultural tailoring of psychologically informed physical therapy management approaches for chronic musculoskeletal pain by maintaining fidelity to essential treatment elements while also leveraging the unique sociocultural context of different culturally and linguistically diverse communities to improve health outcomes.

Protocol for a randomised trial of a self-directed digital pain management intervention (Empowered Relief) tailored to adults with chronic pain and prescription opioid misuse/disorder: the MOBILE Relief study

INTRODUCTION

Chronic pain increases the risk of prescription opioid misuse or opioid use disorder (OUD). Non-pharmacological treatments are needed to dually address pain and opioid risks. The purpose of the Mobile and Online-Based Interventions to Lessen Pain (MOBILE Relief) study is to compare a one-session, video-based, on-demand digital pain relief skills intervention for chronic pain ('Empowered Relief' (ER); tailored to people at risk for opioid misuse or with opioid misuse/OUD) to a one-session digital health education intervention ('Living Better'; no pain management skills).

METHODS AND ANALYSIS

MOBILE Relief is an international online randomised controlled clinical trial. Study participants are adults with chronic, non-cancer pain (≥6 months) with daily pain intensity ≥3/10, taking ≥10 morphine equivalent daily dose and score ≥6 on the Current Opioid Misuse Measure. Participants are recruited through clinician referrals and clinic advertisements. Study procedures include electronic eligibility screening, informed consent, automated 1:1 randomisation to the treatment group, baseline measures, receipt of assigned digital treatment and six post-treatment surveys spanning 3 months. Study staff will call participants at baseline and 1-month and 3 months post-treatment to verify the opioid prescription. The main statistical analyses will include analysis of covariance and mixed effects model for repeated measurements regression.

MAIN OUTCOMES

Primary outcomes are self-reported pain catastrophising, pain intensity, pain interference, opioid craving and opioid misuse at 1-month and 3 months post-treatment. We will determine the feasibility of ER (≥50% participant engagement, ≥70% treatment appraisal ratings). We hypothesise the ER group will be superior to the Living Better group in the reduction of multiprimary pain outcomes at 1-month post-treatment and opioid outcomes at 1-month and 3 months post-treatment.

ETHICS AND DISSEMINATION

The study protocol was approved by the Stanford University School of Medicine Institutional Review Board (IRB 61643). We will publish results in peer-reviewed journals; National Institute of Drug Abuse (funder) and MOBILE Relief participants will receive result summaries.

TRIAL REGISTRATION NUMBER

NCT05152134.

Cognitive-Behavioral-Based Physical Therapy for Improving Recovery After a Traumatic Lower-Extremity Injury: The Results of a Randomized Controlled Trial

BACKGROUND

Lower-extremity injuries can result in severe impairment and substantial years lived with a disability. Persistent pain and psychological distress are risk factors for poor long-term outcomes and negatively influence the recovery process following a traumatic injury. Cognitive-behavioral therapy (CBT) interventions have the potential to address these risk factors and subsequently improve outcomes. This study aimed to evaluate the effect of a telephone-delivered cognitive-behavioral-based physical therapy (CBPT) program on physical function, pain, and general health at 12 months after hospital discharge following lower-extremity trauma. The CBPT program was hypothesized to improve outcomes compared with an education program.

METHODS

A multicenter, randomized controlled trial was conducted involving 325 patients who were 18 to 60 years of age and had at least 1 acute orthopaedic injury to the lower extremity or to the pelvis or acetabulum requiring operative fixation. Patients were recruited from 6 Level-I trauma centers and were screened and randomized to the CBPT program or the education program early after hospital discharge. The primary outcome was the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) scale. The secondary outcomes were objective physical function tests (4-square step test, timed stair ascent test, sit-to-stand test, and self-selected walking speed test), PROMIS Pain Intensity and Pain Interference, and the Veterans RAND 12-Item Health Survey. Treatment effects were calculated using targeted maximum likelihood estimation, a robust analytical approach appropriate for causal inference with longitudinal data.

RESULTS

The mean treatment effect on the 12-month baseline change in PROMIS PF was 0.94 (95% confidence interval, -0.68 to 2.64; p = 0.23). There were also no observed differences in secondary outcomes between the intervention group and the control group.

CONCLUSIONS

The telephone-delivered CBPT did not appear to yield any benefits for patients with traumatic lower-extremity injuries in terms of physical function, pain intensity, pain interference, or general health. Improvements were observed in both groups, which questions the utility of telephone-delivered cognitive-behavioral strategies over educational programs.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Shared and distinct effect mediators in exposure-based and traditional cognitive behavior therapy for fibromyalgia: Secondary analysis of a randomized controlled trial

Fibromyalgia is a chronic pain condition associated with substantial suffering and societal costs. Traditional cognitive behavior therapy (T-CBT) is the most evaluated psychological treatment, but exposure therapy (Exp-CBT) has shown promise with a pronounced focus on the reduction of pain-related avoidance behaviors. In a recent randomized controlled trial (N = 274), we found that Exp-CBT was not superior to T-CBT (d = -0.10) in reducing overall fibromyalgia severity. This study investigated pain-related avoidance behaviors, pain catastrophizing, hypervigilance, pacing, overdoing and physical activity as potential mediators of the treatment effect. Mediation analyses were based on parallel process growth models fitted on 11 weekly measurement points, and week-by-week time-lagged effects were tested using random intercepts cross-lagged panel models. Results indicated that a reduction in avoidance behaviors, pain catastrophizing, and hypervigilance were significant mediators of change in both treatments. An increase in pacing and a reduction in overdoing were significant mediators in T-CBT only. Physical activity was not a mediator. In the time-lagged analyses, an unequivocal effect on subsequent fibromyalgia severity was seen of avoidance and catastrophizing in Exp-CBT, and of overdoing in T-CBT. Exposure-based and traditional CBT for fibromyalgia appear to share common treatment mediators, namely pain-related avoidance behavior, catastrophizing and hypervigilance.

Psychological treatments for temporomandibular disorder pain-A systematic review

OBJECTIVE

Temporomandibular disorders (TMD) are common. They affect abilities for carrying out daily tasks and influence different psychological aspects. In addition to standard treatment, psychological treatments have been suggested. The aim was to investigate the effects of psychological treatments on patients with painful TMD in a short- and long-term perspective.

MATERIALS AND METHODS

An electronic search was conducted in the databases MEDLINE, CINAHL, EMBASE, the Cochrane Central Registry of Controlled Trials (CENTRAL), and Web of Science for randomized clinical trials (RCTs) reporting psychological interventions for TMD. Registered beforehand in PROSPERO (CRD42022320106). In total, 18 RCTs were included; six RCTs that could be used in the meta-analysis, and all 18 RCTs were used in the narrative synthesis. Risk of bias was assessed by the Cochrane's tool for assessing risk of bias and certainty of evidence by GRADE.

RESULTS

The narrative synthesis indicates that psychological treatment options seem equivalent to standard treatment for painful TMD. The meta-analysis showed that a combination of psychological treatment and standard treatment and manual treatment (very low-quality evidence) are significantly better in pain reduction than just counselling and standard treatments of TMD.

CONCLUSION

This study indicates that psychological treatments seem to reduce pain intensity in individuals with painful TMD, and that the effect seems to be equally good as standard treatment. However, a combination of psychological treatments and standard treatments seems to have an even better effect. This indicates that psychological treatments are promising as an additional treatment approach for painful TMDs.

Coronavirus Anxiety, COVID Anxiety Syndrome and Mental Health: A Test Among Six Countries During March 2021

The negative impact of the COVID-19 pandemic on mental health outcomes is widely documented. Specifically, individuals experiencing greater degrees of severity in coronavirus anxiety have demonstrated higher levels of generalized anxiety, depression and psychological distress. Yet the pathways in which coronavirus anxiety confers vulnerability are not well known. The present investigation sought to address this gap in the scientific literature by testing the indirect effect of the COVID-19 anxiety syndrome, which centres on the function of detecting and managing the environmental threat of virus exposure and its sequalae. Data were collected during the height of the pandemic (March 2021) and included 5297 adults across six countries. Structural equation modelling techniques revealed that the COVID-19 anxiety syndrome evidenced a statistically significant indirect effect between coronavirus anxiety and generalized anxiety, depression and work/social adjustment. Overall, results suggest there could be public health merit to targeting anxiety related to virus exposure to improve behavioural health for those who are struggling with excessive fear and worry.

To allow or avoid pain during shoulder rehabilitation exercises for patients with chronic rotator cuff tendinopathy-Study protocol for a randomized controlled trial (the PASE trial)

BACKGROUND

Rotator cuff (RC) tendinopathy is the most reported shoulder disorder in the general population with highest prevalence in overhead athletes and adult working-age population. A growing body of evidence support exercise therapy as an effective intervention, but to date there are no prospective randomized controlled trials addressing pain as an intervention variable.

METHODS

A single-site, prospective, pragmatic, assessor-blinded randomized controlled superiority trial. Eighty-four patients aged 18-55 years with chronic (symptom duration over 3 months) RC tendinopathy are randomized 1:1 to receive shoulder exercise during which pain is either allowed or avoided. The intervention period lasts 26 weeks. During that period, participants in both groups are offered 8 individual on-site sessions with an assigned sports physiotherapist. Participants perform home exercises and are provided with a pain and exercise logbook and asked to report completed home-based exercise sessions and reasons for not completing sessions (pain or other reasons). Patients are also asked to report load and the number of sets and repetitions per sets for each exercise session. The logbooks are collected continuously throughout the intervention period. The primary and secondary outcomes are obtained at baseline, 6 weeks, 26 weeks, and 1 year after baseline. The primary outcome is patient-reported pain and disability using the Shoulder PAin and Disability Index (SPADI). Secondary outcomes are patient-reported pain and disability using Disability Arm Shoulder and Hand short-form (Quick DASH), and shoulder pain using Numeric Pain Rating Scale. Objective outcomes are shoulder range of motion, isometric shoulder muscle strength, pain sensitivity, working ability, and structural changes in the supraspinatus tendon and muscle using ultrasound.

DISCUSSION

The results of this study will contribute knowledge about the treatment strategies for patients with RC tendinopathy and help physiotherapists in clinical decision-making. This is the first randomized controlled trial comparing the effects of allowing pain versus avoiding pain during shoulder exercises in patients with chronic RC tendinopathy. If tolerating pain during and after exercise proves to be effective, it will potentially expand our understanding of "exercising into pain" for this patient group, as there is currently no consensus.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05124769. Registered on August 11, 2021.

Postoperative Psychological Predictors for Chronic Postsurgical Pain After a Knee Arthroplasty: A Prospective Observational Study

OBJECTIVE

Chronic postsurgical pain (CPSP) is a significant adverse effect shown in around 20% of people who had undergone a knee arthroplasty (KA). Psychological risk factors have emerged as significant and potentially modifiable risk factors for its development. However, there is still little evidence when assessing these factors during the acute postoperative period. This study aimed to assess the predictive value of postoperative pain catastrophizing, pain-related fear of movement, anxiety, depression, and pain attitudes in developing CPSP after KA.

METHODS

A 6-month follow-up prospective observational study design was used. The study sample comprised 115 people who underwent a KA due to painful primary osteoarthritis. Measures of pain catastrophizing, pain-related fear of movement, anxiety, depression, and pain attitudes were obtained 1 week after surgery. CPSP was set at an intensity of ≥30 using a 100-mm visual analog scale at 3 and 6 months after surgery.

RESULTS

Analysis revealed that baseline pain intensity, pain catastrophizing, pain-related fear of movement, anxiety, depression, and maladaptive pain attitudes were significant predictors of chronic pain at 3 and 6 months after surgery in a univariate analysis. However, at 3 months after surgery, only pain intensity and pain catastrophizing were predictors in the final multivariate model forecasting disturbing pain. Moreover, 6 months after surgery, pain intensity and distrust in medical procedures remained independent predictors. Most of the psychological factors can be grouped into a single dimension defined as pain-related psychological distress.

CONCLUSION

The results suggest that postoperative pain intensity, pain catastrophizing, and pain attitudes are independent predictors for CPSP after KA.

IMPACT

Postoperative cognitive and emotional factors should be considered alongside pain intensity during postoperative rehabilitation after KA because they could influence the development of CPSP.

The Management of Chronic Pain: Re-Centring Person-Centred Care

The drive for a more person-centred approach in the broader field of clinical medicine is also gaining traction in chronic pain treatment. Despite current advances, a further departure from 'business as usual' is required to ensure that the care offered or received is not only effective but also considers personal values, goals, abilities, and day-to-day realities. Existing work typically focuses on explaining pain symptoms and the development of standardised interventions, at the risk of overlooking the broader consequences of pain in individuals' lives and individual differences in pain responses. This review underscores the importance of considering additional factors, such as the influence of chronic pain on an individual's sense of self. It explores innovative approaches to chronic pain management that have the potential to optimise effectiveness and offer person-centred care. Furthermore, it delves into research applying hybrid and individual formulations, along with self-monitoring technologies, to enhance pain assessment and the tailoring of management strategies. In conclusion, this review advocates for chronic pain management approaches that align with an individual's priorities and realities while fostering their active involvement in self-monitoring and self-management.

Individual Dimensions of Pain Catastrophizing Do Not Mediate the Effect of Sociodemographic and Psychological Factors on Chronic Orofacial Pain Severity, Interference, and Jaw Limitation: A Structural Equation Modeling Approach

Pain catastrophization (PC), involving rumination, magnification, and helplessness, can be viewed as a coping strategy associated with chronic pain. PC is considered a driving force in mediating pain-related outcomes, but it is still unclear whether PC mediates the relationship between psychological and sociodemographic factors with chronic pain when considered in a single model. Using baseline data from a parent study, this study examined the effect of positive and negative psychological and sociodemographic factors on pain severity, interference, and jaw limitation mediated by the PC dimensions in a sample of 397 temporomandibular disorder (TMD) participants using structural equation modeling (SEM). SEM revealed that pain severity regressed on age, sex, education, and income; interference regressed on positive and negative psychological factors, education, and income; and jaw limitation regressed on age. The PC dimensions did not individually mediate these relationships. Although they jointly mediated the relationships between negative psychological factors and pain severity and between age and pain interference, the effect size was small, suggesting that PC is not a critical factor in mediating TMD pain outcomes. Reducing negative cognitions, not just PC, may be of greatest benefit to the most vulnerable TMD populations. PERSPECTIVE: This study examines sociodemographic and psychological factors that affect orofacial pain, finding that the pain catastrophizing dimensions do not mediate these relationships. Understanding which factors most strongly affect pain outcomes will help identify targets for intervention to produce the greatest benefit for the most vulnerable persons suffering from pain.

Predicting heterogeneous treatment effects of an Internet-based depression intervention for patients with chronic back pain: Secondary analysis of two randomized controlled trials

Background

Depression is highly prevalent among individuals with chronic back pain. Internet-based interventions can be effective in treating and preventing depression in this patient group, but it is unclear who benefits most from this intervention format.

Method

In an analysis of two randomized trials (N = 504), we explored ways to predict heterogeneous treatment effects of an Internet-based depression intervention for patients with chronic back pain. Univariate treatment-moderator interactions were explored in a first step. Multilevel model-based recursive partitioning was then applied to develop a decision tree model predicting individualized treatment benefits.

Results

The average effect on depressive symptoms was d = -0.43 (95 % CI: -0.68 to -0.17; 9 weeks; PHQ-9). Using univariate models, only back pain medication intake was detected as an effect moderator, predicting higher effects. More complex interactions were found using recursive partitioning, resulting in a final decision tree with six terminal nodes. The model explained a large amount of variation (bootstrap-bias-corrected R2 = 45 %), with predicted subgroup-conditional effects ranging from di = 0.24 to -1.31. External validation in a pilot trial among patients on sick leave (N = 76; R2 = 33 %) pointed to the transportability of the model.

Conclusions

The studied intervention is effective in reducing depressive symptoms, but not among all chronic back pain patients. Predictions of the multivariate tree learning model suggest a pattern in which patients with moderate depression and relatively low pain self-efficacy benefit most, while no benefits arise when patients' self-efficacy is already high. If corroborated in further studies, the developed tree algorithm could serve as a practical decision-making tool.

Mechanisms of change in digital cognitive behavioral therapy for depression in patients with chronic back pain: A mediation analysis of a multicenter randomized clinical trial

BACKGROUND

While there is evolving knowledge on change processes of digital cognitive behavioral therapy (CBT) in the treatment of depression, little is known about how these interventions produce therapeutic change in the comorbid constellation of chronic back pain (CBP). Here, we examined whether the effects of a digital intervention to treat depression in patients with CBP are mediated by three pain-related variables (i.e., pain self-efficacy, pain-related disability, pain intensity).

METHODS

This study is a secondary analysis of a randomized clinical trial conducted in routine care at 82 orthopedic clinics across Germany. In total, 209 adults with CBP and diagnosed depression (SCID interview) were randomly assigned to the intervention (n = 104) or treatment-as-usual (n = 105). Cross-lagged mediation models were estimated to investigate longitudinal mediation effects of putative mediators with depression symptom severity (PHQ-9) as primary outcome at post-treatment.

RESULTS

Longitudinal mediation effects were observed for pain self-efficacy (ß = -0.094, 95%-CI [-0.174, -0.014], p = 0.021) and pain-related disability (ß = -0.068, 95%-CI [-0.130, -0.001], p = 0.047). Furthermore, the hypothesized direction of the mediation effects was supported, reversed causation did not occur. Pain intensity did not reveal a mediation effect.

CONCLUSIONS

The results suggest a relevant role of pain self-efficacy and pain-related disability as change processes in the treatment of depression for patients with CBP in routine care. However, further research is needed to disclose potential reciprocal relationships of mediators, and to extend and specify our knowledge of the mechanisms of change in digital CBT for depression.

Calcitonin Gene-Related Peptide-Mediated Trigeminal Ganglionitis: The Biomolecular Link between Temporomandibular Disorders and Chronic Headaches

A bidirectional causal relationship has been established between temporomandibular disorders (TMDs) and chronic headaches. Recent advances in the neurobiology of chronic pain offer a framework for understanding the comorbidity between these two conditions that might reside in the shared biomolecular mechanisms of peripheral and central sensitization. The initiation of these processes is inflammatory in nature and is most likely mediated by key molecules, including calcitonin gene-related peptide (CGRP). This scoping review proposes that CGRP-mediated neuroinflammation in the trigeminal ganglion may partly explain the biomolecular bidirectional link between TMDs and chronic headaches. Finally, clinical implications of this neuropathologic process are briefly discussed.

The Role of Psychological Factors in Chronic Pain Treatment Outcomes in the Military

PURPOSE

Chronic pain treatment in the military includes complementary and integrative health (CIH) therapies that may affect psychological factors such as pain catastrophizing, chronic pain acceptance, pain self-efficacy, and patient activation. The unique roles that psychosocial factors play in how CIH approaches reduce pain are not clear. This study examined if a holistic pain management program improved pain outcomes through psychological mediators in service members with chronic pain.

DESIGN

Secondary analysis of a clinical trial.

METHODS

Active-duty service members (n = 210) were randomly assigned to a 3-week course of standard rehabilitative care or standard rehabilitative care combined with CIH therapies. Both treatments were followed by a 3-week functional restoration program. Study measures were completed pre- and post-treatment using the Military Health System's Pain Assessment Screening Tool and Outcomes Registry. Mediation analyses tested the indirect effects of the change in psychological factors before functional restoration on the change in pain impact (e.g., pain intensity, pain interference, functional status) after functional restoration.

RESULTS

All psychological factors except for chronic pain acceptance were related to improved pain impact (p<.05). Furthermore, a change in psychological factors prior to functional restoration was related to the change in pain impact after functional restoration. However, the addition of CIH therapies to standard rehabilitative care did not result in changes in pain outcomes mediated by the psychological factors.

CONCLUSIONS

Although psychological factors were related to pain outcomes, the effect of CIH therapies on chronic pain did not occur via a change in the four psychological factors.

Moderators and Nonspecific Predictors of Treatment Benefits in a Randomized Trial of Mindfulness-Based Stress Reduction vs Cognitive-Behavioral Therapy vs Usual Care for Chronic Low Back Pain

Both mindfulness-based stress reduction (MBSR) and cognitive-behavioral therapy (CBT) are effective for chronic low back pain (CLBP), but little is known regarding who might benefit more from one than the other. Using data from a randomized trial comparing MBSR, CBT, and usual care (UC) for adults aged 20 to 70 years with CLBP (N = 297), we examined baseline characteristics that moderated treatment effects or were associated with improvement regardless of treatment. Outcomes included 8-week function (modified Roland Disability Questionnaire), pain bothersomeness (0-10 numerical rating scale), and depression (Patient Health Questionnaire-8). There were differences in the effects of CBT versus MBSR on pain based on participant gender (P = .03) and baseline depressive symptoms (P = .01), but the only statistically significant moderator after Bonferroni correction was the nonjudging dimension of mindfulness. Scores on this measure moderated the effects of CBT versus MBSR on both function (P = .001) and pain (P = .04). Pain control beliefs (P <.001) and lower anxiety (P < .001) predicted improvement regardless of treatment. Replication of these findings is needed to guide treatment decision-making for CLBP. TRIAL REGISTRATION: The trial and analysis plan were preregistered in ClinicalTrials.gov (Identifier: NCT01467843). PERSPECTIVE: Although few potential moderators and nonspecific predictors of benefits from CBT or MBSR for CLBP were statistically significant after adjustment for multiple comparisons, these findings suggest potentially fruitful directions for confirmatory research while providing reassurance that patients could reasonably expect to benefit from either treatment.

Pain intensity and psychological distress show different associations with interference and lack of life control: A clinical registry-based cohort study of >40,000 chronic pain patients from SQRP

Background

Both chronic pain and depressive and/or anxiety symptoms are associated with negative impacts on daily living, including interference and lack of life control. However, little is known about how pain and psychological distress affect these impacts.

Aim

The first aim was to assess how pain intensity, psychological distress, and social support interact with interference and lack of life control. A second aim was to investigate whether the strength of these relationships is moderated by the presence or absence of depression and/or anxiety.

Subjects and methods

Patient-Reported Outcome Measures (PROMs), which are available in the Swedish Quality Registry for Pain Rehabilitation (SQRP), were retrieved for patients with chronic pain (N = 40,184). A theoretical model with the constructs/latent variables pain intensity, psychological distress, interference, lack of life control, and social support was proposed and analyzed using Partial Least Squares Structural Equation Modelling (PLS-SEM). Indicators for these constructs were identified from the PROMs of the SQRP. Two models of the total cohort, which differed with respect to the causal relationship between pain intensity and psychological distress, were investigated. The moderating effects of anxiety and/or depression were also analyzed.

Results

Relatively low correlation and explanatory power (R ²= 0.16) were found for the pain intensity-psychological distress relationship. Pain intensity had a stronger effect on interference than on lack of life control. The reverse was found for psychological distress - i.e., psychological distress seemed to have a higher negative influence on function than on interference. The underlying assumption of the causal relationship between pain intensity and psychological distress determined how strong pain intensity and psychological distress influenced interference and lack of life control. Social support showed very similar absolute significant correlations with interference and lack of life control. Interference and lack of life control showed relatively weak associations. The psychological distress level was a moderating factor for several of the paths investigated.

Discussion and conclusion

A clinical treatment consequence of the low correlation between pain intensity and psychological distress may be that clinically treating one may not reduce the effect of the other. The relative importance of pain intensity and psychological distress on interference and lack of life control depends on the underlying assumption concerning the pain intensity-psychological distress relationship. Interference and lack of life control showed relatively weak associations, underscoring the need to clinically assess them separately. Social support influenced both impact constructs investigated. The cohort display heterogeneity and thus presence of definite signs of anxiety and/or depression or not was a moderating factor for several of the associations (paths) investigated. The results are important both for the assessments and the design of treatments for patients with chronic pain.

A Study Protocol for a Multisite Randomized Controlled Trial of an Intervention to Improve Outcomes After Spinal Cord Injury

Background

The consequences of spinal cord injury (SCI) can place significant demands on an individual's coping mechanisms. Interventions to promote psychological adjustment and coping are often included in inpatient rehabilitation programs; however, following discharge, many individuals with SCI do not receive ongoing counseling or education about psychological adjustment to disability. Effective postacute treatment models are needed to help individuals with SCI build skills that help them adapt to the stresses associated with a chronic physical disability, alleviate the consequences of anxiety and depression, and enhance subjective well-being.

Objectives

To describe the protocol for a randomized clinical trial (RCT) of a 6-week intervention designed to improve psychosocial outcomes after SCI.

Methods

To test efficacy and replicability of the intervention, we designed a three-arm, multisite RCT with assessments conducted at six time points. Our primary hypothesis is that participants in the Group arm will report greater improvements in psychosocial outcomes than participants who complete the intervention individually via video (Individual arm) or those who do not receive the intervention (Control arm). We also hypothesize that participants in the Group arm will maintain greater improvements in psychosocial outcomes longer than those in the individual or control arms.

Conclusion

Results of the RCT will be presented and published to professionals and consumers, and intervention training and materials will be made available upon request.

Preliminary study: quantification of chronic pain from physiological data

Supplemental Digital Content is Available in the Text.

Preliminary evidence suggests that physiological variables collected with our low-cost pain meter are correlated with chronic pain, both for individuals and populations.

Introduction:

It is unknown if physiological changes associated with chronic pain could be measured with inexpensive physiological sensors. Recently, acute pain and laboratory-induced pain have been quantified with physiological sensors.

Objectives:

To investigate the extent to which chronic pain can be quantified with physiological sensors.

Methods:

Data were collected from chronic pain sufferers who subjectively rated their pain on a 0 to 10 visual analogue scale, using our recently developed pain meter. Physiological variables, including pulse, temperature, and motion signals, were measured at head, neck, wrist, and finger with multiple sensors. To quantify pain, features were first extracted from 10-second windows. Linear models with recursive feature elimination were fit for each subject. A random forest regression model was used for pain score prediction for the population-level model.

Results:

Predictive performance was assessed using leave-one-recording-out cross-validation and nonparametric permutation testing. For individual-level models, 5 of 12 subjects yielded intraclass correlation coefficients between actual and predicted pain scores of 0.46 to 0.75. For the population-level model, the random forest method yielded an intraclass correlation coefficient of 0.58. Bland–Altman analysis shows that our model tends to overestimate the lower end of the pain scores and underestimate the higher end.

Conclusion:

This is the first demonstration that physiological data can be correlated with chronic pain, both for individuals and populations. Further research and more extensive data will be required to assess whether this approach could be used as a “chronic pain meter” to assess the level of chronic pain in patients.

Are group identity and sense of belonging relevant for group pain management programmes? An exploratory pilot study

Introduction

Cognitive Behaviour Therapy (CBT)-based programmes for chronic pain are often conducted in groups, most likely for time and cost efficiencies. However, there has been very little investigation of the role that the group itself, and particularly the processes occurring within the group, may play in individual outcomes. The objective of this study was to explore whether social group processes were relevant to key treatment outcomes of group CBT for chronic pain.

Method

Data were collected from 15 groups (N = 118) undertaking a pain management programme in a tertiary setting. Intraclass correlations were computed to determine any clustering of outcomes in groups, and linear mixed modelling analysis explored pre-registered hypotheses of associations between treatment outcomes and the social group processes of Group Identification and Sense of Belonging.

Results

A weak association between early identification with the group and changes in pain-related disability was shown. In addition, an enhanced global Sense of Belonging was associated with increased pain self-efficacy.

Conclusion

These associations, in a programme that had not been designed to address group processes, suggest that their relevance is worth further investigation, particularly in group programmes that do focus on the social consequences of chronic pain. Future studies should investigate whether manipulation of social group processes within a CBT-based pain programme enhances pain-related outcomes and improves the overall well-being of people with chronic pain.

Mindfulness-Based Stress Reduction, Cognitive Behavioral Therapy, and Acupuncture in Chronic Low Back Pain: Protocol for Two Linked Randomized Controlled Trials

BACKGROUND

Nonpharmacologic mind-body therapies have demonstrated efficacy in low back pain. However, the mechanisms underlying these therapies remain to be fully elucidated.

OBJECTIVE

In response to these knowledge gaps, the Stanford Center for Low Back Pain-a collaborative, National Institutes of Health P01-funded, multidisciplinary research center-was established to investigate the common and distinct biobehavioral mechanisms of three mind-body therapies for chronic low back pain: cognitive behavioral therapy (CBT) that is used to treat pain, mindfulness-based stress reduction (MBSR), and electroacupuncture. Here, we describe the design and implementation of the center structure and the associated randomized controlled trials for characterizing the mechanisms of chronic low back pain treatments.

METHODS

The multidisciplinary center is running two randomized controlled trials that share common resources for recruitment, enrollment, study execution, and data acquisition. We expect to recruit over 300 chronic low back pain participants across two projects and across different treatment arms within each project. The first project will examine pain-CBT compared with MBSR and a wait-list control group. The second project will examine real versus sham electroacupuncture. We will use behavioral, psychophysical, physical measure, and neuroimaging techniques to characterize the central pain modulatory and emotion regulatory systems in chronic low back pain at baseline and longitudinally. We will characterize how these interventions impact these systems, characterize the longitudinal treatment effects, and identify predictors of treatment efficacy.

RESULTS

Participant recruitment began on March 17, 2015, and will end in March 2023. Recruitment was halted in March 2020 due to COVID-19 and resumed in December 2021.

CONCLUSIONS

This center uses a comprehensive approach to study chronic low back pain. Findings are expected to significantly advance our understanding in (1) the baseline and longitudinal mechanisms of chronic low back pain, (2) the common and distinctive mechanisms of three mind-body therapies, and (3) predictors of treatment response, thereby informing future delivery of nonpharmacologic chronic low back pain treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02503475; https://clinicaltrials.gov/ct2/show/NCT02503475.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/37823.

Psychological therapies for temporomandibular disorders (TMDs)

BACKGROUND

Temporomandibular disorders (TMDs) are a group of musculoskeletal disorders affecting the jaw. They are frequently associated with pain that can be difficult to manage and may become persistent (chronic). Psychological therapies aim to support people with TMDs to manage their pain, leading to reduced pain, disability and distress.

OBJECTIVES

To assess the effects of psychological therapies in people (aged 12 years and over) with painful TMD lasting 3 months or longer.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched six bibliographic databases up to 21 October 2021 and used additional search methods to identify published, unpublished and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of any psychological therapy (e.g. cognitive behaviour therapy (CBT), behaviour therapy (BT), acceptance and commitment therapy (ACT), mindfulness) for the management of painful TMD. We compared these against control or alternative treatment (e.g. oral appliance, medication, physiotherapy).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We reported outcome data immediately after treatment and at the longest available follow-up. We used the Cochrane RoB 1 tool to assess the risk of bias in included studies. Two review authors independently assessed each included study for any risk of bias in sequence generation, allocation concealment, blinding of outcome assessors, incomplete outcome data, selective reporting of outcomes, and other issues. We judged the certainty of the evidence for each key comparison and outcome as high, moderate, low or very low according to GRADE criteria.

MAIN RESULTS

We identified 22 RCTs (2001 participants), carried out between 1967 and 2021. We were able to include 12 of these studies in meta-analyses. The risk of bias was high across studies, and we judged the certainty of the evidence to be low to very low overall; further research may change the findings. Our key outcomes of interest were: pain intensity, disability caused by pain, adverse events and psychological distress. Treatments varied in length, with the shortest being 4 weeks. The follow-up time ranged from 3 months to 12 months. Most studies evaluated CBT.   At treatment completion, there was no evidence of a benefit of CBT on pain intensity when measured against alternative treatment (standardised mean difference (SMD) 0.03, confidence interval (CI) -0.21 to 0.28; P = 0.79; 5 studies, 509 participants) or control (SMD -0.09, CI -0.30 to 0.12; P = 0.41; 6 studies, 577 participants). At follow-up, there was evidence of a small benefit of CBT for reducing pain intensity compared to alternative treatment (SMD -0.29, 95% CI -0.50 to -0.08; 5 studies, 475 participants) and control (SMD -0.30, CI -0.51 to -0.09; 6 studies, 639 participants). At treatment completion, there was no evidence of a difference in disability outcomes (interference in activities caused by pain) between CBT and alternative treatment (SMD 0.15, CI -0.40 to 0.10; P = 0.25; 3 studies, 245 participants), or between CBT and control/usual care (SMD 0.02, CI -0.21 to 0.24; P = 0.88; 3 studies, 315 participants). Nor was there evidence of a difference at follow-up (CBT versus alternative treatment: SMD -0.15, CI -0.42 to 0.12; 3 studies, 245 participants; CBT versus control: SMD 0.01 CI - 0.61 to 0.64; 2 studies, 240 participants). There were very few data on adverse events. From the data available, adverse effects associated with psychological treatment tended to be minor and to occur less often than in alternative treatment groups. There were, however, insufficient data available to draw firm conclusions. CBT showed a small benefit in terms of reducing psychological distress at treatment completion compared to alternative treatment (SMD -0.32, 95% CI -0.50 to -0.15; 6 studies, 553 participants), which was maintained at follow-up (SMD -0.32, 95% CI -0.51 to -0.13; 6 studies, 516 participants). For CBT versus control, only one study reported results for distress and did not find evidence of a difference between groups at treatment completion (mean difference (MD) 2.36, 95% CI -1.17 to 5.89; 101 participants) or follow-up (MD -1.02, 95% CI -4.02 to 1.98; 101 participants). We assessed the certainty of the evidence to be low or very low for all comparisons and outcomes. The data were insufficient to draw any reliable conclusions about psychological therapies other than CBT.

AUTHORS' CONCLUSIONS

We found mixed evidence for the effects of psychological therapies on painful temporomandibular disorders (TMDs). There is low-certainty evidence that CBT may reduce pain intensity more than alternative treatments or control when measured at longest follow-up,  but not at treatment completion. There is low-certainty evidence that CBT may be better than alternative treatments, but not control, for reducing psychological distress at treatment completion and follow-up. There is low-certainty evidence that CBT may not be better than other treatments or control for pain disability outcomes.  There is insufficient evidence to draw conclusions about alternative psychological therapeutic approaches, and there are insufficient data to be clear about adverse effects that may be associated with psychological therapies for painful TMD.  Overall, we found insufficient evidence on which to base a reliable judgement about the efficacy of psychological therapies for painful TMD. Further research is needed to determine whether or not psychological therapies are effective, the most effective type of therapy and delivery method, and how it can best be targeted. In particular, high-quality RCTs conducted in primary care and community settings are required, which evaluate a range of psychological approaches against alternative treatments or usual care, involve both adults and adolescents, and collect measures of pain intensity, pain disability and psychological distress until at least 12 months post-treatment.

Effectiveness of the online Acceptance and Commitment Therapy intervention "Embrace Pain" for cancer survivors with chronic painful chemotherapy-induced peripheral neuropathy: study protocol for a randomized controlled trial

BACKGROUND

About 30% of cancer survivors suffer from chemotherapy-induced peripheral neuropathy (CIPN) ≥6 months after completion of chemotherapy. This condition, for which treatment options are scarce, comes with limitations in daily life functioning and decreased quality of life. The current study examines the effectiveness of an online self-help intervention based on Acceptance and Commitment Therapy (ACT) in comparison to a waiting list condition (WLC) to deal with CIPN. In addition, it examines which factors moderate effects and to what extent the effects differ between guided and unguided ACT intervention.

METHODS

A two-parallel, non-blinded randomized controlled trial (RCT) will be carried out. Adult cancer survivors who experience painful CIPN for at least 3 months and completed chemotherapy at least 6 months ago will be recruited (n=146). In the intervention condition, participants will follow an 8-week self-management course containing 6 modules regarding psychoeducation and ACT processes, including therapeutic email guidance. By means of text and experiential exercises, supplemented with illustrations, metaphors, and audio files, people will learn to carry out value-oriented activities in their daily life with pain. Participants will learn new ways of coping with pain, including reducing pain avoidance and increasing pain acceptance. Participants in the WLC will be invited to follow the intervention without therapeutic guidance 5 months after start. Pain interference is the primary outcome, while psychological distress, quality of life, CIPN symptom severity, pain intensity, psychological flexibility, mindfulness skills, values-based living, and pain catastrophizing will serve as secondary outcomes. All outcome measures will be evaluated at inclusion and baseline, early-intervention, mid-intervention, post-treatment, and 3- and 6-month post-treatment. Qualitative interviews will be conducted post-treatment regarding experiences, usage, usability, content fit, and satisfaction with the intervention.

DISCUSSION

This study will provide valuable information on the effectiveness of an online self-help intervention based on ACT versus WLC for chronic painful CIPN patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05371158 . Registered on May 12, 2022.

PROTOCOL VERSION

version 1, 24-05-2022.

An integrated mindfulness meditation and acceptance and commitment therapy intervention for chronic pain: Rationale, design, and methodology of a pilot randomized controlled trial of Acting with Mindfulness for Pain (AMP)

Acceptance and commitment therapy (ACT) is an evidence-based psychosocial intervention for chronic pain; however, in its present form ACT produces modest improvements in function and is no more effective than cognitive behavioral therapy (CBT), the current gold standard. This protocol paper describes the Acting with Mindfulness for Pain (AMP) protocol, which emphasizes and integrates formal mindfulness meditation practice within an ACT-based approach. This paper presents the rationale, design and methodology of an ongoing pilot randomized controlled trial (RCT) comparing AMP to CBT among Veterans with chronic pain (N = 86). Specifically, we argue that formal meditation practice is a necessary treatment component that directly targets key ACT processes which will help facilitate large treatment effects on function (e.g., general activity, social relationships, life enjoyment) among individuals with chronic pain. This study will be the first to consider formal mindfulness meditation practice as a principal treatment ingredient in the context of ACT for chronic pain. The purpose of this trial is to evaluate the feasibility of recruitment and collection of measures, and to examine preliminary treatment effects to determine the appropriateness of a subsequent full-scale RCT. This study will also explore within and between group change on primary and secondary outcomes including pain interference, pain acceptance, trait mindfulness, pain catastrophizing, values-based living, quality of life, practice adherence, and objective measures of physical activity. This study will help delineate the role of formal mindfulness practice within an ACT-based approach for chronic pain and provide preliminary data for a future fully powered RCT.

Exploration of the trait-activation model of pain catastrophizing in Native Americans: results from the Oklahoma Study of Native American pain risk (OK-SNAP)

OBJECTIVES

Native Americans (NAs) have the highest prevalence of chronic pain of any racial/ethnic group. This issue has received little attention from the scientific community. One factor that may contribute to racial pain disparities is pain catastrophizing. Pain catastrophizing is a construct related to negative pain outcomes in persons with/without chronic pain. It has been suggested that the relationship between trait catastrophizing and pain is mediated by situation-specific (state) catastrophizing. The present study has 2 aims: (1) to investigate whether state pain catastrophizing mediates the relationship between trait catastrophizing and experimental pain (e.g., cold, ischemic, heat and electric tolerance), and (2) to investigate whether this relationship is stronger for NAs.

METHODS

145 non-Hispanic Whites (NHWs) and 137 NAs completed the study. Bootstrapped indirect effects were calculated for 4 unmoderated and 8 moderated mediation models (4 models with path a moderated and 4 with path b).

RESULTS

Consistent with trait-activation theory, significant indirect effects indicated a tendency for trait catastrophizing to be associated with greater state catastrophizing which in turn is associated with reduced pain tolerance during tonic cold (a × b=-0.158) and ischemia stimuli (a × b=-0.126), but not during phasic electric and heat stimuli. Moderation was only noted for the prediction of cold tolerance (path a). Contrary to expectations, the indirect path was stronger for NHWs (a × b for NHW=-.142).

CONCLUSIONS

Together, these findings suggest that state catastrophizing mediates the relationship between trait catastrophizing and some measures of pain tolerance but this indirect effect was non-significant for NAs.

Predictors of Pain Reduction Among Fibromyalgia Patients Using Medical Cannabis: A Long-Term Prospective Cohort Study

OBJECTIVE

Many patients with fibromyalgia (FM) report using cannabis as a strategy to improve pain. Given that pain often co-occurs with symptoms of anxiety and depression (i.e., negative affect) and sleep problems among patients with FM, improvements in these symptoms might indirectly contribute to reductions in pain intensity following cannabis use. The main objective of the study was to examine whether changes in pain intensity following initiation of medical cannabis among patients with FM could be attributed to concurrent changes (i.e., reductions) in negative affect and sleep problems.

METHODS

This was a 12-month prospective cohort study among patients with FM (n = 323) initiating medical cannabis under the care of physicians. Patients were assessed at baseline, and follow-up assessment visits occurred every 3 months after initiation of medical cannabis. Patients' levels of pain intensity, negative affect, and sleep problems were assessed across all visits.

RESULTS

Multilevel mediation analyses indicated that reductions in patients' levels of pain intensity were partly explained by concurrent reductions in sleep problems and negative affect (both P < 0.001). This remained significant even when accounting for patients' baseline characteristics or changes in medical cannabis directives over time (all P > 0.05).

CONCLUSION

Our findings provide preliminary insight into the potential mechanisms of action underlying pain reductions among patients with FM who are using medical cannabis. Given the high attrition rate (i.e., 75%) observed in the present study at 12 months, our findings cannot be generalized to all patients with FM who are using medical cannabis.

Delivery of a Group Hypnosis Protocol for Managing Chronic Pain in Outpatient Integrative Medicine

Although strong evidence exists for using individual hypnosis to treat pain, evidence regarding group applications is limited. This project evaluated changes in multiple outcome measures in persons with chronic pain treated with 8 weeks of group hypnosis. Eighty-five adults with diverse chronic pain etiologies completed an 8-session, structured group hypnosis treatment. Pain intensity, pain interference, and global health were evaluated at baseline, posttreatment, and 3- and 6-months posttreatment. Linear mixed effects models assessed changes in outcomes over time. In a model testing, all three outcome measures simultaneously, participants improved substantially from pre- to posttreatment and maintained improvement across follow-up. Analyses of individual outcomes showed significant pre- to posttreatment reductions in pain intensity and interference, which were maintained for pain intensity and continued to improve for pain interference across follow-up. The findings provide compelling preliminary evidence that a group format is an effective delivery system for teaching individual skills in using hypnosis for chronic pain management. Larger randomized controlled trials are warranted to demonstrate equivalence of outcomes between treatment modes.

What Are the Mechanisms of Action of Cognitive-Behavioral, Mind-Body, and Exercise-based Interventions for Pain and Disability in People With Chronic Primary Musculoskeletal Pain?: A Systematic Review of Mediation Studies From Randomized Controlled Trials

OBJECTIVES

This systematic review examined studies that used mediation analysis to investigate the mechanisms of action of cognitive-behavioral, mind-body, and exercise-based interventions for pain and disability in people with chronic primary musculoskeletal pain.

MATERIALS AND METHODS

We searched 5 electronic databases for articles that conducted mediation analyses of randomized controlled trials to either test or estimate indirect effects.

RESULTS

We found 17 studies (n=4423), including 90 mediation models examining the role of 22 putative mediators on pain or disability, of which 4 had partially mediated treatment effect; 8 had mixed results, and 10 did not mediate treatment effect. The conditions studied were chronic whiplash-associated pain, chronic low back pain, chronic knee pain, and mixed group of chronic primary musculoskeletal pain.

DISCUSSION

We observed that several of the studies included in our systematic review identified similar mechanisms of action, even between different interventions and conditions. However, methodological limitations were common. In conclusion, there are still substantial gaps with respect to understanding how cognitive-behavioral, mind-body, and exercise-based interventions work to reduce pain and disability in people with chronic primary musculoskeletal pain.

How do psychologically based interventions for chronic musculoskeletal pain work? A systematic review and meta-analysis of specific moderators and mediators of treatment

Psychologically based interventions aim to improve pain-related functioning by targeting pain-related fears, cognitions and behaviors. Mediation and moderation analyses permit further examination of the effect of treatment on an outcome. This systematic review and meta-analysis aims to synthetize the evidence of specific mediators and moderators (i.e., treatment targets) of psychologically based treatment effects on pain and disability. A total of 28 mediation and 11 moderation analyses were included. Thirteen mediation studies were included in a meta-analysis, and the rest was narratively synthetized. Reductions in pain-related fear (indirect effect [IE]: -0.07; 95% confidence interval [CI]: -0.11, -0.04) and catastrophizing (IE: -0.07; 95%CI: -0.14, -0.00), as well as increases in self-efficacy (IE: -0.07; 95%CI: -0.11, -0.04), mediated effects of cognitive behavioral therapy on disability but not on pain intensity, when compared to control treatments. Enhancing pain acceptance (IE: -0.17; 95%CI: -0.31, -0.03) and psychological flexibility (IE: -0.30; 95%CI: -0.41, -0.18) mediated acceptance and commitment therapy effects on disability. The narrative synthesis showed conflicting evidence, which did not support a robust moderated effect for any of the examined constructs. Overall, the methodological quality regarding mediation was low, and some key pitfalls are highlighted alongside recommendations to provide a platform for future research.

Hierarchical Structure of Depression Knowledge Network and Co-word Analysis of Focus Areas

Contemporarily, depression has become a common psychiatric disorder that influences people's life quality and mental state. This study presents a systematic review analysis of depression based on a hierarchical structure approach. This research provides a rich theoretical foundation for understanding the hot spots, evolutionary trends, and future related research directions and offers further guidance for practice. This investigation contributes to knowledge by combining robust methodological software for analysis, including Citespace, Ucinet, and Pajek. This paper employed the bibliometric methodology to analyze 5,000 research articles concerning depression. This current research also employed the BibExcel software to bibliometrically measure the keywords of the selected articles and further conducted a co-word matrix analysis. Additionally, Pajek software was used to conduct a co-word network analysis to obtain a co-word network diagram of depression. Further, Ucinet software was utilized to calculate K-core values, degree centrality, and mediated centrality to better present the research hotspots, sort out the current status and reveal the research characteristics in the field of depression with valuable information and support for subsequent research. This research indicates that major depressive disorder, anxiety, and mental health had a high occurrence among adolescents and the aged. This present study provides policy recommendations for the government, non-governmental organizations and other philanthropic agencies to help furnish resources for treating and controlling depression orders.

Functional Rehabilitation: An Integrated Treatment Model for Patients With Complex Physical and Psychiatric Conditions

The health care delivery system in the United States, structured to provide single-disease care, presents unique challenges for patients with complex physical and psychiatric comorbidities. Patients in these populations are often referred to multiple specialty clinics, encounter little continuity of care or collaboration among their providers, incur high health care costs, and experience poor treatment outcomes. Given these barriers, questions remain about the extent to which siloed and fragmented care, as opposed to the complex nature of the illnesses themselves, contribute to poor outcomes. If given the opportunity to receive well-integrated, consistent, and personalized care, can patients with historically difficult-to-treat comorbid medical and mental illnesses make progress? This article describes an innovative model of care called functional rehabilitation that is designed to address existing barriers in treatment. The functional rehabilitation program seeks to disrupt the escalating effects of interacting comorbidities by offering highly collaborative treatment from a small team of clinicians, personalized interventions using a shared decision-making framework, multipronged treatment options, colocation in a large hospital system, and significant 1:1 time with patients. The article includes a case example with longitudinal outcome data that illustrates how progress can be made with appropriate programmatic supports. Future research should examine the cost-effectiveness of this model of care.

Somatosensory amplification moderates the efficacy of internet-delivered CBT for somatic symptom distress in emerging adults: Exploratory analysis of a randomized controlled trial

OBJECTIVE

While studies mainly provide positive evidence for the efficacy of internet-delivered cognitive-behavioral therapy (ICBT) for various persistent somatic symptoms, it remains largely unclear for whom these interventions work or not. This exploratory analysis aimed to identify moderators for the outcome between ICBT for somatic symptom distres and a waitlist control group (WL) in a vulnerable target group of emerging adults.

METHODS

Based on data from a randomized controlled trial on 156 university students with varying degrees of somatic symptom distress who were allocated to either an eight-week, therapist guided ICBT (iSOMA) or to the WL, we examined pretreatment demographic characteristics, health-related variables (e.g., somatic symptom duration), mental distress (e.g., depression, anxiety) and cognitive-emotional factors (emotional reactivity, somatosensory amplification) as candidate moderators of the outcome, somatic symptom distress (assessed by the Patient Health Questionnaire, PHQ-15) from pre- to posttreatment.

RESULTS

Somatosensory amplification (assessed by the Somatosensory Amplification Scale, SSAS) moderated the outcome in favor of iSOMA (B = -0.17, SE = 0.08, p = 0.031), i.e., higher pretreatment somatosensory amplification was associated with better outcome in the active compared to the control intervention. No significant moderation effects were found among demographic characteristics, health-related variables, or mental distress.

CONCLUSION

Our findings suggest that an internet-delivered CBT for somatic symptom distress should be preferred over no active treatment particularly in individuals with moderate to high levels of somatosensory amplification, which as a next step should be tested against further treatments and in clinical populations.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00014375).

Evaluation of Cognitive Behavioral Therapy on Improving Pain, Fear Avoidance, and Self-Efficacy in Patients with Chronic Low Back Pain: A Systematic Review and Meta-Analysis

Background. Cognitive-behavioral therapy (CBT) is commonly adopted in pain management programs for patients with chronic low back pain (CLBP). However, the benefits of CBT are still unclear. Objectives. This review investigated the effectiveness of CBT on pain, disability, fear avoidance, and self-efficacy in patients with CLBP. Methods. Databases including PubMed, EMBASE, Web of Science, Cochrane Library, and PsycINFO were searched. RCTs examining the effects of CBT in adults with CLBP were included. The data about the outcome of pain, disability, fear avoidance, and self-efficacy were retained. Subgroup analysis about the effects of CBT on posttreatment was conducted according to CBT versus control groups (waiting list/usual care, active therapy) and concurrent CBT versus CBT alone. A random-effects model was used, and statistical heterogeneity was explored. Results. 22 articles were included. The results indicated that CBT was superior to other therapies in improving disability (SMD −0.44, 95% CI −0.71 to −0.17, $P<0.05$ ), pain (SMD −0.32, 95% CI −0.57 to −0.06, $P<0.05$ ), fear avoidance (SMD −1.24, 95% CI −2.25 to −0.23, $P<0.05$ ), and self-efficacy (SMD 0.27, 95% CI 0.15 to 0.40, $P<0.05$ ) after intervention. No different effect was observed between CBT and other therapies in all the follow-up terms. Subgroup analysis suggested that CBT in conjunction with other interventions was in favor of other interventions alone to reduce pain and disability ( $P<0.05$ ). Conclusion. CBT is beneficial in patients with CLBP for improving pain, disability, fear avoidance, and self-efficacy in CLBP patients. Further study is recommended to investigate the long-term benefits of CBT. This meta-analysis is registered with Prospero (registration number CRD42021224837).

The Contribution of “Individual Participant Data” Meta-Analyses of Psychotherapies for Depression to the Development of Personalized Treatments: A Systematic Review

While randomized trials typically lack sufficient statistical power to identify predictors and moderators of outcome, ”individual participant data” (IPD) meta-analyses, which combine primary data of multiple randomized trials, can increase the statistical power to identify predictors and moderators of outcome. We conducted a systematic review of IPD meta-analyses on psychological treatments of depression to provide an overview of predictors and moderators identified. We included 10 (eight pairwise and two network) IPD meta-analyses. Six meta-analyses showed that higher baseline depression severity was associated with better outcomes, and two found that older age was associated with better outcomes. Because power was high in most IPD meta-analyses, non-significant findings are also of interest because they indicate that these variables are probably not relevant as predictors and moderators. We did not find in any IPD meta-analysis that gender, education level, or relationship status were significant predictors or moderators. This review shows that IPD meta-analyses on psychological treatments can identify predictors and moderators of treatment effects and thereby contribute considerably to the development of personalized treatments of depression.

Cognitive-Behavioral-Based Physical Therapy for Improving Recovery After Traumatic Orthopaedic Lower Extremity Injury (CBPT-Trauma)

SUMMARY

Physical and psychological impairment resulting from traumatic injuries is often significant and affects employment and functional independence. Extremity trauma has been shown to negatively affect long-term self-reported physical function, the ability to work, and participation in recreational activities and contributes to increased rates of anxiety and/or depression. High pain levels early in the recovery process and psychosocial factors play a prominent role in recovery after traumatic lower extremity injury. Cognitive-behavioral therapy pain programs have been shown to mitigate these effects. However, patient access issues related to financial and transportation constraints and the competing demands of treatment focused on the physical sequelae of traumatic injury limit patient participation in this treatment modality. This article describes a telephone-delivered cognitive-behavioral-based physical therapy (CBPT-Trauma) program and design of a multicenter trial to determine its effectiveness after lower extremity trauma. Three hundred twenty-five patients from 7 Level 1 trauma centers were randomized to CBPT-Trauma or an education program after hospital discharge. The primary hypothesis is that compared with patients who receive an education program, patients who receive the CBPT-Trauma program will have improved physical function, pain, and physical and mental health at 12 months after hospital discharge.

Cognitive Behavioral Therapy for Migraine Headache: A Systematic Review and Meta-Analysis

Background and Objectives: Migraine headaches are chronic neurological diseases that reduce the quality of life by causing severe headaches and autonomic nervous system dysfunction, such as facial flushing, nasal stuffiness, and sweating. Their major treatment methods include medication and cognitive behavioral therapy (CBT). CBT has been used for pain treatment and various psychogenic neurological diseases by reducing pain, disability, and emotional disorders caused by symptoms of mental illness and improving the understanding of mental health. This study aimed to evaluate the effectiveness and safety of CBT in treating migraines. Materials and Methods: Seven electronic databases were searched from the date of inception to December 2020. Randomized controlled studies (RCTs) using CBT as an intervention for migraine were included. The primary outcome of this study was to determine the frequency of migraines and the intensity of migraines on Visual Analog Scale (VAS), the frequency of drug use, Migraine Disability Assessment (MIDAS), and Headache Impact Test (HIT-6) index. The two authors independently conducted the data extraction and quality assessment of the included RCTs, and conducted meta-analysis with RevMan V.5.4. Results: Among the 373 studies, 11 RCTs were included in this systematic review. Seven out of the 11 RCTs were conducted in the USA, and four were conducted in the UK, Germany, Iran, and Italy, respectively. Headache frequency and MIDAS scores were statistically significant reduced. In the subgroup analysis, headache strength was significantly reduced. Two of the included studies reported adverse effects, including worsening of migraine intensity and frequency, respiratory symptoms, and vivid memory of a traumatic event. Conclusions: CBT for migraine effectively reduced headache frequency and MIDAS score in meta-analysis and headache intensity subgroup analysis, with few adverse events. Additional RCTs with CBT for migraine headaches are needed for a more accurate analysis.

Choosing what works for whom: towards a better use of mechanistic knowledge in clinical practice

BACKGROUND

Clinicians commonly try to use mechanism-based knowledge to make sense of the complexity and uncertainty of chronic pain treatments to create a rationale for their clinical decision-making. Although this seems intuitive, there are some problems with this approach.

DISCUSSION

The widespread use of mechanism-based knowledge in clinical practice can be a source of confusion for clinicians, especially when complex interventions with different proposed mechanisms of action are equally effective. Although the available mechanistic evidence is still of very poor quality, in choosing from various treatment options for people with chronic pain, an approach that correctly incorporates mechanistic reasoning might aid clinical thinking and practice.

CONCLUSION

By explaining that not all evidence of mechanism is the same and by making a proposal to start using mechanism-based knowledge in clinical practice properly, we hope to help clinicians to incorporate mechanistic reasoning to prioritize and start choosing what may best work for whom.

Pain Medication Beliefs Mediate the Relationship Between Pain Catastrophizing and Opioid Prescription Use in Patients With Chronic Non-Cancer Pain

Little is known about the mechanisms by which pain catastrophizing may be associated with opioid use outcomes. This study aimed to investigate the potential mediating role of beliefs about the appropriateness of pain medicines for pain treatment on the association between pain catastrophizing and prescription opioid use in a community chronic non-cancer pain (CNCP) sample. Individuals (N = 420) diagnosed with CNCP participated in a cross-sectional online self-report study with validated measures of pain medication beliefs, pain catastrophizing, and current prescription opioid use. Two parallel multiple mediator analyses with percentile-based bootstrapping examined pathways to both prescription opioid use and high-dose use (≥ 100mg oral morphine equivalents/day), while controlling for pain intensity and other relevant covariates. Pain medication beliefs significantly mediated the association between pain catastrophizing and prescription opioid use (CI = 0.011, 0.033). A similar pattern of findings was found for high-dose opioid use, with pain medication beliefs significantly mediating the pain catastrophizing-high-dose use association (CI = 0.006, 0.050). Pain medication beliefs are a potentially modifiable psychological mechanism by which pain catastrophizing is associated with opioid use, including high-dose use. These findings have important implications for personalizing prevention and treatment programs.

Structural equation modelling provides insights to understand the construct of chronic pain in women with rheumatoid arthritis

OBJECTIVES

We aimed to adopt a multidimensional approach and investigate the interconnections between biomarkers (cytokines, matrix metalloproteinases, and cortisol) and psychosocial aspects considering pain acceptance, the individual construct of pain perception in terms of blood inflammation biomarkers, anxiety, self-efficacy, and functional performance and to define the quality of life (QoL) in women with rheumatoid arthritis (RA).

METHODS

An observational cross-sectional study with a total of 42-RA participants, with chronic pain and 42-women without rheumatic diseases or chronic pain were included. A structural equation model was used to investigate the association between independent variables.

RESULTS

Women with RA presented high blood biomarker levels, representing an intense inflammatory process. The participants with RA reported moderate pain most of the time, a worsening QoL, functionality, engagement in activities, and a willingness to live with pain and self-efficacy. It was found that the higher the chronic pain, the greater the intensity of pain perceived by these women with RA, as well as, the worse the functionality, the higher the perceived pain.

CONCLUSIONS

The exacerbation of pain perception leads to worsening of the experience of chronic pain. The new construct of pain experience should include functionality as a crucial factor in understanding the mechanisms underlying pain.

Mechanisms of Mindfulness Meditation, Cognitive Therapy, and Mindfulness-based Cognitive Therapy for Chronic Low Back Pain

OBJECTIVES

This study evaluated theoretically derived mechanisms and common therapeutic factors to test their role in accounting for pain-related outcome change during group-delivered cognitive therapy, mindfulness meditation, and mindfulness-based cognitive therapy for chronic low back pain.

METHODS

A secondary analysis of a pilot randomized controlled trial was used to explore the primary mechanisms of pretreatment to posttreatment changes in pain control beliefs, mindful observing, and pain catastrophizing, and the secondary common factor mechanisms of therapeutic alliance, group cohesion, and amount of at-home skill practice during treatment. The primary outcome was pain interference; pain intensity was a secondary outcome.

RESULTS

Large effect size changes in the 3 primary mechanisms and the outcome variables were found across the conditions. Across all 3 treatment conditions, change in pain control beliefs and pain catastrophizing were significantly associated with improved pain interference, but not pain intensity. Therapeutic alliance was significantly associated with pain intensity improvement and change in the therapy-specific mechanisms across the 3 conditions. Mindful observing, group cohesion, and amount of at-home practice were not significantly associated with changes in the outcomes.

DISCUSSION

Cognitive therapy, mindfulness meditation, and mindfulness-based cognitive therapy for chronic low back pain were all associated with significant changes in the primary mechanisms to a similar degree. Change in perceived pain control and pain catastrophizing emerged as potential "meta-mechanisms" that might be a shared pathway that contributes to improved pain-related outcomes across treatments. Further, strong working alliance may represent a critical therapeutic process that both promotes and interacts with therapeutic techniques to influence outcome.

The role of affect in chronic pain: A systematic review of within-person symptom dynamics

OBJECTIVE

Chronic pain is conceptualized as a biopsychosocial phenomenon that involves both physical and emotional processes. The vast majority of research regarding these facets of chronic pain characterizes differences between individuals. In this review, we describe problems with assuming that differences between persons accurately characterize within-person processes. We also provide a systematic review of studies that have examined within-person relationships between pain and affect among individuals with chronic pain.

METHOD

Articles published by December 2020 that pertained to within-person assessment of pain and emotion, affect, or mood were identified. Data regarding study design, adherence, and concurrent and prospective relationships among pain and affect variables were extracted and summarized.

RESULTS

Of 611 abstracts, 55 studies met inclusion criteria. Results suggest that individuals with chronic pain tend to experience increased negative affect and decreased positive affect when experiencing more severe pain (r_pooled = .18 and - .19, respectively). However, the size of these effects appeared smaller than between-person associations, and there was evidence of significant variability between individuals. Examination of predictive relationships between pain and affect largely suggested the tendency of symptoms to predict themselves, rather than pain predicting affect or vice versa.

CONCLUSIONS

Consistent with group-level relationships, experiencing more severe pain relative to an individual's average seems to be associated with more negative affect and less positive affect. However, individuals vary in the size and even direction of these effects. More research is necessary to understand the implications of such variability for the assessment and treatment of chronic pain.

Senior WISE intervention: Gender differences in bodily pain and trait anxiety

PURPOSE

In this secondary analysis we tested whether 12 h of Senior WISE (Wisdom Is Simply Exploration) memory or health training with older adults would produce better outcomes by gender in perceptions of anxiety and bodily pain and whether the effects of the Senior WISE training on pain were mediated by anxiety.

DESIGN

An implemented Phase III randomized clinical trial with follow up for 24 months in Central Texas. The sample was mostly female (79%), 71% Caucasian, 17% Hispanic, and 12% African American with an average age of 75 and 13 years of education.

RESULTS

The effects of the memory intervention on anxiety were consistent across time, with effects present for males but not females at post-treatment and end-of-study. Although males had more anxiety in the health promotion group, the memory training reduced males' anxiety such that no gender difference was present in this group. The Senior WISE intervention reduced pain for both males and females at post-intervention but not at end-of-study. Although gender differences did not depend on the treatment group for pain, females reported somewhat, but not significantly, less pain at post-treatment and end-of-study. Mediation analysis indicated that, for males, the memory intervention indirectly affected pain at post-treatment, in part, by reducing anxiety, which lowered pain. However, at end-of-study, no indirect effect was present. Males responded to memory training. Training tailored to gender may increase the efficacy of the programs and "buy-in" from male participants, especially if tailored to anxiety and pain.