Are intensive data collection methods in pain research feasible in those with physical disability? A study in persons with chronic pain and spinal cord injury

Measurement reactivity in ambulatory assessment: Increase in emotional clarity over time independent of sampling frequency

Ambulatory assessment (AA) studies are frequently used to study emotions, cognitions, and behavior in daily life. But does the measurement itself produce reactivity, that is, are the constructs that are measured influenced by participation? We investigated individual differences in intraindividual change in momentary emotional clarity and momentary pleasant-unpleasant mood over the course of an AA study. Specifically, we experimentally manipulated sampling frequency and hypothesized that the intraindividual change over time would be stronger when sampling frequency was high (vs. low). Moreover, we assumed that individual differences in dispositional mood regulation would moderate the direction of intraindividual change in momentary pleasant-unpleasant mood over time. Students (n = 313) were prompted either three or nine times a day for 1 week (data collection took place in 2019 and 2020). Multilevel growth curve models showed that momentary emotional clarity increased within participants over the course of the AA phase, but this increase did not differ between the two sampling frequency groups. Pleasant-unpleasant mood did not show a systematic trend over the course of the study, and mood regulation did not predict individual differences in mood change over time. Again, results were not moderated by the sampling frequency group. We discuss limitations of our study (e.g., WEIRD sample) and potential practical implications regarding sampling frequency in AA studies. Future studies should further systematically investigate the circumstances under which measurement reactivity is more likely to occur.

The feasibility of using ecological momentary assessment to understand urinary and fecal incontinence experiences in adults with spina bifida: A 30-day study

In this paper, we evaluate the feasibility of using ecological momentary assessment (EMA) to understand urinary (UI) and fecal (FI) incontinence in adults with spina bifida (SB). As part of a larger 30-day prospective study to understand the incontinence in adults with SB (N = 89), participants completed end-of-day EMA diaries assessing the frequency and context of UI and FI. We used these data to assess the method feasibility across six dimensions: (a) compliance, or data entry which is consistent with study protocol and substantially complete; (b) reactivity, or behavior change attributed to study participation; (c) participant acceptability, or convenience and ease of method beneficial to compliance; (d) data capture, or the volume of incontinence behaviors collected; (e) the accuracy of incontinence reports; and f) participant-provided feedback for future studies. Participants were highly compliant with diary entry protocol and schedule: submitting 95.7% (2576/2700) of the expected total daily entries. The average completion time was two minutes. Neither the total number of submissions nor the completion time varied by demographic characteristics or health history. A sufficient volume of incontinence and affective outcomes were captured, with small downtrends in reporting of UI and affect over time. Exit survey recall was highly correlated with diary reports. Participants found the methodology to be acceptable, reported their experiences honestly, enjoyed and felt comfortable participating in the study and would engage in similar study in the future. Accurate information about the daily context of UI and FI is a key factor in the success of intervention or education programs relying on this information. Our findings demonstrate that EMA is a feasible way to describe UI and FI in adults with SB.

Synthesis of evidence on the use of ecological momentary assessments to monitor health outcomes after traumatic injury: rapid systematic review

BACKGROUND

With the increasing use of mobile technology, ecological momentary assessments (EMAs) may enable routine monitoring of patient health outcomes and patient experiences of care by health agencies. This rapid review aims to synthesise the evidence on the use of EMAs to monitor health outcomes after traumatic unintentional injury.

METHOD

A rapid systematic review of nine databases (MEDLINE, Web of Science, Embase, CINAHL, Academic Search Premier, PsychINFO, Psychology and Behavioural Sciences Collection, Scopus, SportDiscus) for English-language articles from January 2010-September 2021 was conducted. Abstracts and full-text were screened by two reviewers and each article critically appraised. Key information was extracted by population characteristics, age and sample size, follow-up time period(s), type of EMA tools, physical health or pain outcome(s), psychological health outcome(s), general health or social outcome(s), and facilitators or barriers of EMA methods. Narrative synthesis was undertaken to identify key EMA facilitator and barrier themes.

RESULTS

There were 29 articles using data from 25 unique studies. Almost all (84.0%) were prospective cohort studies and 11 (44.0%) were EMA feasibility trials with an injured cohort. Traumatic and acquired brain injuries and concussion (64.0%) were the most common injuries examined. The most common EMA type was interval (40.0%). There were 10 key facilitator themes (e.g. feasibility, ecological validity, compliance) and 10 key barrier themes (e.g. complex technology, response consistency, ability to capture a participant's full experience, compliance decline) identified in studies using EMA to examine health outcomes post-injury.

CONCLUSIONS

This review highlighted the usefulness of EMA to capture ecologically valid participant responses of their experiences post-injury. EMAs have the potential to assist in routine follow-up of the health outcomes of patients post-injury and their use should be further explored.

Daily Variation in Sleep Quality is Associated With Health-Related Quality of Life in People With Spinal Cord Injury

OBJECTIVE

Although sleep difficulties are common after spinal cord injury (SCI), little is known about how day-to-day fluctuations in sleep quality affects health-related quality of life (HRQOL) among these individuals. We examined the effect of sleep quality on same-day HRQOL using ecological momentary assessment methods over a 7-day period.

DESIGN

Repeated-measures study involving 7 days of home monitoring; participants completed HRQOL measures each night and ecological momentary assessment ratings 3 times throughout the day; multilevel models were used to analyze data.

SETTING

Two academic medical centers.

PARTICIPANTS

A total of 170 individuals with SCI (N=170).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Daily sleep quality was rated on a scale of 0 (worst) to 10 (best) each morning. Participants completed end-of-day diaries each night that included several HRQOL measures (Sleep Disturbance, Sleep-related Impairment, Fatigue, Cognitive Abilities, Pain Intensity, Pain Interference, Ability to Participate in Social Roles and Activities, Depression, Anxiety) and ecological momentary assessment ratings of HRQOL (pain, fatigue, subjective thinking) 3 times throughout each day.

RESULTS

Multilevel models indicated that fluctuations in sleep quality (as determined by end-of-day ratings) were significantly related to next-day ratings of HRQOL; sleep quality was related to other reports of sleep (Sleep Disturbance; Sleep-related Impairment; Fatigue) but not to other aspects of HRQOL. For ecological momentary assessment ratings, nights of poor sleep were related to worse pain, fatigue, and thinking. Generally, sleep quality showed consistent associations with fatigue and thinking across the day, but the association between sleep quality and these ecological momentary assessment ratings weakened over the course of the day.

CONCLUSIONS

Findings highlight the important association between sleep and HRQOL for people with SCI. Future work targeting sleep quality improvement may have positive downstream effects for improving HRQOL in people with SCI.

How is quality of life defined and assessed in published research?

PURPOSE

To ensure clarity in communication in the field of quality of life research, and meaningful use of 'quality of life' as a research outcome, requires two things: awareness that there is a range of conceptualisations and definitions of 'quality of life', and for any particular study, consistency between the way the term is defined and operationalised in that setting. We aimed to identify how frequently research articles described (HR)QOL as a construct of interest, how frequently they referred to "patient-reported outcome (measures)", which patient-reported outcome measures were used, and how (HR)QOL was defined.

METHODS

We reviewed all Quality of Life Research articles published in 2017 and recorded whether they described health-related quality of life or quality of life as constructs of interest, and/or mentioned the term(s) patient-reported outcome (measures). We recorded definitions of (HR)QOL stated and questionnaires used. We classified articles according to constructs assessed and instruments used, and examined whether articles citing the same definition used the same questionnaires.

RESULTS

We reviewed 300 articles; 65% stated that (HR)QOL was a construct of interest, 27% mentioned patient-reported outcome (measures), and 20% mentioned neither. Fifty-one articles provided definitions of (HR)QOL, citing 66 sources, with 11 definitions cited more than once. PROMIS, SF, EQ-5D, and EORTC instruments were the most commonly used. The only definition and questionnaire consistently used together were the WHO definitions/instruments.

CONCLUSION

These results demonstrate considerable heterogeneity in the definition and operationalisation of (HR)QOL, between and within studies. This limits meaningful interpretation of (HR)QOL scores and complicates literature searches. Investigators should define constructs and select instruments aligned with their definitions.

Using ecological momentary assessment to evaluate neuropathic pain experienced by adults with SCI: recommendations and participant perceptions

PURPOSE

Neuropathic pain is a debilitating consequence of spinal cord injury. Ecological momentary assessment can be a valuable research tool for understanding temporal fluctuations in neuropathic pain and designing effective management strategies. The objectives of this study were to (a) describe strategies necessary to adapt ecological momentary assessment to measure neuropathic pain in adults with spinal cord injury, and (b) explore participant perceptions of using ecological momentary assessment to measure pain sensations.

METHODS

End-users with spinal cord injury provided input to guide development of an ecological momentary assessment protocol. Six adults with spinal cord injury (ages 27-50 years, M = 39.33 ± 8.24) engaged in the six-day protocol and completed six daily neuropathic pain assessments. Upon finishing participants completed a semi-structured interview regarding their protocol experiences. A qualitative content analysis was used to analyze the interview data.

RESULTS

Participants reported that this specific ecological momentary assessment protocol was unobtrusive to their daily routines, and effectively captured their neuropathic pain sensations. However, participants experienced increased neuropathic pain due to the repeated nature of assessments.

CONCLUSION

Ecological momentary assessment can capture the dynamic nature of neuropathic pain experienced by persons with spinal cord injury. However, caution should be taken when designing intensive pain-related protocols to minimize pain exacerbation.IMPLICATIONS FOR REHABILITATIONNeuropathic pain affects up to 75% of people with spinal cord injury and is one of the most frequently occurring, debilitating forms of pain.Appropriate and feasible pain data collection methods are necessary to acquire a better understanding of how neuropathic pain manifests in people with spinal cord injury.Implementing ecological momentary assessment in a rehabilitation setting may help facilitate the monitoring of neuropathic pain for both rehabilitation professionals and persons with SCI.Using ecological momentary assessment may lead to a better understanding of individual temporal patterns of neuropathic pain that could inform the design of tailored neuropathic pain management techniques.

Medicate or Meditate? Greater Pain Acceptance is Related to Lower Pain Medication Use in Persons With Chronic Pain and Spinal Cord Injury

OBJECTIVES

There is little information about whether use of pain self-management skills that are common targets of psychosocial interventions for pain are associated with reduced reliance on pain medications. The aim of this study was to test whether higher chronic pain acceptance, which is a readily modified pain self-management approach, is related to lower use of pain medications (eg, opioid medications, and gabapentinoids) in a sample with chronic pain and spinal cord injury (SCI).

MATERIALS AND METHODS

This is a cross-sectional survey study of pain medication use, pain severity and distribution (Brief Pain Inventory [BPI]), depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]), and chronic pain acceptance (Chronic Pain Acceptance Questionnaire [CPAQ]) administered to a sample of 120 adults with chronic pain and SCI.

RESULTS

Regression results indicated that, above and beyond the effects of pain intensity, pain distribution, and depressive symptoms, higher pain acceptance was related to lower use of all types of pain medications, and lower odds of using opioid medications or gabapentinoids. Pain intensity was not related to pain medication use, but greater pain distribution was related to using more pain medications in general and to greater odds of using gabapentinoids.

DISCUSSION

Findings from this study indicate that those with chronic pain and SCI who have a more accepting orientation to pain are less reliant on pain medications, and thereby experience lower risks associated with medication consumption. Longitudinal, daily process, and clinical trial studies are needed to better understand the association between pain acceptance and pain medication consumption.

The reliability of end of day and ecological momentary assessments of pain and pain interference in individuals with spinal cord injury

PURPOSE

This study investigated the most efficient means of measuring pain intensity and pain interference comparing ecological momentary assessment (EMA) to end of day (EOD) data, with the highest level of measurement reliability as examined in individuals with spinal cord injury.

METHODS

EMA (five times throughout the day) and EOD ratings of pain and pain interference were collected over a 7-day period. Multilevel models were used to examine the reliability for both EOD and EMA assessments in order to determine the amount of variability in these assessments over the course of a week or the day, and a multilevel version of the Spearman-Brown Prophecy formula was used to estimate values for reliability.

RESULTS

Findings indicate the minimum of number of EOD and EMA assessments needed to achieve different levels of reliability ("adequate" > 0.70, "good" > 0.80 and excellent > 0.90). In addition, the time of day (either morning, midday or evening) did not impact the estimated reliability for the EMA assessments.

CONCLUSIONS

These findings can help researchers and clinician balance the cost/benefit tradeoffs of these different types of assessments by providing specific cutoffs for the numbers of each type of assessment that are needed to achieve excellent reliability.

Willingness to Participate in Longitudinal Research Among People with Chronic Pain Who Take Medical Cannabis: A Cross-Sectional Survey

Background: Regulatory barriers limit clinical trials of medical cannabis in the United States. Longitudinal cohort studies may be one feasible alternative that could yield clinically relevant information. Willingness to participate in such studies is not known.

Materials and Methods: In October 2016, we surveyed a convenience sample of patients with chronic pain from two New York registered organizations (responsible for growing, processing, distributing, and retailing medical cannabis products). After a vignette describing a longitudinal cohort study involving weekly patient-reported outcomes and quarterly assessments of physical functioning and urine and blood tests, we asked about respondents' willingness to participate. We examined willingness to participate, duration of participation, and frequency of data collections overall and by subgroups, using multivariable logistic regression models.

Results: Of 405 respondents (estimated response rate: 30%), 54% were women and 81% were white non-Hispanic. Neuropathy was the most common pain condition (67%) followed by inflammatory bowel disease (19%). Of respondents, 94% (95% CI 92–97%) thought that the study should be done, 85% (95% CI 81–88%) would definitely or probably enroll if asked, 76% (95% CI 72–81%) would participate for ≥1 year, and 59% (95% CI 54–64%) would respond to questions at least daily. Older age was the only factor associated with lower willingness to participate, lower willingness to participate for ≥1 year, and lower willingness to respond to questions at least daily.

Conclusions: Nearly all respondents were supportive of the proposed study and most reported that they would enroll if asked. Enhanced engagement with older individuals may be needed to promote equal enrollment. Recruitment for longitudinal cohort studies with frequent data collection appears feasible in this patient population.

Using the experience-sampling method to examine the psychological mechanisms by which participatory art improves wellbeing

AIMS

To measure the immediate impact of art-making in everyday life on diverse indices of wellbeing ('in the moment' and longer term) in order to improve understanding of the psychological mechanisms by which art may improve mental health.

METHODS

Using the experience-sampling method, 41 artists were prompted (with a 'beep' on a handheld computer) at random intervals (10 times a day, for one week) to answer a short questionnaire. The questionnaire tracked art-making and enquired about mood, cognition and state of consciousness. This resulted in 2,495 sampled experiences, with a high response rate in which 89% of questionnaires were completed.

RESULTS

Multi-level modelling was used to evaluate the impact of art-making on experience, with 2,495 'experiences' (experiential-level) nested within 41 participants (person-level). Recent art-making was significantly associated with experiential shifts: improvement in hedonic tone, vivid internal imagery and the flow state. Furthermore, the frequency of art-making across the week was associated with person-level measures of wellbeing: eudemonic happiness and self-regulation. Cross-level interactions, between experiential and person-level variables, suggested that hedonic tone improved more for those scoring low on eudemonic happiness, and further that, those high in eudemonic happiness were more likely to experience phenomenological features of the flow state and to experience inner dialogue while art-making.

CONCLUSION

Art-making has both immediate and long-term associations with wellbeing. At the experiential level, art-making affects multiple dimensions of conscious experience: affective, cognitive and state factors. This suggests that there are multiple routes to wellbeing (improving hedonic tone, making meaning through inner dialogue and experiencing the flow state). Recommendations are made to consider these factors when both developing and evaluating public health interventions that involve participatory art.