Neglected topics in the treatment of chronic pain patients--relapse, noncompliance, and adherence enhancement

Mobile health intervention to address chronic pain among those who engage in hazardous drinking: A pilot study

BACKGROUND

Hazardous drinking has been associated with chronic pain in community and medical samples. The purpose of this study was to develop a novel, integrated mobile health intervention that improves pain management and reduces hazardous drinking that may be implemented in primary care settings.

METHODS

Forty-eight participants with moderate or greater chronic pain and hazardous drinking were recruited from primary care clinics and through social media sites. Following baseline assessment, participants were randomized to a counselor-supported smartphone app intervention (INTV) or a counselor delivered treatment-as-usual control condition (CTL).

RESULTS

Results supported the feasibility and acceptability of the smartphone app intervention. Participants found it easy to use, reported high levels of satisfaction, and showed high levels of engagement with the app. Between-group effect size estimates at follow-up showed small effects for the intervention on pain ratings. However, using clinically meaningful change thresholds of 30% and 50% improvement in pain scores, 38% and 25% respectively of those in the INTV condition showed reductions compared to 20% and 12.5% respectively in the CTL condition. Effect size estimates did not indicate intervention superiority on alcohol outcomes as participants in both conditions showed considerable reductions in drinking over the course of the study.

CONCLUSIONS

Results supported the view that a mobile health intervention delivered via smartphone with electronic coaching is a feasible and acceptable method of addressing chronic pain among those who engage in hazardous drinking. Future work should test the efficacy of this approach in a fully powered trial.

Factors Associated With Interest in Engaging in Psychological Interventions for Pain Management

OBJECTIVE

Engagement in evidence-based psychological interventions for pain management is low. Identifying characteristics associated with interest in interventions can inform approaches to increase uptake and engagement. The purpose of this study was to examine factors associated with interest in psychological interventions among persons with chronic noncancer pain receiving prescription opioids.

METHODS

Participants with chronic noncancer pain and a new 30 to 90 day opioid prescription were recruited from 2 health systems. Participants (N=845) completed measures regarding pain, opioid use, psychiatric symptoms, emotional support, and interest in psychological interventions for pain management.

RESULTS

There were 245 (29.0%) participants who reported a high interest in psychological interventions for pain management. In bivariate analyses, variables associated with interest included younger age, female sex, greater pain severity, greater pain interference, greater number of pain sites, lower emotional support, depression, anxiety, and post-traumatic stress disorder ( P <0.05). In a multivariate model, greater pain severity (odds ratio [OR]=1.17; CI: 1.04-1.32), depression (OR=2.10; CI: 1.39-3.16), post-traumatic stress disorder (OR=1.85; CI: 1.19-2.95), and lower emotional support (OR=0.69; CI: 0.5-0.97) remained statistically significant.

DISCUSSION

The rate of interest in psychological interventions for pain management was low, which may indicate that patients initiating opioid treatment of chronic noncancer pain have low interest in psychological interventions. Greater pain severity and psychiatric distress were related to interest, and patients with these characteristics may especially benefit from psychological interventions. Providers may want to refer to psychological interventions before or when opioids are initiated. Additional work is needed to determine whether this would reduce long-term opioid use.

"I've got a spring in my step" participants experience of action observation therapy and eccentric exercises, a telehealth study for mid-portion Achilles Tendinopathy: a qualitative study

BACKGROUND

Quantitative research has dominated the field of Achilles Tendinopathy. The use of qualitative research allows in-depth exploration of participants' perspectives, offering great insight in the evaluation of a trial's processes, particularly when exploring a novel intervention such as Action Observation Therapy combined with eccentric exercises which has not been previously researched. This study aimed to qualitatively explore participants' experiences of partaking in a telehealth study including the acceptability of the intervention, motivators for participation, and perspectives on the trial processes.

METHOD

A thematic analysis as guided by Braun and Clarke was used to analyse the semi-structured interviews conducted on a purposive sample of participants with mid-portion Achilles Tendinopathy who recently completed a pilot feasibility study. The study adhered to the criteria for reporting qualitative research guidelines (COREQ).

RESULTS/DISCUSSION

Sixteen participants were interviewed. The five themes identified were: (i) The impact of Achilles Tendinopathy is commonly not prioritised with 'The acceptance and minimisation of pain' as a sub-theme (ii) Therapeutic alliance has the greatest impact on support (iii) Factors which influenced adherence (iv) Action Observation Therapy is valued and recommended (v) Recommendations for future interventions.

CONCLUSION

This study provides insightful recommendations around; exploring the use of Action Observation Therapy in Achilles Tendinopathy, the relative importance of therapeutic alliance rather than mode of therapy delivery, and that sufferers of Achilles Tendinopathy may not prioritise health seeking for this condition.

The Effect of Patients' Understanding of Sling Necessity and Home Assistance on Sling Wear After Shoulder Surgery

BACKGROUND

Perioperative education and socioeconomic factors influence patient behavior. Recent evidence has suggested that sling compliance is associated with improved outcomes after shoulder surgery; it is important to investigate factors that influence sling compliance.

PURPOSE

To determine the associations between postoperative sling wear and patients' understanding of sling necessity, postoperative home assistance, and social deprivation.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 66 patients were prospectively enrolled from 2018 to 2020 if they were ≥18 years of age and undergoing shoulder surgery requiring a sling for at least 1 month postoperatively. Sling wear was measured using a temperature-sensing device. At 6 weeks postoperatively, patients' understanding for sling necessity was determined by their response to a question on the Medical Adherence Measure questionnaire, "Why did you have to wear a shoulder sling?" The Patient Understanding Grading Scale (PUGS) was developed to quantify patient responses. PUGS was graded 1 to 3, with grade 1 corresponding to the least technical knowledge. Patient characteristics, social deprivation (Area Deprivation Index [ADI]), and home assistance were additionally analyzed.

RESULTS

There were no significant differences in baseline characteristics between patients when stratified by PUGS grade. Multivariable linear regression analysis for total hours of sling wear per week showed that patients with PUGS grade 2 (β, 48.2 hours; P = .007) and grade 3 (β, 59.5 hours; P = .003) wore their slings significantly more than grade 1 patients. Patients with home assistance had significantly greater day hours (73.5 ± 33.0 vs 44.0 ± 24.5 hours; P = .037) of sling wear per week, but there was no difference in night sling hours. Patients older than 60 years wore their slings significantly more, while men and those with a higher body mass index (BMI) wore their slings significantly less. ADI was not significantly associated with sling wear.

CONCLUSION

This study demonstrates that patients with greater understanding for sling necessity, those with home assistance, and patients >60 years have greater sling wear, while male patients and those with a higher BMI have lower sling compliance. ADI was not a significant contributor.

Pain and suicide: what should we tell our trainees?

Chronic pain is a debilitating medical condition affecting a significant percentage of the population worldwide. Considerable evidence suggests that pain is an independent risk factor for suicide and inadequately managing pain has been identified as a risk for suicidal behaviour. Additionally, medications used to treat pain may also contribute to suicidal behaviour. Extensive research on pain highlights deficiencies in the clinical management on pain with more gaps in care when patients have pain in combination with mental illness and suicidal behaviour. Providing trainees additional knowledge and equipping them with relevant tools to screen and manage chronic pain efficiently is a potential strategy to mitigate suicide risk. Also, trainees need to be educated on how to screen for suicidality in individuals with pain and apply suicide prevention interventions. This paper will emphasise the necessity to improve education about pain, its close relationship with suicide and effective suicide screening as well as management strategies for medical providers. With additional research, it is the hope that novel treatment modalities will be developed to treat pain to improve the quality of life of individuals suffering from this condition and to decrease suicide risk in this patient population.

Depression and Anxiety Are Associated With Worse Subjective and Functional Baseline Scores in Patients With Frozen Shoulder Contracture Syndrome: A Systematic Review

Purpose

To investigate whether psychological factors, such as avoidance behavior, fear, pain catastrophization, kinesiophobia, anxiety, depression, optimism, and expectation are associated with different subjective and functional baseline scores in patients with frozen shoulder contracture syndrome (FSCS).

Methods

Searches were conducted in MEDLINE, Cochrane Library (CENTRAL Database), PEDro, Pubpsych, and PsychNET.APA without restrictions applied to language, date, or status of publication. Two authors reviewed study titles, abstract, and full text based on the following inclusion criteria: adult population (≥ 30 < 70 years old) with FSCS.

Results

Seven hundred and seventy-six records were included by the search strategies. After title final screening, 6 studies were included for the qualitative synthesis. Psychological features investigated were anxiety, depression, pain-related fear, pain catastrophizing, and pain self-efficacy; reported outcomes included pain, function, disability, quality of life, and range of motion. Data suggest that anxiety and depression impact self-assessed function, pain, and quality of life. There is no consensus on the correlation between psychological variables and range of motion. Associations were suggested between pain-related fear, pain-related beliefs, and pain-related behavior and perceived arm function; pain-related conditions showed no significant correlation with range of motion and with perceived stiffness at baseline.

Conclusion

Scores traditionally thought to assess physical dimensions like shoulder pain, disability, and function seem to be influenced by psychological variables. In FSCS patients, depression and anxiety were associated with increased pain perception and decreased function and quality of life at baseline. Moreover, pain-related fear and catastrophizing seem to be associated with perceived arm function.

Longitudinal outcome evaluations of Interdisciplinary Multimodal Pain Treatment programmes for patients with chronic primary musculoskeletal pain: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Although Interdisciplinary Multimodal Pain Treatment (IMPT) programmes share a biopsychosocial approach to increase the wellbeing of patients with chronic pain, substantial variation in content and duration have been reported. In addition, it is unclear to what extent any favourable health outcomes are maintained over time. Therefore, our first aim was to identify and analyse the change over time of patient-related outcome measures in cohorts of patients who participated in IMPT programmes. Our second aim was to acquire insight into the heterogeneity of IMPT programmes.

DATABASES AND DATA TREATMENT

The study protocol was registered in Prospero under CRD42018076093. We searched Medline, Embase, PsycInfo and Cinahl from inception to May 2020. All study selection, data extraction and risk of bias assessments were independently performed by two researchers. Study cohorts were eligible if they included adult patients with chronic primary musculoskeletal pain for at least 3 months. We assessed the change over time, by calculating pre-post, post-follow-up and pre-follow-up contrasts for seven different patient-reported outcome domains. To explore the variability between the IMPT programmes, we summarized the patient characteristics and treatment programmes using the intervention description and replication checklist.

RESULTS

The majority of the 72 included patient cohorts significantly improved during treatment. Importantly, this improvement was generally maintained at follow-up. In line with our expectations and with previous studies, we observed substantial methodological and statistical heterogeneity.

CONCLUSIONS

This study shows that participation in an IMPT programme is associated with considerable improvements in wellbeing that are generally maintained at follow-up. The current study also found substantial heterogeneity in dose and treatment content, which suggests different viewpoints on how to optimally design an IMPT programme.

SIGNIFICANCE

The current study provides insight into the different existing approaches regarding the dose and content of IMPT programs. This analysis contributes to an increased understanding of the various approaches by which a biopsychosocial perspective on chronic pain can be translated to treatment programs. Furthermore, despite theoretical and empirical assertions regarding the difficulty to maintain newly learned health behaviors over time, the longitudinal analysis of health outcomes did not find a relapse pattern for patients who participated in IMPT programs.

Internet-Delivered Acceptance and Commitment Therapy Added to Multimodal Pain Rehabilitation: A Cluster Randomized Controlled Trial

Internet-delivered interventions hold the possibility to make pain rehabilitation more accessible and adaptable by providing qualified individualized psychological care to chronic pain patients in their homes. Acceptance and commitment therapy (ACT) has shown promising results on psychological functioning and pain acceptance. Internet-delivered ACT (IACT) added to multimodal pain rehabilitation program (MMRP) in primary care has, so far, not shown better results than MMRP alone. The aim of this cluster randomized controlled study was to investigate the effects of adding IACT during and after MMRP in specialist care on psychological outcomes. In total, 122 patients who enrolled in a specialist pain clinic were cluster randomized groupwise to either MMRP (n = 12 groups) or to MMRP with added IACT (n = 12 groups). The IACT addition included 6 weeks of treatment during MMRP and 11 weeks of aftercare following MMRP. Online and paper-and-pencil self-report measures of pain acceptance, psychological inflexibility, self-efficacy, and psychosocial consequences of pain, were collected at four occasions: prior to and post MMRP, post aftercare intervention and at 1 year follow-up. Dropout was extensive with 25% dropping out at post treatment, an additional 35% at post aftercare, and 29% at 1 year follow-up. Medium treatment between-group effects were found on pain acceptance in favor of the group who received IACT added to MMRP, at post treatment and at post aftercare. Large effects were seen on psychological inflexibility and self-efficacy at post aftercare. A medium effect size was seen on affective distress at post aftercare. Moreover, a medium effect on self-efficacy was found at 1 year follow-up. The results indicate that IACT added during MMRP may enhance the treatment effects on pain-related psychological outcomes. Results also suggest that IACT as aftercare may strengthen the long-term effect of MMRP. However, adding a second pain treatment, IACT, to an already extensive pain treatment, MMRP, could be perceived as too comprehensive and might hence influence completion negatively. Further research on adverse events and negative effects could be helpful to improve adherence. Next step of implementation trials could focus on adding IACT before MMRP to improve psychological functioning and after MMRP to prolong its effect.

Pain and medication adherence in adult cigarette smokers living with HIV: a cross-sectional observational study

The present study examines relationships between pain, mental health symptoms, and medication adherence in adult smokers living with HIV. Sixty-eight adult HIV-positive smokers taking antiretroviral medication completed a survey measuring medication adherence, mental health symptoms, and pain. The presence of pain, OR = 3.81, 95% CI (1.19, 12.14), higher pain severity, OR = 1.22, 95% CI (1.05, 1.41), and higher anxiety, OR = 1.09, 95% CI (1.03, 1.14) were associated with inferior medication adherence (MMAS-8 score <6). Anxiety mediated the relationships between presence of pain (ab = .56, BCa CI (0.05, 1.61)) and pain severity (ab = .09, BCa CI (0.01, 0.24)) and medication adherence. The results of this study suggest that pain and anxiety are factors that significantly contribute to medication nonadherence and thus are important areas of assessment by clinicians treating adult smokers living with HIV.

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.

Complementary treatment comparison for chronic pain management: A randomized longitudinal study

Background

In chronic pain, it seems that the effect of cognitive-behavioral therapy (CBT) is boosted when it is combined with hypnosis. The aim of this study was to assess the efficacy of self-hypnosis combined with self-care (i.e., a type of CBT) compared to music/self-care, self-care and psychoeducation/CBT and to evaluate their long-term effects.

Methods

An open label randomized clinical trial enrolled patients with chronic pain and was carried out at the University Hospital of Liège (Belgium). Patients were randomized into four groups: self-hypnosis/self-care, music/self-care, self-care, psychoeducation/CBT (7 monthly sessions of 2 hours). Two follow-up sessions were delivered at 6- and 12-month. Levels of pain, fatigue intensity, anxiety, depression, insomnia severity, disability, health locus of control, mental and physical quality of life and attitudes (control, disability, harm, emotion, medical cure, medication, solicitude) towards pain were assessed before and after the treatments, and at follow-up.

Results

203 patients were randomized: 52 in self-hypnosis/self-care, 59 in music/self-care, 47 in self-care, and 45 in psychoeducation/CBT. No group effect was found. A significant time effect was showed. Directly after the treatment, all groups decreased in pain attitudes and physical quality of life. Perceived control increased. At 6-month, all patients kept their levels of physical quality of life and perceived control, and showed decrease in pain intensity, harm, emotion and medical cure. At 12-month, scores that had change previously remained ameliorated, a decrease in insomnia severity and an increase in internal locus of control were observed.

Conclusions

The present findings are encouraging as they display long-term beneficial effects of complementary biopsychosocial-based treatments in chronic pain. It seems that patients continued to apply the learnt strategies as improvements were observed one year after the treatments had ended.

Cognitive Change and Relaxation as Key Mechanisms of Treatment Outcome in Chronic Pain: Evidence From Routine Care

Despite effective treatment approaches within the cognitive behavioral framework general treatment effects for chronic pain are rather small to very small. Translation from efficacy trials to naturalistic settings is questionable. There is an urgent need to improve the effectiveness of well-established treatments, such as cognitive-behavior therapy (CBT) and the investigation of mechanisms of change is a promising opportunity. We performed secondary data analysis from routine data of 1,440 chronic pain patients. Patients received CBT in a multidisciplinary setting in two inpatient clinics. Effect sizes and reliable change indices were computed for pain-related disability and depression. The associations between changes in the use of different pain coping skills (cognitive restructuring, activity despite pain, relaxation techniques and mental distraction) and changes in clinical outcomes were analyzed in structural equation models. Pre-post effect sizes range from g = 0.47 (disability) to g = 0.89 (depression). Changes in the use of cognitive restructuring, relaxation and to a lesser degree mental distraction were associated with changes in disability and depression. Effects from randomized trials can be translated to naturalistic settings. The results complement experimental research on mechanisms of change in the treatment of chronic pain and indicate an important role of cognitive change and relaxation as mechanisms of change. Our findings cautiously suggest that clinicians should optimize these processes in chronic pain patients to reduce their physical and emotional disability.

Integrating patient perspectives in the development of a mobile health intervention to address chronic pain and heavy drinking in primary care: a qualitative study of patients in an urban, safety-net hospital setting

Background

Chronic pain and heavy drinking are conditions that commonly co-occur among primary care patients. Despite the availability of behavioral interventions that target these conditions individually, engagement and adherence to treatment remain a challenge, and there have been no interventions designed to address both of these conditions together for patients presenting to primary care. This study seeks to incorporate the perspectives of patients regarding symptoms, treatment experiences, views on behavior change, and technology use to develop a tailored, integrated mobile health intervention that addresses both pain and heavy drinking among patients in primary care.

Methods

Twelve participants with moderate or greater chronic pain intensity and heavy drinking were recruited from primary care clinics in a large urban safety-net hospital. One-on-one interviews were recorded and transcribed. Codes were developed from interview transcripts, followed by thematic analysis in which specific meanings were assigned to codes. Participants also completed a series of Likert-based rating scales to evaluate components of the proposed intervention to supplement qualitative interviews.

Results

A number of themes were identified that had implications for intervention tailoring including: ambivalence about changing drinking, low expectations about pain treatment success, desire for contact with a designated provider, common use of smartphones but lack of familiarity with functions as a potential barrier to use, and strategies to maintain engagement and adherence. Evaluative ratings indicated that the proposed intervention content was perceived as helpful and the proposed structure, layout and design of the mobile intervention was acceptable to patients.

Conclusions

Results supported the view that a mobile health intervention delivered via smartphone with electronic coaching is an acceptable method of addressing chronic pain and heavy drinking among patients in primary care. The interviews highlight the need to utilize an intervention approach that addresses motivation to change drinking, sets realistic expectations for change, provides careful attention to training/education of the use of technology components, and fosters engagement through the use of reminders, feedback, and personalized activities.

Innovation in Pain Rehabilitation Using Co-Design Methods During the Development of a Relapse Prevention Intervention: Case Study

Background

Many intervention development projects fail to bridge the gap from basic research to clinical practice. Instead of theory-based approaches to intervention development, co-design prioritizes the end users’ perspective as well as continuous collaboration between stakeholders, designers, and researchers throughout the project. This alternative approach to the development of interventions is expected to promote the adaptation to existing treatment activities and to be responsive to the requirements of end users.

Objective

The first objective was to provide an overview of all activities that were employed during the course of a research project to develop a relapse prevention intervention for interdisciplinary pain treatment programs. The second objective was to examine how co-design may contribute to stakeholder involvement, generation of relevant insights and ideas, and incorporation of stakeholder input into the intervention design.

Methods

We performed an embedded single case study and used the double diamond model to describe the process of intervention development. Using all available data sources, we also performed deductive content analysis to reflect on this process.

Results

By critically reviewing the value and function of a co-design project with respect to idea generation, stakeholder involvement, and incorporation of stakeholder input into the intervention design, we demonstrated how co-design shaped the transition from ideas, via concepts, to a prototype for a relapse prevention intervention.

Conclusions

Structural use of co-design throughout the project resulted in many different participating stakeholders and stimulating design activities. As a consequence, the majority of the components of the final prototype can be traced back to the information that stakeholders provided during the project. Although this illustrates how co-design facilitates the integration of contextual information into the intervention design, further experimental testing is required to evaluate to what extent this approach ultimately leads to improved usability as well as patient outcomes in the context of clinical practice.

Exploring the Feasibility of Relapse Prevention Strategies in Interdisciplinary Multimodal Pain Therapy Programs: Qualitative Study

BACKGROUND

Although interdisciplinary multimodal pain treatment (IMPT) programs are widely regarded as treatment of choice for patients with chronic pain, there are signs that many patients are unable to maintain their treatment gains in the long term. To facilitate the maintenance of positive treatment outcomes over time, we developed two relapse prevention strategies.

OBJECTIVE

The main objective of this study was to explore the feasibility of these strategies within the context of IMPT programs.

METHODS

We performed a feasibility study using 3 workbook prototypes containing either one or both strategies. For a period of 6 months, the workbooks were made available in two IMPT facilities. Qualitative data were collected through a focus group and semistructured interviews. We performed a thematic analysis using a deductive approach with (1) applicability to the treatment program, (2) acceptability of the workbook content, and (3) form, as predefined themes.

RESULTS

The final dataset consisted of transcripts from a focus group with health care providers and 11 telephone interviews and 2 additional in-depth interviews with patients. In general, the intervention was perceived as useful, easy to use, and in line with the treatment program. The data also include suggestions to further improve the use of both strategies, including more specific implementation guidelines, revised goal-setting procedure, and development of a mobile health version. However, several factors, including a high dropout rate and small sample size, impact the external validity of our findings.

CONCLUSIONS

This study should be regarded as a first step in the process of transforming the prototype workbook into an effective intervention for clinical practice. Although these initial results indicate a favorable evaluation of both behavior regulation strategies within the workbook, this study encountered multiple barriers regarding implementation and data collection that limit the generalizability of these results. Future research efforts should specifically address the fidelity of HCPs and patients and should include clear procedures regarding recruitment and use of both relapse prevention strategies during treatment.

Predicting treatment adherence and outcome to outpatient multimodal rehabilitation in chronic low back pain

BACKGROUND

There is a growing need to identify patient pre-treatment characteristics that could predict adherence and outcome following specific interventions.

OBJECTIVE

To identify predictors of adherence and outcome to outpatient multimodal rehabilitation in chronic low back pain (CLBP).

METHODS

A total of 273 CLBP patients participated in an exercise-based rehabilitation program. Patients who completed ⩾ 70% of the treatment course were classified as adherent. Patients showing a post-treatment reduction of ⩾ 30% in Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) back pain intensity scores were assigned to the favorable outcome group.

RESULTS

Multivariate logistic regression revealed that higher age, higher ability to perform low-load activities, and higher degrees of kinesiophobia increased the odds to complete the rehabilitation program. By contrast, lower levels of education and back pain unrelated to poor posture increased the odds for non-adherence. Furthermore, a favorable outcome was predicted in case the cause for LBP was known, shorter symptom duration, no pain in the lower legs, no difficulties falling asleep, and short-term work absenteeism.

CONCLUSIONS

Assessment and consideration of patient pre-treatment characteristics is of great importance as they may enable therapists to identify patients with a good prognosis or at risk for non-responding to outpatient multimodal rehabilitation.

Barriers to Outpatient Pediatric Chronic Pain Clinic Participation Among Referred Patients

Initial clinic evaluation among referred patients and factors limiting treatment initiation are not well characterized. We conducted a retrospective review of referrals to our outpatient pain clinic to identify intake visits and factors associated with treatment initiation among adolescents with chronic pain. We identified adolescents aged 13 to 18 years at the time of referral to clinic (2010-2016). Factors associated with completion of visits were evaluated using logistic regression. Patients who completed visits more frequently had private insurance than public or no insurance (P = .053). The most common reasons for caregiver decision not to attend the pain clinic included use of another pain clinic, that services were not wanted or no longer needed, and that their child was undergoing further testing. The current study demonstrated that patients with head pain were more likely to complete an intake visit, while there was a trend showing that lack of private insurance decreased this likelihood.

Mobile Health App (AGRIPPA) to Prevent Relapse After Successful Interdisciplinary Treatment for Patients With Chronic Pain: Protocol for a Randomized Controlled Trial

BACKGROUND

To facilitate adherence to adaptive pain management behaviors after interdisciplinary multimodal pain treatment, we developed a mobile health app (AGRIPPA app) that contains two behavior regulation strategies.

OBJECTIVE

The aims of this project are (1) to test the effectiveness of the AGRIPPA app on pain disability; (2) to determine the cost-effectiveness; and (3) to explore the levels of engagement and usability of app users.

METHODS

We will perform a multicenter randomized controlled trial with two parallel groups. Within the 12-month inclusion period, we plan to recruit 158 adult patients with chronic pain during the initial stage of their interdisciplinary treatment program in one of the 6 participating centers. Participants will be randomly assigned to the standard treatment condition or to the enhanced treatment condition in which they will receive the AGRIPPA app. Patients will be monitored from the start of the treatment program until 12 months posttreatment. In our primary analysis, we will evaluate the difference over time of pain-related disability between the two conditions. Other outcome measures will include health-related quality of life, illness perceptions, pain self-efficacy, app system usage data, productivity loss, and health care expenses.

RESULTS

The study was approved by the local Medical Research Ethics Committee in October 2019. As of March 20, 2020, we have recruited 88 patients.

CONCLUSIONS

This study will be the first step in systematically evaluating the effectiveness and efficiency of the AGRIPPA app. After 3 years of development and feasibility testing, this formal evaluation will help determine to what extent the app will influence the maintenance of treatment gains over time. The outcomes of this trial will guide future decisions regarding uptake in clinical practice.

TRIAL REGISTRATION

Netherlands Trial Register NL8076; https://www.trialregister.nl/trial/8076.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18632.

The Effects of a Ketogenic Diet on Sensorimotor Function in a Thoracolumbar Mouse Spinal Cord Injury Model

Spinal cord injury and peripheral nerve injuries are traumatic events that greatly impact quality of life. One factor that is being explored throughout patient care is the idea of diet and the role it has on patient outcomes. But the effects of diet following neurotrauma need to be carefully explored in animal models to ensure that they have beneficial effects. The ketogenic diet provides sufficient daily caloric requirements while being potentially neuroprotective and analgesic. In this study, animals were fed a high-fat, low-carbohydrate diet that led to a high concentration of blood ketone that was sustained for as long as the animals were on the diet. Mice fed a ketogenic diet had significantly lower levels of tyrosine and tryptophan, but the levels of other monoamines within the spinal cord remained similar to those of control mice. Mice were fed a standard or ketogenic diet for 7 d before and 28 d following the injury. Our results show that mice hemisected over the T10–T11 vertebrae showed no beneficial effects of being on a ketogenic diet over a 28 d recovery period. Similarly, ligation of the common peroneal and tibial nerve showed no differences between mice fed normal or ketogenic diets. Tests included von Frey, open field, and ladder-rung crossing. We add to existing literature showing protective effects of the ketogenic diet in forelimb injuries by focusing on neurotrauma in the hindlimbs. The results suggest that ketogenic diets need to be assessed based on the type and location of neurotrauma.

Patient and practitioner perspectives of psychological need support in physical therapy

PURPOSE

To examine strategies utilized by physical therapists that contributed to patient perceptions of basic psychological needs support articulated within Self-Determination Theory (SDT).

METHODS

Semi-structured interviews were conducted with physical therapists (n = 9) and physical therapy patients (n = 9) undergoing rehabilitation for a variety of musculoskeletal injuries.

RESULTS

Both patients and practitioners articulated the value of specific competence (e.g. matching rehabilitation challenges with patient abilities) and autonomy support strategies (e.g. active decision-making). Interestingly, both patients and therapists emphasized the salience of relatedness need support, a finding indicative of the potential importance of this need in a rehabilitation environment. The possibility that relatedness need support may be of equal - or potentially greater - importance than the other two needs in a rehabilitation setting, is however, antithetical to SDT contentions. Whether the primacy of relatedness need support is an artifact of the sample used in the current study or a reflection of a broader rehabilitation trend, is uncertain and remains a topic for further investigation.

CONCLUSIONS

Understanding the strategies physical therapists use to support patients' psychological needs may have substantial implications for patient motivation and rehabilitation adherence, such as, improved psychological well-being, enhanced function, and increased adherence to physical therapists' recommendations.

A randomized trial to examine the mechanisms of cognitive, behavioral and mindfulness-based psychosocial treatments for chronic pain: Study protocol

This randomized trial will evaluate the mechanisms of three chronic pain treatments: cognitive therapy (CT), mindfulness meditation (MM), and activation skills (AS). We will determine the extent to which late-treatment improvement in primary outcome (pain interference) is predicted by early-treatment changes in cognitive content, cognitive process, and/or activity level. The shared versus specific role of these mechanisms across the three treatments will be evaluated during treatment (Primary Aim), and immediately post-treatment to examine relapse mechanisms (Secondary Aim). We will enroll 300 individuals with chronic pain (with low back pain as a primary or secondary condition), with 240 projected to complete the study. Participants will be randomly assigned to eight, 1.5 h telehealth group sessions of CT, MM, or AS. Mechanisms and outcomes will be assessed twice daily during 2-week baseline, 4-week treatment period, and 4-week post-treatment epoch via random cue-elicited ecological momentary assessment (EMA); activity level will be monitored during these time epochs via daily monitoring with ActiGraph technology. The primary outcome will be measured by the PROMIS 5-item Pain Interference scale. Structural equation modeling (SEM) will be used to test the primary aims. This study is pre-registered on clinicaltrials.gov (Identifier: NCT03687762). This study will determine the temporal sequence of lagged mediation effects to evaluate rates of change in outcome as a function of change in mediators. The findings will provide an empirical basis for enhancing and streamlining psychosocial chronic pain interventions. Further, results will guide future efforts towards optimizing maintenance of gains to effectively reduce relapse risk.

A Smartphone-Based Health Care Chatbot to Promote Self-Management of Chronic Pain (SELMA): Pilot Randomized Controlled Trial

BACKGROUND

Ongoing pain is one of the most common diseases and has major physical, psychological, social, and economic impacts. A mobile health intervention utilizing a fully automated text-based health care chatbot (TBHC) may offer an innovative way not only to deliver coping strategies and psychoeducation for pain management but also to build a working alliance between a participant and the TBHC.

OBJECTIVE

The objectives of this study are twofold: (1) to describe the design and implementation to promote the chatbot painSELfMAnagement (SELMA), a 2-month smartphone-based cognitive behavior therapy (CBT) TBHC intervention for pain self-management in patients with ongoing or cyclic pain, and (2) to present findings from a pilot randomized controlled trial, in which effectiveness, influence of intention to change behavior, pain duration, working alliance, acceptance, and adherence were evaluated.

METHODS

Participants were recruited online and in collaboration with pain experts, and were randomized to interact with SELMA for 8 weeks either every day or every other day concerning CBT-based pain management (n=59), or weekly concerning content not related to pain management (n=43). Pain-related impairment (primary outcome), general well-being, pain intensity, and the bond scale of working alliance were measured at baseline and postintervention. Intention to change behavior and pain duration were measured at baseline only, and acceptance postintervention was assessed via self-reporting instruments. Adherence was assessed via usage data.

RESULTS

From May 2018 to August 2018, 311 adults downloaded the SELMA app, 102 of whom consented to participate and met the inclusion criteria. The average age of the women (88/102, 86.4%) and men (14/102, 13.6%) participating was 43.7 (SD 12.7) years. Baseline group comparison did not differ with respect to any demographic or clinical variable. The intervention group reported no significant change in pain-related impairment (P=.68) compared to the control group postintervention. The intention to change behavior was positively related to pain-related impairment (P=.01) and pain intensity (P=.01). Working alliance with the TBHC SELMA was comparable to that obtained in guided internet therapies with human coaches. Participants enjoyed using the app, perceiving it as useful and easy to use. Participants of the intervention group replied with an average answer ratio of 0.71 (SD 0.20) to 200 (SD 58.45) conversations initiated by SELMA. Participants' comments revealed an appreciation of the empathic and responsible interaction with the TBHC SELMA. A main criticism was that there was no option to enter free text for the patients' own comments.

CONCLUSIONS

SELMA is feasible, as revealed mainly by positive feedback and valuable suggestions for future revisions. For example, the participants' intention to change behavior or a more homogenous sample (eg, with a specific type of chronic pain) should be considered in further tailoring of SELMA.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00017147; https://tinyurl.com/vx6n6sx, Swiss National Clinical Trial Portal: SNCTP000002712; https://www.kofam.ch/de/studienportal/suche/70582/studie/46326.

Use of the nominal group technique to identify UK stakeholder views of the measures and domains used in the assessment of therapeutic exercise adherence for patients with musculoskeletal disorders

OBJECTIVES

The objective was to the undertake nominal group technique (NGT) to evaluate current exercise adherence measures and isolated domains to develop stakeholder consensus on the domains to include in the measurement of therapeutic exercise adherence for patients with musculoskeletal disorders.

DESIGN

A 1-day NGT workshop was convened. Six exercise adherence measures were presented to the group that were identified in our recent systematic review. Discussions considered these measures and isolated domains of exercise adherence. Following discussions, consensus voting identified stakeholder agreement on the suitability of the six offered adherence measures and the inclusion of isolated domains of exercise adherence in future measurement.

SETTING

One stakeholder NGT workshop held in Sheffield, UK.

PARTICIPANTS

Key stakeholders from the UK were invited to participate from four identified populations. 14 participants represented patients, clinicians, researchers and service managers.

RESULTS

All six exercise adherence measures were deemed not appropriate for use in clinical research or routine practice with no measure reaching 70% group agreement for suitability, relevance, acceptability or appropriateness. Three measures were deemed feasible to use in clinical practice. 25 constructs of exercise adherence did reach consensus threshold and were supported to be included as domains in the future measurement of exercise adherence.

CONCLUSION

A mixed UK-based stakeholder group felt these six measures of exercise adherence were unacceptable. Differences in opinion within the stakeholder group highlighted the lack of consensus as to what should be measured, the type of assessment that is required and whose perspective should be sought when assessing exercise adherence. Previously unused domains may be needed alongside current ones, from both a clinician's and patient's perspective, to gain understanding and to inform future measurement development. Further conceptualisation of exercise adherence is required from similar mixed stakeholder groups in various socioeconomic and cultural populations.

Exploring the Meaning of Cognitive Behavioral Therapy for Insomnia for Patients with Chronic Pain

OBJECTIVE

Insomnia is one of the most common, persistent, and distressing symptoms associated with chronic pain. Cognitive behavioral therapy for insomnia (CBT-I) is the firstline treatment for insomnia, but patient preferences and perspectives about CBT-I within the context of chronic pain are unknown. The current qualitative study sought to understand the experience of CBT-I among patients with chronic pain, including aspects of CBT-I that were found to be difficult (e.g., pain as a specific barrier to adherence/dropout), changes in sleep and pain functioning after CBT-I, and aspects of CBT-I that were appreciated.

DESIGN

Qualitative semistructured interviews.

METHODS

We conducted individual semistructured interviews with 17 veterans with chronic pain and insomnia who had recently participated in CBT-I, as well as their CBT-I therapists, and used thematic analysis to identify conceptual themes.

RESULTS

Results revealed that patients and CBT-I therapists found changing sleep habits during CBT-I challenging due to anxiety and temporary increases in fatigue, but did not identify major pain-related barriers to adhering to CBT-I recommendations; patients experienced better sleep, mood, energy, and socialization after CBT-I despite minimal changes in pain intensity; and patients highly valued CBT-I as a personalized treatment for sleep and strongly recommended it for other patients with chronic pain.

CONCLUSIONS

Findings of improved sleep and functional outcomes support efforts to incorporate CBT-I into chronic pain treatment, including educating patients and providers about the strong feasibility of improving sleep and quality of life despite ongoing pain.

Are Processes in Acceptance & Commitment Therapy (ACT) Related to Chronic Pain Outcomes Within Individuals Over Time? An Exploratory Study Using n-of-1 Designs

Introduction

Acceptance & Commitment Therapy (ACT) explicitly postulates experiential avoidance (EA) and values-based living (VBL) as essential treatment processes. As outcomes from between-subject studies cannot readily be generalized to within-subject processes in individuals, we explored the unfolding of, and relationship between, EA and VBL and levels of pain interference in daily life and emotional well-being within individuals experiencing chronic pain.

Methods

Using n-of-1 designs, three participants following a multidisciplinary treatment program filled out a 12-item daily questionnaire (87-110 days). After multiple imputation of missing data, McKnight Time-series analysis procedures were performed for each participant separately. The interrelationships of EA, VBL and pain intensity, and the relationship of EA and VBL beyond pain intensity with both chronic pain outcomes were assessed both concurrently (same day) and prospectively (consecutive days).

Results

Both EA and VBL were associated with at least one of five outcome variables (four domains of pain interference and emotional well-being) beyond pain intensity in two participants, but not in the third participant. These associations primarily existed for concurrent, but not consecutive, days. In contrast to VBL, EA was not associated with emotional well-being for any of the three participants.

Conclusions

Although the finding that ACT-processes were associated with pain outcomes on concurrent days is consistent with ACT theory, the absence of such associations on consecutive days means that alternative explanations cannot be rule out. One possibility is that pain interference fluctuates within days at a higher variability rate than was currently assessed. Future research should consider using a higher measurement frequency to be able to grasp time-lagged effects.

The basic psychological need support in physical therapy questionnaire

Given the limitations of current inventories of basic psychological need measurement, and the importance of psychological need support within an injury rehabilitation context, there is an evident need to develop the present inventory. Utilizing Self-Determination Theory (SDT) as a theoretical framework, two studies were conducted to develop and psychometrically test a measure of patients' perceptions of basic psychological needs support in physical therapy: The Basic Psychological Needs Support in Physical Therapy Questionnaire (BPNS-PT). In study 1, a panel of Self-Determination Theory academics assessed a pool of items for content relevance, representativeness, and item clarity. In study 2, responses from 199 physical therapy patients were used to identify the best fitting model through confirmatory factor analysis. A 3-factor 10-item measure displayed good fit to the data and illustrated evidence of internal consistency. Findings from these studies provide initial psychometric support (i.e. internal consistency and evidence of construct validity) for the BPNSPT as a measure of patient perceptions of basic psychological needs support in a physical therapy context.

Enhancing Motivation for Change in the Management of Chronic Painful Conditions: a Review of Recent Literature

PURPOSE OF REVIEW

The purpose of this review is to evaluate and summarize recent empirical research investigating motivational factors for management of chronic pain and headache disorders.

RECENT FINDINGS

Research on motivation for non-pharmacological treatment of chronic pain and headache disorders has identified factors that influence initiation of and adherence to treatment. To address common factors that inhibit initiation of treatment (i.e., cost, time commitment), several electronic treatments have been developed. Self-efficacy is the most commonly studied psychosocial influence on treatment adherence, with evidence that it is positively correlated with adherence. Other studies have sought to improve adherence to treatment using motivational interviewing interventions. There is currently limited research on how to enhance motivation for initial adherence to non-pharmacological treatment for chronic pain and headache disorders. Instead of enhancing motivation, researchers have looked to reduce barriers to treatment with electronic health treatments; however, many of these studies have focused on intervention feasibility, rather than efficacy or effectiveness. Numerous studies have identified a relationship between self-efficacy and treatment adherence. Although motivational interviewing interventions have been shown to improve adherence to treatment, there is little evidence that they improve treatment outcomes. Recommendations for further investigation include improving interventions to enhance accessibility and adherence to treatment with the goal of improving outcomes, as well as identifying ways to improve treatment initiation and adherence in patients who are currently engaged in long-term opioid therapy.

Predictors of Adherence to Psychological Treatment for Insomnia and Pain: Analysis from a Randomized Trial

OBJECTIVES

Poor adherence to psychological treatment for insomnia is common and limits treatment gains. Very little is known about predictors of adherence among patients with chronic pain, although adherence is theorized to be more critical and more challenging for these patients. This secondary data analysis examines predictors of drop-out and therapy nonattendance in an osteoarthritis population receiving psychological treatment for insomnia and pain.

METHODS

Data were analyzed from the "Lifestyles" trial, a randomized controlled trial of a 6-week group cognitive behavioral pain coping skills intervention (CBT-P), group cognitive-behavioral therapy for pain and insomnia (CBT-PI), and an education only attention control group (EOC). The current analysis focuses on 122 participants randomized to CBT-PI from 6 primary care clinics. Measures of treatment acceptability, demographics, and symptoms were collected at baseline. Factor analysis was used to clarify the boundaries of these domains, and hierarchical regression was used to examine the incremental predictive power of these patient characteristics on therapy attendance.

RESULTS

Ratings of treatment acceptability were distinct from demographic and medical variables and baseline symptoms. Treatment acceptability was significantly related to session attendance and drop-out (rs ranging from 0.24 to 0.32) and was also one of the strongest predictors of session attendance (β=0.20; P<0.05).

DISCUSSION

Perceptions of treatment acceptability early in treatment represent a potentially modifiable target to enhance adherence to psychological treatment for insomnia and pain among patients with chronic pain. This work represents an important step towards understanding how to best maximize sleep treatments for this patient population.

Interleukin 1β inhibition contributes to the antinociceptive effects of voluntary exercise on ischemia/reperfusion-induced hypersensitivity

Issues of peripheral circulation have been increasingly suggested as an underlying cause of musculoskeletal pain in many conditions, including sickle cell anemia and peripheral vascular disease. We have previously shown in our model of transient ischemia and reperfusion (I/R) injury of the forelimb that individual group III and IV muscle afferents display altered chemosensitivity and mechanical thresholds 1 day after injury. Functional alterations corresponded to increased evoked and spontaneous pain-related behaviors and decreased muscle strength and voluntary activity-all actions that echo clinical symptoms of ischemic myalgia. These behavioral and physiological changes appeared to originate in part from the action of increased interleukin 1β (IL1β) in the injured muscles at its upregulated IL1 receptor 1 within the dorsal root ganglion. Here, we describe that two days of voluntary wheel running prior to I/R blocks both injury-induced IL1β enhancement and the subsequent development of ischemic myalgia-like behaviors. Furthermore, the protective effects of 2 days prior exercise on the I/R-evoked increases in pain-related behaviors were also paralleled with systemic injection of the IL1 receptor antagonist during I/R. Interleukin 1 receptor antagonist treatment additionally prevented the I/R-induced changes in mechanical and chemical sensitivity of individual primary muscle afferents. Altogether, these data strengthen the evidence that transient I/R injury sensitizes group III and IV muscle afferents via increased IL1β in the muscles to stimulate ischemic myalgia development. Targeting IL1β may, therefore, be an effective treatment strategy for this insidious type of muscle pain.

Japanese cross-cultural validation study of the Pain Stage of Change Questionnaire

INTRODUCTION

Although evidence supports efficacy of treatments that enhance self-management of chronic pain, the efficacy of these treatments has been hypothesized to be influenced by patient readiness for self-management. The Pain Stage of Change Questionnaire (PSOCQ) is a reliable and valid measure of patient readiness to self-manage pain. However, there is not yet a Japanese version of the PSOCQ (PSOCQ-J), which limits our ability to evaluate the role of readiness for pain self-management in function and treatment response in Japanese patients with chronic pain.

OBJECTIVE

Here, we sought to develop the PSOCQ-J and evaluate its psychometric properties.

METHODS

We recruited 201 patients with chronic pain. The study participants were asked to complete the PSOCQ-J and other measures assessing pain severity, pain interference, catastrophizing, self-efficacy, and pain coping strategies.

RESULTS

The results supported a 4-factor structure of the PSOCQ-J. We also found good to excellent internal consistencies and good test-retest reliabilities for the 4 scales. The Precontemplation scale had weak to moderate positive correlations with measures of pain-related dysfunction and maladaptive coping. The Action and Maintenance scales had weak to moderate positive correlations with measures of self-efficacy and adaptive coping. The Contemplation scale had weak positive correlations with measures of pain interference and both adaptive and maladaptive coping.

CONCLUSIONS

The PSOCQ-J demonstrated adequate psychometric properties in a sample of Japanese patients with chronic pain. This measure can be used to evaluate the role that readiness to self-manage pain may play in adjustment to chronic pain in Japanese pain populations.

Exploring the potential role of mesocorticolimbic circuitry in motivation for and adherence to chronic pain self-management interventions

Adherence to pain self-management strategies is associated with favorable psychobehavioral outcomes among individuals with chronic pain. Substantive adherence to treatments teaching these adaptive skills often proves challenging, resulting in poor individual and societal outcomes. Evidence demonstrates motivation for behavior change as a key predictor of treatment adherence. Despite behavioral techniques that target motivation, however, nonadherence persists as a barrier to positive clinical outcomes in chronic pain. Understanding the neurobiological mechanisms underlying treatment motivation might highlight novel avenues for augmentative therapies. The purpose of this review is to present theory and evidence that the mesocorticolimbic system (i.e., brain circuitry associated with reward processing and motivation) contributes to treatment motivation among chronic pain patients, ultimately influencing adherence. We review evidence for motivation as a key adherence determinant, detail neuroimaging findings relating mesocorticolimbic circuitry and motivation, and discuss data supporting mesocorticolimbic dysfunction among chronic pain patients. We propose a neurobehavioral model for adherence to pain self-management interventions, listing testable hypotheses. Finally, we discuss potential research and intervention implications from the proposed model.

A Pilot Randomized Controlled Trial Comparing Mindfulness Meditation, Cognitive Therapy, and Mindfulness-Based Cognitive Therapy for Chronic Low Back Pain

Objective

This pilot trial compared the feasibility, tolerability, acceptability, and effects of group-delivered mindfulness meditation (MM), cognitive therapy (CT), and mindfulness-based cognitive therapy (MBCT) for chronic low back pain (CLBP).

Setting

University of Queensland Psychology Clinic.

Subjects

Participants were N = 69 (intent-to-treat [ITT] sample) adults with CLBP.

Design

A pilot, assessor-blinded randomized controlled trial.

Methods

Participants were randomized to treatments. The primary outcome was pain interference; secondary outcomes were pain intensity, physical function, depression, and opioid medication use. The primary study end point was post-treatment; maintenance of gains was evaluated at three- and six-month follow-up.

Results

Ratings of acceptability, and ratios of dropout and attendance showed that MBCT was acceptable, feasible, and well tolerated, with similar results found across conditions. For the ITT sample, large improvements in post-treatment scores for pain interference, pain intensity, physical function, and depression were found (P < 0.001), with no significant between-group differences. Analysis of the follow-up data (N = 43), however, revealed that MBCT participants improved significantly more than MM participants on pain interference, physical function, and depression. The CT group improved more than MM in physical function. The MBCT and CT groups did not differ significantly on any measures.

Conclusions

This is the first study to examine MBCT for CLBP management. The findings show that MBCT is a feasible, tolerable, acceptable, and potentially efficacious treatment option for CLBP. Further, MBCT, and possibly CT, could have sustained benefits that exceed MM on some important CLBP outcomes. A future definitive randomized controlled trial is needed to evaluate these treatments and their differences.

Internet-delivered aftercare following multimodal rehabilitation program for chronic pain: a qualitative feasibility study

Purpose

Methods for delivering aftercare to help chronic pain patients to continue practice self-management skills after rehabilitation are needed. Internet-delivered cognitive behavioral therapy (ICBT) has the potential to partly fill this gap given its accessibility and emphasis on self-care. Methods for engaging and motivating patients to persist throughout the full length of treatment are needed. The aim of this study was to describe how chronic pain patients work in an ICBT program, through their descriptions of what is important when they initiate behavior change in aftercare and their descriptions of what is important for ongoing practice of self-management skills in aftercare.

Patients and methods

Following a multimodal rehabilitation program, 29 chronic pain patients participated in a 20-week-long Internet-delivered aftercare program (ACP) based on acceptance-based cognitive behavioral therapy. Latent content analysis was made on 138 chapters of diary-like texts written by participants in aftercare.

Results

Attitudes regarding pain and body changed during ACP, as did attitudes toward self and the future for some participants. How participants practiced self-management skills was influenced by how they expressed motivation behind treatment goals. Whether they practiced acceptance strategies influenced their continuous self-management practice. Defusion techniques seemed to be helpful in the process of goal setting. Mindfulness strategies seemed to be helpful when setbacks occurred.

Conclusion

Self-motivating goals are described as important both to initiate and in the ongoing practice of self-management skills. Experiencing a helpful effect of acceptance strategies seems to encourage participants to handle obstacles in new ways and to persist throughout treatment. Research on whether tailored therapist guidance might be helpful in stating self-motivating goals and contribute to ongoing practice of self-management skills is needed.

The effectiveness of generic self-management interventions for patients with chronic musculoskeletal pain on physical function, self-efficacy, pain intensity and physical activity: A systematic review and meta-analysis

Generic self‐management programs aim to facilitate behavioural adjustment and therefore have considerable potential for patients with chronic musculoskeletal pain. Our main objective was to collect and synthesize all data on the effectiveness of generic self‐management interventions for patients with chronic musculoskeletal pain in terms of physical function, self‐efficacy, pain intensity and physical activity. Our secondary objective was to describe the content of these interventions, by means of classification according to the Behaviour Change Technique Taxonomy. We searched PubMed, CENTRAL, Embase and Psycinfo for eligible studies. Study selection, data extraction and risk of bias were assessed by two researchers independently. Meta‐analyses were only performed if the studies were sufficiently homogeneous and GRADE was used to determine the quality of evidence. We identified 20 randomized controlled trials that compared a self‐management intervention to any type of control group. For post‐intervention results, there was moderate quality evidence of a statistically significant but clinically unimportant effect for physical function and pain intensity, both favouring the self‐management group. At follow‐up, there was moderate quality evidence of a small clinically insignificant effect for self‐efficacy, favouring the self‐management group. All other comparisons did not indicate an effect. Classification of the behaviour change techniques showed large heterogeneity across studies. These results indicate that generic self‐management interventions have a marginal benefit for patients with chronic musculoskeletal pain in the short‐term for physical function and pain intensity and for self‐efficacy in the long‐term, and vary considerably with respect to intervention content.

Significance

This study contributes to a growing body of evidence that generic self‐management interventions have limited effectiveness for patients with chronic musculoskeletal pain. Furthermore, this study has identified substantial differences in both content and delivery mode across self‐management interventions.

Patients' Perspectives on and Experiences of Home Exercise Programmes Delivered with a Mobile Application

Purpose: We explored patients' perspectives on home exercise programmes (HEPs) and their experiences using a mobile application designed to facilitate home exercise. Method: Data were generated using qualitative, semi-structured, face-to-face interviews with 10 participants who were receiving outpatient physiotherapy. Results: Establishing a therapeutic partnership between physiotherapists and patients enabled therapists to customize the HEPs to the patients' lifestyles and preferences. Analysis suggests that using the mobile application improved participants' ability to integrate the HEP into their daily life and was overwhelmingly preferred to traditional paper handouts. Conclusions: The results suggest that efforts to engage patients in HEPs need to take their daily lives into account. To move in this direction, sample exercise prescription questions are offered. Mobile applications do not replace the clinical encounter, but they can be an effective tool and an extension of delivering personalized HEPs in an existing therapeutic partnership.

Patient Involvement With Home-Based Exercise Programs: Can Connected Health Interventions Influence Adherence?

Adherence to home exercise in rehabilitation is a significant problem, with estimates of nonadherence as high as 50%, potentially having a detrimental effect on clinical outcomes. In this viewpoint, we discuss the many reasons why patients may not adhere to a prescribed exercise program and explore how connected health technologies have the ability to offer numerous interventions to enhance adherence; however, it is hard to judge the efficacy of these interventions without a robust measurement tool. We highlight how well-designed connected health technologies, such as the use of mobile devices, including mobile phones and tablets, as well as inertial measurement units, provide us with the opportunity to better support the patient and clinician, with a data-driven approach that incorporates features designed to increase adherence to exercise such as coaching, self-monitoring and education, as well as remotely monitor adherence rates more objectively.

Subliminal (latent) processing of pain and its evolution to conscious awareness

By unconscious or covert processing of pain we refer to nascent interactions that affect the eventual deliverance of pain awareness. Thus, internal processes (viz., repeated nociceptive events, inflammatory kindling, reorganization of brain networks, genetic) or external processes (viz., environment, socioeconomic levels, modulation of epigenetic status) contribute to enhancing or inhibiting the presentation of pain awareness. Here we put forward the notion that for many patients, ongoing sub-conscious changes in brain function are significant players in the eventual manifestation of chronic pain. In this review, we provide clinical examples of nascent or what we term pre-pain processes and the neurobiological mechanisms of how these changes may contribute to pain, but also potential opportunities to define the process for early therapeutic interventions.

Mindfulness-based cognitive therapy for headache pain: An evaluation of the long-term maintenance of effects

OBJECTIVES

This study aimed to examine the durability of gain patterns following an 8-week Mindfulness-Based Cognitive Therapy (MBCT) for headache pain program.

DESIGN

A secondary analysis of a randomized controlled trial was conducted. Participants (N=19) were individuals with headache pain who completed both the MBCT program as well as a 6-month follow-up assessment at a headache clinic or a university psychology clinic. Standardized measures of the primary outcomes (pain intensity and pain interference) and secondary outcomes (pain catastrophizing, mindfulness, activity engagement, pain willingness, and self-efficacy) were administered. Paired-samples t tests and effect sizes were examined.

RESULTS

Significant (uncorrected ps<.05) pre- to post-treatment gains were found for pain intensity, pain interference, pain catastrophizing, activity engagement and self-efficacy, and these gains were maintained at 6-months post-treatment. Effect sizes for the significant changes from pre- to post-treatment, and from pre-treatment to follow-up were mostly consistent across epochs (.62≤ds≤-1.40), indicating steady maintenance of effects. Improvement in mindfulness and pain willingness was non-significant immediately post-treatment and at follow-up, with small effects observed.

CONCLUSIONS

This study adds to a growing body of literature supporting the durability of MBCT for painful conditions. Results indicated a consistent pattern of maintenance of treatment-related gains across a number of key pain-related outcomes. Future research with a larger sample is needed to investigate the mechanisms underlying these continued gains in order to optimize targeted relapse-prevention.

Toward Patient-Centered Telerehabilitation Design: Understanding Chronic Pain Patients' Preferences for Web-Based Exercise Telerehabilitation Using a Discrete Choice Experiment

Background

Patient-centered design that addresses patients’ preferences and needs is considered an important aim for improving health care systems. At present, within the field of pain rehabilitation, patients’ preferences regarding telerehabilitation remain scarcely explored and little is known about the optimal combination between human and electronic contact from the patients’ perspective. In addition, limited evidence is available about the best way to explore patients’ preferences. Therefore, the assessment of patients’ preferences regarding telemedicine is an important step toward the design of effective patient-centered care.

Objective

To identify which telerehabilitation treatment options patients with chronic pain are most likely to accept as alternatives to conventional rehabilitation and assess which treatment attributes are most important to them.

Methods

A discrete choice experiment with 15 choice tasks, combining 6 telerehabilitation treatment characteristics, was designed. Each choice task consisted of 2 hypothetical treatment scenarios and 1 opt-out scenario. Relative attribute importance was estimated using a bivariate probit regression analysis. One hundred and thirty surveys were received, of which 104 were usable questionnaires; thus, resulting in a total of 1547 observations.

Results

Physician communication mode, the use of feedback and monitoring technology (FMT), and exercise location were key drivers of patients’ treatment preferences (P<.001). Patients were willing to accept less frequent physician consultation offered mainly through video communication, provided that they were offered FMT and some face-to-face consultation and could exercise outside their home environment at flexible exercise hours. Home-based telerehabilitation scenarios with minimal physician supervision were the least preferred. A reduction in health care premiums would make these telerehabilitation scenarios as attractive as conventional clinic-based rehabilitation.

Conclusions

“Intermediate” telerehabilitation treatments offering FMT, some face-to-face consulting, and a gym-based exercise location should be pursued as promising alternatives to conventional chronic pain rehabilitation. Further research is necessary to explore whether strategies other than health care premium reductions could also increase the value of home telerehabilitation treatment.

Deconstructing Chronic Low Back Pain in the Older Adult--Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment. Part V: Maladaptive Coping

OBJECTIVE

As part of a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults, this article focuses on maladaptive coping--a significant contributor of psychological distress, increased pain, and heightened disability in older adults with CLBP.

METHODS

A modified Delphi technique was used to develop a maladaptive coping algorithm and table providing the rationale for the various components of the algorithm. A seven-member content expert panel and a nine-member primary care panel were involved in the iterative development of the materials. While the algorithm was developed keeping in mind resources available within the Veterans Health Administration (VHA) facilities, panelists were not exclusive to the VHA, and therefore, materials can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributors' clinical practice.

RESULTS

We present a treatment algorithm and supporting table to be used by providers treating older adults who have CLBP and engage in maladaptive coping strategies. A case of an older adult with CLBP and maladaptive coping is provided to illustrate the approach to management.

CONCLUSIONS

To promote early engagement in skill-focused treatments, providers can routinely evaluate pain coping strategies in older adults with CLBP using a treatment algorithm.

Validation of the four-dimensional symptom questionnaire (4DSQ) and prevalence of psychological symptoms in orthopedic shoulder patients

Psychological problems are common in shoulder patients. A validated psychological questionnaire measuring clinically relevant psychological symptoms (including distress, depression, anxiety, and somatization) in shoulder patients is lacking. The Four-Dimensional Symptom Questionnaire (4DSQ) is a self-report questionnaire to identify distress, depression, anxiety, and somatization which has been validated in primary care populations. The aim of this study was to validate the 4DSQ in orthopedic shoulder patients. We assessed whether the 4DSQ measures these four constructs the same way in an orthopedic population with shoulder problems compared to a general practice population. We also investigated the prevalence of psychological symptoms in shoulder patients. The shoulder group consisted of 200 consecutive patients and the general practice group comprised 368 patients, matched for gender and age. Differential item functioning analysis showed that the 4DSQ measures the different psychological symptoms in orthopedic shoulder patients the same way as in general practice patients. The shoulder patients tended to score higher on the somatization scale, resulting in a new cut-off point for somatization. The prevalence of distress, somatization, anxiety, and depression in the shoulder group was 23%, 14%, 10%, and 8%, respectively. It can be concluded from this study that the 4DSQ in orthopedic shoulder patients measures the same constructs as in general practice patients and can therefore be used in orthopedic practice to measure psychological symptoms in patients with shoulder complaints.